ogb pelican hsa 775 cdhp maintenance/preventive care drug list · ogb pelican hsa 775 cdhp ......
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04HQ1393 R011/17
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
Preventive care medications are drugs that can help you prevent health problems or problems caused by a health condition. The OGB Pelican HSA 775 CDHP (consumer‐driven health plan) Maintenance/Preventive Care Drug List shows certain brand and generic preventive drugs covered by your plan.
Drugs on this list are covered with no deductible, when you fill them at a network pharmacy, though they may require you or your doctor to follow some rules based on your plan. Please see your benefit plan for a full list of these rules, which are listed as benefits, limitations and exclusions.
DRUG NAME DRUG CLASSIFICATION
1ST CHOICE LANCETS Prevention of Diabetes‐Related Complications
1ST TIER UNIFINE PENTIPS Prevention of Diabetes‐Related Complications
1ST TIER UNIFINE PENTIPS PLUS Prevention of Diabetes‐Related Complications
1ST TIER UNILET COMFORTOUCH Prevention of Diabetes‐Related Complications
acarbose Prevention of Diabetes‐Related Complications
ACCOLATE Prevention of Asthma‐Related Complications
ACCU‐CHEK Prevention of Diabetes‐Related Complications
ACCU‐CHEK AVIVA Prevention of Diabetes‐Related Complications
ACCU‐CHEK AVIVA PLUS Prevention of Diabetes‐Related Complications
ACCU‐CHEK COMFORT CURVE Prevention of Diabetes‐Related Complications
ACCU‐CHEK COMPACT Prevention of Diabetes‐Related Complications
ACCU‐CHEK COMPACT PLUS STRIPS Prevention of Diabetes‐Related Complications
ACCU‐CHEK FASTCLIX Prevention of Diabetes‐Related Complications
ACCU‐CHEK GUIDE TEST STRIP Prevention of Diabetes‐Related Complications
ACCU‐CHEK SAFE‐T‐PRO Prevention of Diabetes‐Related Complications
ACCU‐CHEK SAFE‐T‐PRO PLUS Prevention of Diabetes‐Related Complications
ACCU‐CHEK SMARTVIEW Prevention of Diabetes‐Related Complications
ACCU‐CHEK SOFTCLIX Prevention of Diabetes‐Related Complications
ACCUPRIL Prevention of Cardiovascular Disease
ACCURETIC Prevention of Cardiovascular Disease
ACCUTREND GLUCOSE Prevention of Diabetes‐Related Complications
acebutolol hcl Prevention of Cardiovascular Disease
ACEON Prevention of Cardiovascular Disease
acetylcysteine Prevention of Asthma‐Related Complications
ACTHIB Prevention of Infections
acti‐lance Prevention of Diabetes‐Related Complications
ACTONEL Prevention of Osteoporosis
ACTOPLUS MET Prevention of Diabetes‐Related Complications
ACTOPLUS MET XR Prevention of Diabetes‐Related Complications
ACTOS Prevention of Diabetes‐Related Complications
ADACEL TDAP Prevention of Infections
BRAND medications are listed in UPPER CASE and generics in lower case.
Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
DRUG NAME DRUG CLASSIFICATION
ADALAT CC Prevention of Cardiovascular Disease
ADLYXIN Prevention of Diabetes‐Related Complications
ADVAIR DISKUS Prevention of Asthma‐Related Complications
ADVAIR HFA Prevention of Asthma‐Related Complications
ADVANCED GLUCOSE TEST STRIPS Prevention of Diabetes‐Related Complications
ADVANCED TRAVEL LANCETS Prevention of Diabetes‐Related Complications
ADVOCATE LANCET Prevention of Diabetes‐Related Complications
ADVOCATE LANCETS Prevention of Diabetes‐Related Complications
ADVOCATE PEN NEEDLE Prevention of Diabetes‐Related Complications
ADVOCATE PEN NEEDLES Prevention of Diabetes‐Related Complications
ADVOCATE REDI‐CODE Prevention of Diabetes‐Related Complications
ADVOCATE REDI‐CODE+ Prevention of Diabetes‐Related Complications
ADVOCATE SYRINGES Prevention of Diabetes‐Related Complications
ADVOCATE TEST STRIP Prevention of Diabetes‐Related Complications
AEROSPAN Prevention of Asthma‐Related Complications
afeditab cr Prevention of Cardiovascular Disease
AFLURIA 2017‐2018 Prevention of Infections
AFREZZA Prevention of Diabetes‐Related Complications
AGAMATRIX AMP Prevention of Diabetes‐Related Complications
AGGRENOX Prevention of Cardiovascular Disease
AIRDUO RESPICLICK Prevention of Asthma‐Related Complications
albuterol sulfate Prevention of Asthma‐Related Complications
ALDACTAZIDE Prevention of Cardiovascular Disease
ALDACTONE Prevention of Cardiovascular Disease
alendronate sodium Prevention of Osteoporosis
ALOGLIPTIN Prevention of Diabetes‐Related Complications
ALOGLIPTIN‐METFORMIN Prevention of Diabetes‐Related Complications
ALOGLIPTIN‐PIOGLITAZONE Prevention of Diabetes‐Related Complications
ALTACE Prevention of Cardiovascular Disease
ALTERNATE SITE LANCETS Prevention of Diabetes‐Related Complications
ALTOPREV Prevention of Cardiovascular Disease
ALVESCO Prevention of Asthma‐Related Complications
amantadine Prevention of Infections
AMARYL Prevention of Diabetes‐Related Complications
amiloride hcl Prevention of Cardiovascular Disease
amiloride‐hydrochlorothiazide Prevention of Cardiovascular Disease
amlodipine besylate Prevention of Cardiovascular Disease
amlodipine besylate‐benazepril Prevention of Cardiovascular Disease
amlodipine‐atorvastatin Prevention of Cardiovascular Disease
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
amlodipine‐olmesartan Prevention of Cardiovascular Disease
amlodipine‐valsartan Prevention of Cardiovascular Disease
amlodipine‐valsartan‐hctz Prevention of Cardiovascular Disease
AMTURNIDE Prevention of Cardiovascular Disease
ANORO ELLIPTA Prevention of Asthma‐Related Complications
ANTARA Prevention of Cardiovascular Disease
APIDRA Prevention of Diabetes‐Related Complications
APIDRA SOLOSTAR Prevention of Diabetes‐Related Complications
ARCAPTA NEOHALER Prevention of Asthma‐Related Complications
ARMONAIR RESPICLICK Prevention of Asthma‐Related Complications
ARNUITY ELLIPTA Prevention of Asthma‐Related Complications
ASMANEX Prevention of Asthma‐Related Complications
ASMANEX HFA Prevention of Asthma‐Related Complications
aspirin‐dipyridamole er Prevention of Cardiovascular Disease
ASSURE 4 Prevention of Diabetes‐Related Complications
ASSURE HAEMOLANCE PLUS Prevention of Diabetes‐Related Complications
ASSURE ID INSULIN SAFETY Prevention of Diabetes‐Related Complications
ASSURE LANCE Prevention of Diabetes‐Related Complications
ASSURE LANCE PLUS Prevention of Diabetes‐Related Complications
ASSURE PLATINUM Prevention of Diabetes‐Related Complications
ASSURE PRISM MULTI Prevention of Diabetes‐Related Complications
ASSURE PRO Prevention of Diabetes‐Related Complications
ATABEX EC Prevention of Prenatal Complications
ATACAND Prevention of Cardiovascular Disease
ATACAND HCT Prevention of Cardiovascular Disease
ATELVIA Prevention of Osteoporosis
atenolol Prevention of Cardiovascular Disease
atenolol‐chlorthalidone Prevention of Cardiovascular Disease
atorvastatin calcium Prevention of Cardiovascular Disease
atovaquone‐proguanil hcl Prevention of Malaria
ATROVENT HFA Prevention of Asthma‐Related Complications
AUTOSHIELD DUO PEN NEEDLE Prevention of Diabetes‐Related Complications
AUTOSHIELD PEN NEEDLE Prevention of Diabetes‐Related Complications
AVALIDE Prevention of Cardiovascular Disease
AVANDAMET Prevention of Diabetes‐Related Complications
AVANDARYL Prevention of Diabetes‐Related Complications
AVANDIA Prevention of Diabetes‐Related Complications
AVAPRO Prevention of Cardiovascular Disease
AZOR Prevention of Cardiovascular Disease
bal‐care dha Prevention of Prenatal Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
DRUG NAME DRUG CLASSIFICATION
BAL‐CARE DHA ESSENTIAL Prevention of Prenatal Complications
BASAGLAR KWIKPEN U‐100 Prevention of Diabetes‐Related Complications
BD MICROTAINER LANCETS Prevention of Diabetes‐Related Complications
BD ULTRA‐FINE Prevention of Diabetes‐Related Complications
BD ULTRA‐FINE II Prevention of Diabetes‐Related Complications
BD ULTRA‐FINE PEN NEEDLE Prevention of Diabetes‐Related Complications
benazepril hcl Prevention of Cardiovascular Disease
benazepril‐hydrochlorothiazide Prevention of Cardiovascular Disease
BENICAR Prevention of Cardiovascular Disease
BENICAR HCT Prevention of Cardiovascular Disease
betaxolol hcl Prevention of Cardiovascular Disease
BEVESPI AEROSPHERE Prevention of Asthma‐Related Complications
BEVYXXA Prevention of Cardiovascular Disease
BEXSERO Prevention of Infections
BG‐STAR Prevention of Diabetes‐Related Complications
BINOSTO Prevention of Osteoporosis
bisoprolol fumarate Prevention of Cardiovascular Disease
bisoprolol‐hydrochlorothiazide Prevention of Cardiovascular Disease
BLOOD GLUCOSE TEST Prevention of Diabetes‐Related Complications
BLOOD GLUCOSE TEST STRIP Prevention of Diabetes‐Related Complications
BLOOD LANCETS Prevention of Diabetes‐Related Complications
BONIVA Prevention of Osteoporosis
BOOSTRIX TDAP Prevention of Infections
BREEZE 2 Prevention of Diabetes‐Related Complications
BREO ELLIPTA Prevention of Asthma‐Related Complications
BRILINTA Prevention of Cardiovascular Disease
BROVANA Prevention of Asthma‐Related Complications
budesonide Prevention of Asthma‐Related Complications
BULLSEYE MINI SAFETY LANCETS Prevention of Diabetes‐Related Complications
BYDUREON Prevention of Diabetes‐Related Complications
BYDUREON PEN Prevention of Diabetes‐Related Complications
BYETTA Prevention of Diabetes‐Related Complications
BYSTOLIC Prevention of Cardiovascular Disease
CADUET Prevention of Cardiovascular Disease
CALAN Prevention of Cardiovascular Disease
CALAN SR Prevention of Cardiovascular Disease
calcitonin‐salmon Prevention of Osteoporosis
calcium pnv Prevention of Prenatal Complications
candesartan cilexetil Prevention of Cardiovascular Disease
candesartan‐hydrochlorothiazide Prevention of Cardiovascular Disease
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
captopril Prevention of Cardiovascular Disease
captopril‐hydrochlorothiazide Prevention of Cardiovascular Disease
CARDENE SR Prevention of Cardiovascular Disease
CARDIZEM Prevention of Cardiovascular Disease
CARDIZEM CD Prevention of Cardiovascular Disease
CARDIZEM LA Prevention of Cardiovascular Disease
CAREFINE PEN NEEDLE Prevention of Diabetes‐Related Complications
CAREONE Prevention of Diabetes‐Related Complications
CARESENS N Prevention of Diabetes‐Related Complications
CARETOUCH PEN NEEDLE Prevention of Diabetes‐Related Complications
CARETOUCH TWIST LANCET Prevention of Diabetes‐Related Complications
cartia xt Prevention of Cardiovascular Disease
carvedilol Prevention of Cardiovascular Disease
CATAPRES Prevention of Cardiovascular Disease
CATAPRES‐TTS 1 Prevention of Cardiovascular Disease
CATAPRES‐TTS 2 Prevention of Cardiovascular Disease
CATAPRES‐TTS 3 Prevention of Cardiovascular Disease
cavan‐ec sod dha Prevention of Prenatal Complications
CERVARIX Prevention of Infections
CHEMSTRIP K Prevention of Diabetes‐Related Complications
CHEMSTRIP UGK Prevention of Diabetes‐Related Complications
chloroquine phosphate Prevention of Malaria
chlorothiazide Prevention of Cardiovascular Disease
chlorpropamide Prevention of Diabetes‐Related Complications
chlorthalidone Prevention of Cardiovascular Disease
cholestyramine Prevention of Cardiovascular Disease
cholestyramine light Prevention of Cardiovascular Disease
CITRANATAL 90 DHA Prevention of Prenatal Complications
CITRANATAL ASSURE Prevention of Prenatal Complications
CITRANATAL B‐CALM Prevention of Prenatal Complications
CITRANATAL DHA Prevention of Prenatal Complications
CITRANATAL HARMONY Prevention of Prenatal Complications
CITRANATAL RX Prevention of Prenatal Complications
classic prenatal Prevention of Prenatal Complications
CLEVER CHEK LANCETS Prevention of Diabetes‐Related Complications
CLEVER CHOICE MICRO TEST STRIP Prevention of Diabetes‐Related Complications
CLEVER CHOICE PRO Prevention of Diabetes‐Related Complications
CLEVER CHOICE TEST STRIPS Prevention of Diabetes‐Related Complications
CLEVER CHOICE VOICE+ TST STRIP Prevention of Diabetes‐Related Complications
CLICKFINE Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
clonidine Prevention of Cardiovascular Disease
clonidine hcl Prevention of Cardiovascular Disease
clopidogrel Prevention of Cardiovascular Disease
clorpres Prevention of Cardiovascular Disease
c‐nate dha Prevention of Prenatal Complications
COAGUCHEK Prevention of Diabetes‐Related Complications
COLESTID Prevention of Cardiovascular Disease
colestipol hcl Prevention of Cardiovascular Disease
COLOR LANCETS Prevention of Diabetes‐Related Complications
COMBIVENT RESPIMAT Prevention of Asthma‐Related Complications
COMFORT EZ Prevention of Diabetes‐Related Complications
COMFORT LANCETS Prevention of Diabetes‐Related Complications
complete natal dha Prevention of Prenatal Complications
completenate Prevention of Prenatal Complications
COMVAX Prevention of Infections
CONCEPT DHA Prevention of Prenatal Complications
CONCEPT OB Prevention of Prenatal Complications
CONTOUR Prevention of Diabetes‐Related Complications
CONTOUR NEXT Prevention of Diabetes‐Related Complications
CONTROL Prevention of Diabetes‐Related Complications
CONTROL AST TEST STRIP Prevention of Diabetes‐Related Complications
COOL GLUCOSE TEST STRIP Prevention of Diabetes‐Related Complications
COREG Prevention of Cardiovascular Disease
COREG CR Prevention of Cardiovascular Disease
CORGARD Prevention of Cardiovascular Disease
CORZIDE Prevention of Cardiovascular Disease
COUMADIN Prevention of Cardiovascular Disease
COZAAR Prevention of Cardiovascular Disease
CRESTOR Prevention of Cardiovascular Disease
cromolyn sodium Prevention of Asthma‐Related Complications
CYCLOSET Prevention of Diabetes‐Related Complications
daily prenatal Prevention of Prenatal Complications
DALIRESP Prevention of Asthma‐Related Complications
DAPTACEL DTAP Prevention of Infections
DIABETA Prevention of Diabetes‐Related Complications
DIASTIX REAGENT Prevention of Diabetes‐Related Complications
DIATRUE PLUS Prevention of Diabetes‐Related Complications
diltiazem 12hr er Prevention of Cardiovascular Disease
diltiazem 24hr cd Prevention of Cardiovascular Disease
diltiazem 24hr er Prevention of Cardiovascular Disease
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
diltiazem er Prevention of Cardiovascular Disease
diltiazem hcl Prevention of Cardiovascular Disease
DILTIAZEM HCL‐0.9% NACL Prevention of Cardiovascular Disease
dilt‐xr Prevention of Cardiovascular Disease
DIOVAN Prevention of Cardiovascular Disease
DIOVAN HCT Prevention of Cardiovascular Disease
DIPHTHERIA‐TETANUS TOXOIDS‐PED Prevention of Infections
dipyridamole Prevention of Cardiovascular Disease
DIURIL Prevention of Cardiovascular Disease
dothelle dha Prevention of Prenatal Complications
DROPLET LANCETS Prevention of Diabetes‐Related Complications
DROPLET PEN NEEDLE Prevention of Diabetes‐Related Complications
DUET DHA Prevention of Prenatal Complications
DUET DHA 400 Prevention of Prenatal Complications
DUET DHA BALANCED Prevention of Prenatal Complications
DUET DHA EC Prevention of Prenatal Complications
DUETACT Prevention of Diabetes‐Related Complications
DULERA Prevention of Asthma‐Related Complications
DUTOPROL Prevention of Cardiovascular Disease
DYAZIDE Prevention of Cardiovascular Disease
DYRENIUM Prevention of Cardiovascular Disease
EASY COMFORT Prevention of Diabetes‐Related Complications
EASY COMFORT INSULIN SYRINGE Prevention of Diabetes‐Related Complications
EASY COMFORT PEN NEEDLES Prevention of Diabetes‐Related Complications
EASY PLUS II Prevention of Diabetes‐Related Complications
EASY STEP Prevention of Diabetes‐Related Complications
EASY TALK Prevention of Diabetes‐Related Complications
EASY TOUCH Prevention of Diabetes‐Related Complications
EASY TOUCH FLIPLOCK INSULIN Prevention of Diabetes‐Related Complications
EASY TOUCH INSULIN SAFETY Prevention of Diabetes‐Related Complications
EASY TOUCH INSULIN SYRINGE Prevention of Diabetes‐Related Complications
EASY TOUCH LANCETS Prevention of Diabetes‐Related Complications
EASY TOUCH LUER LOCK INSULIN Prevention of Diabetes‐Related Complications
EASY TOUCH PEN NEEDLE Prevention of Diabetes‐Related Complications
EASY TOUCH SHEATHLOCK INSULIN Prevention of Diabetes‐Related Complications
EASY TOUCH TEST STRIP Prevention of Diabetes‐Related Complications
EASY TOUCH UNI‐SLIP Prevention of Diabetes‐Related Complications
EASY TRAK Prevention of Diabetes‐Related Complications
EASY TWIST & CAP LANCETS Prevention of Diabetes‐Related Complications
EASYGLUCO PLUS Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
EASYGLUCO TEST STRIPS Prevention of Diabetes‐Related Complications
EASYMAX Prevention of Diabetes‐Related Complications
EASYMAX 15 Prevention of Diabetes‐Related Complications
EASY‐TOUCH INSULIN SYRINGE Prevention of Diabetes‐Related Complications
ECLIPSE SYRINGE Prevention of Diabetes‐Related Complications
EDARBI Prevention of Cardiovascular Disease
EDARBYCLOR Prevention of Cardiovascular Disease
EFFIENT Prevention of Cardiovascular Disease
ELEMENT COMPACT Prevention of Diabetes‐Related Complications
ELEMENT TEST STRIPS Prevention of Diabetes‐Related Complications
ELIQUIS Prevention of Cardiovascular Disease
elite ob dha Prevention of Prenatal Complications
elite‐ob 400 Prevention of Prenatal Complications
ELIXOPHYLLIN Prevention of Asthma‐Related Complications
EMBRACE Prevention of Diabetes‐Related Complications
EMBRACE EVO Prevention of Diabetes‐Related Complications
EMBRACE PRO Prevention of Diabetes‐Related Complications
enalapril maleate Prevention of Cardiovascular Disease
enalapril‐hydrochlorothiazide Prevention of Cardiovascular Disease
ENBRACE HR Prevention of Prenatal Complications
ENGERIX‐B ADULT Prevention of Infections
ENGERIX‐B PEDIATRIC‐ADOLESCENT Prevention of Infections
EPANED Prevention of Cardiovascular Disease
eplerenone Prevention of Cardiovascular Disease
eprosartan mesylate Prevention of Cardiovascular Disease
etidronate disodium Prevention of Osteoporosis
EVENCARE Prevention of Diabetes‐Related Complications
EVENCARE G2 Prevention of Diabetes‐Related Complications
EVENCARE G3 Prevention of Diabetes‐Related Complications
EVENCARE MINI GLUCOSE TEST STR Prevention of Diabetes‐Related Complications
EVISTA Prevention of Osteoporosis
EVOLUTION TEST STRIPS Prevention of Diabetes‐Related Complications
EXEL INSULIN SYRINGE Prevention of Diabetes‐Related Complications
EXFORGE Prevention of Cardiovascular Disease
EXFORGE HCT Prevention of Cardiovascular Disease
EXTRA‐VIRT PLUS DHA Prevention of Prenatal Complications
e‐z ject lancets Prevention of Diabetes‐Related Complications
EZ SMART Prevention of Diabetes‐Related Complications
EZ SMART LANCETS Prevention of Diabetes‐Related Complications
EZ SMART PLUS Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
ezetimibe Prevention of Cardiovascular Disease
ezetimibe‐simvastatin Prevention of Cardiovascular Disease
e‐zject lancets Prevention of Diabetes‐Related Complications
FARXIGA Prevention of Diabetes‐Related Complications
felodipine er Prevention of Cardiovascular Disease
fenofibrate Prevention of Cardiovascular Disease
fenofibric acid Prevention of Cardiovascular Disease
FENOGLIDE Prevention of Cardiovascular Disease
FIASP Prevention of Diabetes‐Related Complications
FIASP FLEXTOUCH Prevention of Diabetes‐Related Complications
FIBRICOR Prevention of Cardiovascular Disease
FIFTY50 SAFETY SEAL LANCETS Prevention of Diabetes‐Related Complications
FIFTY50 TEST STRIP Prevention of Diabetes‐Related Complications
FINE 30 UNIVERSAL LANCETS Prevention of Diabetes‐Related Complications
FINGERSTIX Prevention of Diabetes‐Related Complications
FLOLIPID Prevention of Cardiovascular Disease
FLOVENT DISKUS Prevention of Asthma‐Related Complications
FLOVENT HFA Prevention of Asthma‐Related Complications
FLUAD 2017‐2018 Prevention of Infections
FLUARIX QUAD 2017‐2018 Prevention of Infections
FLUBLOK 2017‐2018 Prevention of Infections
FLUBLOK QUAD 2017‐2018 Prevention of Infections
FLUCELVAX QUAD 2017‐2018 Prevention of Infections
FLULAVAL QUAD 2017‐2018 Prevention of Infections
FLUMADINE Prevention of Infections
fluor‐a‐day Prevention of Childhood Diseases
fluoride Prevention of Childhood Diseases
fluoritab Prevention of Childhood Diseases
FLUTICASONE‐SALMETEROL Prevention of Asthma‐Related Complications
fluvastatin er Prevention of Cardiovascular Disease
fluvastatin sodium Prevention of Cardiovascular Disease
FLUVIRIN 2017‐2018 Prevention of Infections
FLUZONE HIGH‐DOSE 2017‐2018 Prevention of Infections
FLUZONE INTRADERM QUAD 2017‐18 Prevention of Infections
FLUZONE QUAD 2017‐2018 Prevention of Infections
FLUZONE QUAD PEDI 2017‐2018 Prevention of Infections
focalgin 90 dha Prevention of Prenatal Complications
focalgin ca Prevention of Prenatal Complications
FOCALGIN‐B Prevention of Prenatal Complications
folbecal Prevention of Prenatal Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
FOLET DHA Prevention of Prenatal Complications
FOLET ONE Prevention of Prenatal Complications
folic acid Prevention of Prenatal Complications
folinatal plus b Prevention of Prenatal Complications
folivane‐ob Prevention of Prenatal Complications
folivane‐prx dha nf Prevention of Prenatal Complications
FORA D15G Prevention of Diabetes‐Related Complications
FORA D20 Prevention of Diabetes‐Related Complications
FORA D40‐G31 TEST STRIPS Prevention of Diabetes‐Related Complications
FORA G20 Prevention of Diabetes‐Related Complications
FORA G30A Prevention of Diabetes‐Related Complications
FORA GD50 TEST STRIPS Prevention of Diabetes‐Related Complications
FORA LANCETS Prevention of Diabetes‐Related Complications
FORA TEST N'GO TEST STRIPS Prevention of Diabetes‐Related Complications
FORA TEST STRIP Prevention of Diabetes‐Related Complications
FORA TN'G VOICE TEST STRIPS Prevention of Diabetes‐Related Complications
FORA V10 Prevention of Diabetes‐Related Complications
FORA V10‐V12‐D10‐D20 Prevention of Diabetes‐Related Complications
FORA V12 Prevention of Diabetes‐Related Complications
FORA V20 Prevention of Diabetes‐Related Complications
FORA V30A Prevention of Diabetes‐Related Complications
FORACARE GD20 Prevention of Diabetes‐Related Complications
FORACARE GD40 Prevention of Diabetes‐Related Complications
FORACARE LANCETS Prevention of Diabetes‐Related Complications
FORADIL Prevention of Asthma‐Related Complications
FORTAMET Prevention of Diabetes‐Related Complications
FORTEO Prevention of Osteoporosis
fortical Prevention of Osteoporosis
FORTISCARE GLUCOSE TEST STRIPS Prevention of Diabetes‐Related Complications
FOSAMAX Prevention of Osteoporosis
FOSAMAX PLUS D Prevention of Osteoporosis
fosinopril sodium Prevention of Cardiovascular Disease
fosinopril‐hydrochlorothiazide Prevention of Cardiovascular Disease
FREESTYLE INSULINX Prevention of Diabetes‐Related Complications
FREESTYLE INSULINX TEST STRIPS Prevention of Diabetes‐Related Complications
FREESTYLE LANCETS Prevention of Diabetes‐Related Complications
FREESTYLE LITE STRIPS Prevention of Diabetes‐Related Complications
FREESTYLE LITE TEST STRIPS Prevention of Diabetes‐Related Complications
FREESTYLE PRECISION Prevention of Diabetes‐Related Complications
FREESTYLE PRECISION NEO Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
FREESTYLE TEST STRIPS Prevention of Diabetes‐Related Complications
FREESTYLE UNISTIK 2 Prevention of Diabetes‐Related Complications
GARDASIL Prevention of Infections
GARDASIL 9 Prevention of Infections
GASTROCROM Prevention of Asthma‐Related Complications
GE100 BLOOD GLUCOSE TEST STRIP Prevention of Diabetes‐Related Complications
gemfibrozil Prevention of Cardiovascular Disease
GENSTRIP Prevention of Diabetes‐Related Complications
GESTICARE DHA Prevention of Prenatal Complications
glimepiride Prevention of Diabetes‐Related Complications
glipizide Prevention of Diabetes‐Related Complications
glipizide er Prevention of Diabetes‐Related Complications
glipizide xl Prevention of Diabetes‐Related Complications
glipizide‐metformin Prevention of Diabetes‐Related Complications
GLUCAGEN Prevention of Diabetes‐Related Complications
GLUCAGON EMERGENCY KIT Prevention of Diabetes‐Related Complications
GLUCO NAVII Prevention of Diabetes‐Related Complications
GLUCOCARD 01 SENSOR PLUS Prevention of Diabetes‐Related Complications
GLUCOCARD EXPRESSION Prevention of Diabetes‐Related Complications
GLUCOCARD SHINE Prevention of Diabetes‐Related Complications
GLUCOCARD VITAL Prevention of Diabetes‐Related Complications
GLUCOCARD VITAL SENSOR Prevention of Diabetes‐Related Complications
GLUCOCOM Prevention of Diabetes‐Related Complications
GLUCOCOM GLUCOSE Prevention of Diabetes‐Related Complications
GLUCOCOM LANCETS Prevention of Diabetes‐Related Complications
GLUCOPHAGE Prevention of Diabetes‐Related Complications
GLUCOPHAGE XR Prevention of Diabetes‐Related Complications
GLUCOSE TEST STRIP Prevention of Diabetes‐Related Complications
GLUCOSOURCE Prevention of Diabetes‐Related Complications
GLUCOTROL Prevention of Diabetes‐Related Complications
GLUCOTROL XL Prevention of Diabetes‐Related Complications
GLUCOVANCE Prevention of Diabetes‐Related Complications
GLUMETZA Prevention of Diabetes‐Related Complications
glyburide Prevention of Diabetes‐Related Complications
glyburide micronized Prevention of Diabetes‐Related Complications
glyburide‐metformin hcl Prevention of Diabetes‐Related Complications
GLYNASE Prevention of Diabetes‐Related Complications
GLYSET Prevention of Diabetes‐Related Complications
GLYXAMBI Prevention of Diabetes‐Related Complications
GMATE Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
GMATE TEST STRIPS Prevention of Diabetes‐Related Complications
GOCOVRI Prevention of Infections
guanfacine hcl Prevention of Cardiovascular Disease
HAVRIX Prevention of Infections
HEALTHPRO TEST STRIPS Prevention of Diabetes‐Related Complications
HEALTHY ACCENTS UNIFINE PENTIP Prevention of Diabetes‐Related Complications
HEALTHY ACCENTS UNILET LANCET Prevention of Diabetes‐Related Complications
HEMANGEOL Prevention of Cardiovascular Disease
hemenatal ob Prevention of Prenatal Complications
hemenatal ob + dha Prevention of Prenatal Complications
HIBERIX Prevention of Infections
HUMALOG Prevention of Diabetes‐Related Complications
HUMALOG JUNIOR KWIKPEN Prevention of Diabetes‐Related Complications
HUMALOG KWIKPEN U‐100 Prevention of Diabetes‐Related Complications
HUMALOG KWIKPEN U‐200 Prevention of Diabetes‐Related Complications
HUMALOG MIX 50‐50 Prevention of Diabetes‐Related Complications
HUMALOG MIX 50‐50 KWIKPEN Prevention of Diabetes‐Related Complications
HUMALOG MIX 75‐25 Prevention of Diabetes‐Related Complications
HUMALOG MIX 75‐25 KWIKPEN Prevention of Diabetes‐Related Complications
HUMULIN 70/30 KWIKPEN Prevention of Diabetes‐Related Complications
HUMULIN 70‐30 Prevention of Diabetes‐Related Complications
HUMULIN N Prevention of Diabetes‐Related Complications
HUMULIN N KWIKPEN Prevention of Diabetes‐Related Complications
HUMULIN R Prevention of Diabetes‐Related Complications
HUMULIN R U‐500 Prevention of Diabetes‐Related Complications
HUMULIN R U‐500 KWIKPEN Prevention of Diabetes‐Related Complications
hydrochlorothiazide Prevention of Cardiovascular Disease
HYZAAR Prevention of Cardiovascular Disease
ibandronate sodium Prevention of Osteoporosis
inatal advance Prevention of Prenatal Complications
inatal ultra Prevention of Prenatal Complications
INCONTROL PEN NEEDLE Prevention of Diabetes‐Related Complications
INCONTROL SUPER THIN LANCETS Prevention of Diabetes‐Related Complications
INCONTROL ULTRA THIN LANCETS Prevention of Diabetes‐Related Complications
INCRUSE ELLIPTA Prevention of Asthma‐Related Complications
indapamide Prevention of Cardiovascular Disease
INDERAL LA Prevention of Cardiovascular Disease
INDERAL XL Prevention of Cardiovascular Disease
INFANATE BALANCE Prevention of Prenatal Complications
infanate plus Prevention of Prenatal Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
INFANRIX DTAP Prevention of Infections
INFINITY TEST STRIPS Prevention of Diabetes‐Related Complications
INJECT EASE LANCETS Prevention of Diabetes‐Related Complications
INNOPRAN XL Prevention of Cardiovascular Disease
INSPRA Prevention of Cardiovascular Disease
INSULIN PEN NEEDLE Prevention of Diabetes‐Related Complications
INSULIN SYRINGE Prevention of Diabetes‐Related Complications
INSUPEN Prevention of Diabetes‐Related Complications
INTEGRA SYRINGE Prevention of Diabetes‐Related Complications
INVACARE LANCETS Prevention of Diabetes‐Related Complications
INVOKAMET Prevention of Diabetes‐Related Complications
INVOKAMET XR Prevention of Diabetes‐Related Complications
INVOKANA Prevention of Diabetes‐Related Complications
IPOL Prevention of Infections
ipratropium bromide Prevention of Asthma‐Related Complications
ipratropium‐albuterol Prevention of Asthma‐Related Complications
irbesartan Prevention of Cardiovascular Disease
irbesartan‐hydrochlorothiazide Prevention of Cardiovascular Disease
isradipine Prevention of Cardiovascular Disease
jantoven Prevention of Cardiovascular Disease
JANUMET Prevention of Diabetes‐Related Complications
JANUMET XR Prevention of Diabetes‐Related Complications
JANUVIA Prevention of Diabetes‐Related Complications
JARDIANCE Prevention of Diabetes‐Related Complications
JENTADUETO Prevention of Diabetes‐Related Complications
JENTADUETO XR Prevention of Diabetes‐Related Complications
KAZANO Prevention of Diabetes‐Related Complications
KETO‐DIASTIX REAGENT Prevention of Diabetes‐Related Complications
KETONE Prevention of Diabetes‐Related Complications
KETONE CARE Prevention of Diabetes‐Related Complications
KETOSTIX REAGENT Prevention of Diabetes‐Related Complications
KINNEY BRAND LANCETS Prevention of Diabetes‐Related Complications
KINRIX Prevention of Infections
KOMBIGLYZE XR Prevention of Diabetes‐Related Complications
KOSHER PRENATAL PLUS IRON Prevention of Prenatal Complications
kpn Prevention of Prenatal Complications
labetalol hcl Prevention of Cardiovascular Disease
LANCETS Prevention of Diabetes‐Related Complications
LANCETS THIN Prevention of Diabetes‐Related Complications
LANCETS ULTRA THIN Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
LANTUS Prevention of Diabetes‐Related Complications
LANTUS SOLOSTAR Prevention of Diabetes‐Related Complications
LESCOL Prevention of Cardiovascular Disease
LESCOL XL Prevention of Cardiovascular Disease
levalbuterol concentrate Prevention of Asthma‐Related Complications
levalbuterol hcl Prevention of Asthma‐Related Complications
LEVALBUTEROL TARTRATE HFA Prevention of Asthma‐Related Complications
LEVATOL Prevention of Cardiovascular Disease
LEVEMIR Prevention of Diabetes‐Related Complications
LEVEMIR FLEXPEN Prevention of Diabetes‐Related Complications
LEVEMIR FLEXTOUCH Prevention of Diabetes‐Related Complications
LIBERTY TEST STRIPS Prevention of Diabetes‐Related Complications
LIPITOR Prevention of Cardiovascular Disease
LIPOFEN Prevention of Cardiovascular Disease
LIPTRUZET Prevention of Cardiovascular Disease
lisinopril Prevention of Cardiovascular Disease
lisinopril‐hydrochlorothiazide Prevention of Cardiovascular Disease
LITE TOUCH Prevention of Diabetes‐Related Complications
LITETOUCH INSULIN SYRINGE Prevention of Diabetes‐Related Complications
LIVALO Prevention of Cardiovascular Disease
LOFIBRA Prevention of Cardiovascular Disease
LOPID Prevention of Cardiovascular Disease
LOPRESSOR Prevention of Cardiovascular Disease
LOPRESSOR HCT Prevention of Cardiovascular Disease
losartan potassium Prevention of Cardiovascular Disease
losartan‐hydrochlorothiazide Prevention of Cardiovascular Disease
LOTENSIN Prevention of Cardiovascular Disease
LOTENSIN HCT Prevention of Cardiovascular Disease
LOTREL Prevention of Cardiovascular Disease
lovastatin Prevention of Cardiovascular Disease
LOVAZA Prevention of Cardiovascular Disease
ludent fluoride Prevention of Childhood Diseases
LUER‐LOK SYRINGE Prevention of Diabetes‐Related Complications
LUFYLLIN Prevention of Asthma‐Related Complications
macnatal cn dha Prevention of Prenatal Complications
MAGELLAN INSULIN SAFETY SYRNG Prevention of Diabetes‐Related Complications
MAGELLAN INSULIN SYRINGE Prevention of Diabetes‐Related Complications
MALARONE Prevention of Malaria
MARNATAL‐F Prevention of Prenatal Complications
matzim la Prevention of Cardiovascular Disease
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
MAVIK Prevention of Cardiovascular Disease
MAXI‐COMFORT Prevention of Diabetes‐Related Complications
MAXINATE Prevention of Prenatal Complications
MAXZIDE Prevention of Cardiovascular Disease
MAXZIDE‐25 MG Prevention of Cardiovascular Disease
MEDI‐LANCE Prevention of Diabetes‐Related Complications
MEDISENSE THIN LANCETS Prevention of Diabetes‐Related Complications
medlance plus Prevention of Diabetes‐Related Complications
MEDLANCE PLUS SPECIAL BLADE Prevention of Diabetes‐Related Complications
mefloquine hcl Prevention of Malaria
MENACTRA Prevention of Infections
MENHIBRIX Prevention of Infections
MENOMUNE‐A‐C‐Y‐W‐135 Prevention of Infections
MENVEO A‐C‐Y‐W‐135‐DIP Prevention of Infections
metaproterenol sulfate Prevention of Asthma‐Related Complications
metformin hcl Prevention of Diabetes‐Related Complications
metformin hcl er Prevention of Diabetes‐Related Complications
methyclothiazide Prevention of Cardiovascular Disease
methyldopa Prevention of Cardiovascular Disease
methyldopa‐hydrochlorothiazide Prevention of Cardiovascular Disease
metolazone Prevention of Cardiovascular Disease
metoprolol succinate Prevention of Cardiovascular Disease
METOPROLOL SUCCINATE ER‐HCTZ Prevention of Cardiovascular Disease
metoprolol tartrate Prevention of Cardiovascular Disease
metoprolol‐hydrochlorothiazide Prevention of Cardiovascular Disease
MIACALCIN Prevention of Osteoporosis
MICARDIS Prevention of Cardiovascular Disease
MICARDIS HCT Prevention of Cardiovascular Disease
MICRO Prevention of Diabetes‐Related Complications
MICRO THIN LANCETS Prevention of Diabetes‐Related Complications
MICRODOT Prevention of Diabetes‐Related Complications
MICROLET Prevention of Diabetes‐Related Complications
MICROTAINER LANCETS Prevention of Diabetes‐Related Complications
MICROZIDE Prevention of Cardiovascular Disease
miglitol Prevention of Diabetes‐Related Complications
MINI ULTRA‐THIN II Prevention of Diabetes‐Related Complications
M‐M‐R II VACCINE Prevention of Infections
moexipril hcl Prevention of Cardiovascular Disease
moexipril‐hydrochlorothiazide Prevention of Cardiovascular Disease
MONOJECT Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
MONOJECT INSULIN SAFETY SYRNG Prevention of Diabetes‐Related Complications
MONOJECT INSULIN SYRINGE Prevention of Diabetes‐Related Complications
MONOLET LANCETS Prevention of Diabetes‐Related Complications
MONOLET THIN LANCETS Prevention of Diabetes‐Related Complications
montelukast sodium Prevention of Asthma‐Related Complications
multivitamin and fluoride Prevention of Childhood Diseases
multi‐vitamin w‐fluoride Prevention of Childhood Diseases
multivitamin with fluoride Prevention of Childhood Diseases
multi‐vitamin with fluoride Prevention of Childhood Diseases
multivitamins with fluoride Prevention of Childhood Diseases
mvc‐fluoride Prevention of Childhood Diseases
M‐VIT Prevention of Prenatal Complications
MYGLUCOHEALTH Prevention of Diabetes‐Related Complications
MYGLUCOHEALTH LANCETS Prevention of Diabetes‐Related Complications
mynatal Prevention of Prenatal Complications
mynatal advance Prevention of Prenatal Complications
mynatal plus Prevention of Prenatal Complications
mynatal‐z Prevention of Prenatal Complications
mynate 90 plus Prevention of Prenatal Complications
nadolol Prevention of Cardiovascular Disease
nadolol‐bendroflumethiazide Prevention of Cardiovascular Disease
NATACHEW Prevention of Prenatal Complications
natalvirt 90 dha Prevention of Prenatal Complications
natalvirt ca Prevention of Prenatal Complications
NATALVIT Prevention of Prenatal Complications
nateglinide Prevention of Diabetes‐Related Complications
NATELLE ONE Prevention of Prenatal Complications
NEEDLES Prevention of Diabetes‐Related Complications
NESINA Prevention of Diabetes‐Related Complications
NESTABS Prevention of Prenatal Complications
NESTABS ABC Prevention of Prenatal Complications
NESTABS DHA Prevention of Prenatal Complications
NESTABS ONE Prevention of Prenatal Complications
NEUTEK 2TEK TEST STRIPS Prevention of Diabetes‐Related Complications
newgen Prevention of Prenatal Complications
NEXA PLUS Prevention of Prenatal Complications
niacin er Prevention of Cardiovascular Disease
NIACOR Prevention of Cardiovascular Disease
NIASPAN Prevention of Cardiovascular Disease
nicardipine hcl Prevention of Cardiovascular Disease
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
nifedical xl Prevention of Cardiovascular Disease
nifedipine Prevention of Cardiovascular Disease
nifedipine er Prevention of Cardiovascular Disease
nisoldipine Prevention of Cardiovascular Disease
NORVASC Prevention of Cardiovascular Disease
NOVA MAX GLUCOSE TEST STRIPS Prevention of Diabetes‐Related Complications
NOVA SAFETY LANCETS Prevention of Diabetes‐Related Complications
NOVA SUREFLEX Prevention of Diabetes‐Related Complications
NOVAMAX PLUS Prevention of Diabetes‐Related Complications
NOVOFINE Prevention of Diabetes‐Related Complications
NOVOFINE 32 Prevention of Diabetes‐Related Complications
NOVOFINE AUTOCOVER Prevention of Diabetes‐Related Complications
NOVOFINE PLUS Prevention of Diabetes‐Related Complications
NOVOLIN 70‐30 Prevention of Diabetes‐Related Complications
NOVOLIN N Prevention of Diabetes‐Related Complications
NOVOLIN R Prevention of Diabetes‐Related Complications
NOVOLOG Prevention of Diabetes‐Related Complications
NOVOLOG FLEXPEN Prevention of Diabetes‐Related Complications
NOVOLOG MIX 70‐30 Prevention of Diabetes‐Related Complications
NOVOLOG MIX 70‐30 FLEXPEN Prevention of Diabetes‐Related Complications
NOVOTWIST Prevention of Diabetes‐Related Complications
OB COMPLETE Prevention of Prenatal Complications
OB COMPLETE 400 Prevention of Prenatal Complications
OB COMPLETE GOLD Prevention of Prenatal Complications
OB COMPLETE ONE Prevention of Prenatal Complications
OB COMPLETE PETITE Prevention of Prenatal Complications
OB COMPLETE PREMIER Prevention of Prenatal Complications
OB COMPLETE WITH DHA Prevention of Prenatal Complications
obstetrix dha Prevention of Prenatal Complications
OBSTETRIX EC Prevention of Prenatal Complications
OBSTETRIX ONE Prevention of Prenatal Complications
OBTREX Prevention of Prenatal Complications
OBTREX DHA Prevention of Prenatal Complications
O‐CAL FA Prevention of Prenatal Complications
O‐CAL PRENATAL Prevention of Prenatal Complications
olmesartan medoxomil Prevention of Cardiovascular Disease
olmesartan‐amlodipine‐hctz Prevention of Cardiovascular Disease
olmesartan‐hydrochlorothiazide Prevention of Cardiovascular Disease
omega‐3 acid ethyl esters Prevention of Cardiovascular Disease
ON CALL EXPRESS TEST STRIP Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
ON CALL LANCET Prevention of Diabetes‐Related Complications
ON CALL PLUS LANCET Prevention of Diabetes‐Related Complications
ON CALL PLUS TEST STRIP Prevention of Diabetes‐Related Complications
ON CALL VIVID TEST STRIP Prevention of Diabetes‐Related Complications
one daily prenatal Prevention of Prenatal Complications
ONETOUCH DELICA Prevention of Diabetes‐Related Complications
ONETOUCH FINEPOINT LANCETS Prevention of Diabetes‐Related Complications
ONETOUCH LANCETS Prevention of Diabetes‐Related Complications
ONETOUCH SURESOFT Prevention of Diabetes‐Related Complications
ONETOUCH ULTRA TEST STRIPS Prevention of Diabetes‐Related Complications
ONETOUCH VERIO Prevention of Diabetes‐Related Complications
ONGLYZA Prevention of Diabetes‐Related Complications
ON‐THE‐GO Prevention of Diabetes‐Related Complications
OPTIUM Prevention of Diabetes‐Related Complications
OPTIUM EZ Prevention of Diabetes‐Related Complications
OPTUMRX Prevention of Diabetes‐Related Complications
OSENI Prevention of Diabetes‐Related Complications
PAIRE OB PLUS DHA Prevention of Prenatal Complications
PEDIARIX Prevention of Infections
PEDVAXHIB Prevention of Infections
PEN NEEDLE Prevention of Diabetes‐Related Complications
PEN NEEDLES Prevention of Diabetes‐Related Complications
PENTACEL Prevention of Infections
PENTACEL ACTHIB COMPONENT Prevention of Infections
PENTIPS Prevention of Diabetes‐Related Complications
PERFOROMIST Prevention of Asthma‐Related Complications
perindopril erbumine Prevention of Cardiovascular Disease
perry prenatal Prevention of Prenatal Complications
PERSANTINE Prevention of Cardiovascular Disease
PHARMACIST CHOICE Prevention of Diabetes‐Related Complications
pindolol Prevention of Cardiovascular Disease
pioglitazone hcl Prevention of Diabetes‐Related Complications
pioglitazone‐glimepiride Prevention of Diabetes‐Related Complications
pioglitazone‐metformin Prevention of Diabetes‐Related Complications
PLAVIX Prevention of Cardiovascular Disease
PNEUMOVAX 23 Prevention of Infections
pnv 29‐1 Prevention of Prenatal Complications
PNV FOLIC ACID + IRON Prevention of Prenatal Complications
pnv‐dha Prevention of Prenatal Complications
pnv‐dha + docusate Prevention of Prenatal Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
pnv‐ferrous fumarate‐docu‐fa Prevention of Prenatal Complications
pnv‐omega Prevention of Prenatal Complications
pnv‐select Prevention of Prenatal Complications
pnv‐total Prevention of Prenatal Complications
pnv‐vp‐u Prevention of Prenatal Complications
pr natal 400 Prevention of Prenatal Complications
pr natal 400 ec Prevention of Prenatal Complications
pr natal 430 Prevention of Prenatal Complications
pr natal 430 ec Prevention of Prenatal Complications
PRADAXA Prevention of Cardiovascular Disease
PRANDIMET Prevention of Diabetes‐Related Complications
PRANDIN Prevention of Diabetes‐Related Complications
prasugrel hcl Prevention of Cardiovascular Disease
PRAVACHOL Prevention of Cardiovascular Disease
pravastatin sodium Prevention of Cardiovascular Disease
PRECISION PCX Prevention of Diabetes‐Related Complications
PRECISION PCX PLUS Prevention of Diabetes‐Related Complications
PRECISION POINT OF CARE Prevention of Diabetes‐Related Complications
PRECISION Q‐I‐D Prevention of Diabetes‐Related Complications
PRECISION XTRA Prevention of Diabetes‐Related Complications
PRECOSE Prevention of Diabetes‐Related Complications
PREFERA OB Prevention of Prenatal Complications
PREFERA‐OB ONE Prevention of Prenatal Complications
PREFERA‐OB PLUS DHA Prevention of Prenatal Complications
prefol‐dha Prevention of Prenatal Complications
PREMIUM BLOOD GLUCOSE TEST Prevention of Diabetes‐Related Complications
PREMIUM V10 Prevention of Diabetes‐Related Complications
prena1 Prevention of Prenatal Complications
prena1 chew Prevention of Prenatal Complications
prena1 pearl Prevention of Prenatal Complications
prena1 plus Prevention of Prenatal Complications
prena1 true Prevention of Prenatal Complications
prenaissance Prevention of Prenatal Complications
prenaissance 90 dha Prevention of Prenatal Complications
prenaissance balance Prevention of Prenatal Complications
prenaissance dha Prevention of Prenatal Complications
prenaissance next Prevention of Prenatal Complications
PRENAISSANCE NEXT‐B Prevention of Prenatal Complications
prenaissance plus Prevention of Prenatal Complications
prenaissance promise Prevention of Prenatal Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
prenaplus Prevention of Prenatal Complications
PRENATA Prevention of Prenatal Complications
prenatabs fa Prevention of Prenatal Complications
prenatabs rx Prevention of Prenatal Complications
prenatal Prevention of Prenatal Complications
PRENATAL 19 Prevention of Prenatal Complications
prenatal ad Prevention of Prenatal Complications
prenatal complete Prevention of Prenatal Complications
prenatal formula Prevention of Prenatal Complications
prenatal low iron Prevention of Prenatal Complications
prenatal multi‐dha Prevention of Prenatal Complications
prenatal multivitamin Prevention of Prenatal Complications
prenatal multivitamins Prevention of Prenatal Complications
prenatal one daily Prevention of Prenatal Complications
prenatal plus Prevention of Prenatal Complications
PRENATAL PLUS‐DHA Prevention of Prenatal Complications
prenatal vitamin Prevention of Prenatal Complications
prenatal vitamin plus low iron Prevention of Prenatal Complications
prenatal vitamins Prevention of Prenatal Complications
prenatal‐u Prevention of Prenatal Complications
PRENATE AM Prevention of Prenatal Complications
PRENATE CHEWABLE Prevention of Prenatal Complications
PRENATE DHA Prevention of Prenatal Complications
PRENATE ELITE Prevention of Prenatal Complications
PRENATE ENHANCE Prevention of Prenatal Complications
PRENATE ESSENTIAL Prevention of Prenatal Complications
PRENATE MINI Prevention of Prenatal Complications
PRENATE PIXIE Prevention of Prenatal Complications
PRENATE RESTORE Prevention of Prenatal Complications
PRENATE STAR Prevention of Prenatal Complications
preplus Prevention of Prenatal Complications
PREQUE 10 Prevention of Prenatal Complications
PRESSURE ACTIVATED LANCETS Prevention of Diabetes‐Related Complications
PRESTALIA Prevention of Cardiovascular Disease
pretab Prevention of Prenatal Complications
prevalite Prevention of Cardiovascular Disease
PREVNAR 13 Prevention of Infections
PRIMACARE Prevention of Prenatal Complications
PRIMAQUINE Prevention of Malaria
PRINIVIL Prevention of Cardiovascular Disease
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
PRO COMFORT LANCET Prevention of Diabetes‐Related Complications
PRO COMFORT LANCETS Prevention of Diabetes‐Related Complications
PRO COMFORT PEN NEEDLE Prevention of Diabetes‐Related Complications
PROAIR HFA Prevention of Asthma‐Related Complications
PROAIR RESPICLICK Prevention of Asthma‐Related Complications
PROCARDIA Prevention of Cardiovascular Disease
PROCARDIA XL Prevention of Cardiovascular Disease
PRODIGY INSULIN SYRINGE Prevention of Diabetes‐Related Complications
PRODIGY LANCETS Prevention of Diabetes‐Related Complications
PRODIGY NO CODING Prevention of Diabetes‐Related Complications
PRODIGY TWIST TOP LANCET Prevention of Diabetes‐Related Complications
PROGLYCEM Prevention of Diabetes‐Related Complications
propranolol hcl Prevention of Cardiovascular Disease
propranolol hcl er Prevention of Cardiovascular Disease
propranolol‐hydrochlorothiazide Prevention of Cardiovascular Disease
PROQUAD Prevention of Infections
PROVENTIL HFA Prevention of Asthma‐Related Complications
PROVIDA DHA Prevention of Prenatal Complications
PROVIDA OB Prevention of Prenatal Complications
PULMICORT Prevention of Asthma‐Related Complications
PULMICORT FLEXHALER Prevention of Asthma‐Related Complications
PUREFE OB PLUS Prevention of Prenatal Complications
PUREFE PLUS Prevention of Prenatal Complications
QBRELIS Prevention of Cardiovascular Disease
QUADRACEL DTAP‐IPV Prevention of Infections
QUESTRAN Prevention of Cardiovascular Disease
quinapril hcl Prevention of Cardiovascular Disease
quinapril‐hydrochlorothiazide Prevention of Cardiovascular Disease
QUINTET AC Prevention of Diabetes‐Related Complications
QVAR Prevention of Asthma‐Related Complications
raloxifene hcl Prevention of Osteoporosis
ramipril Prevention of Cardiovascular Disease
READYLANCE SAFETY LANCETS Prevention of Diabetes‐Related Complications
RECOMBIVAX HB Prevention of Infections
REFUAH PLUS Prevention of Diabetes‐Related Complications
RELIAMED Prevention of Diabetes‐Related Complications
RELIAMED SAFETY SEAL LANCETS Prevention of Diabetes‐Related Complications
RELION CONFIRM‐MICRO Prevention of Diabetes‐Related Complications
RELION PEN NEEDLES Prevention of Diabetes‐Related Complications
RELION PRIME TEST STRIPS Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
RELION THIN Prevention of Diabetes‐Related Complications
relnate dha Prevention of Prenatal Complications
repaglinide Prevention of Diabetes‐Related Complications
repaglinide‐metformin hcl Prevention of Diabetes‐Related Complications
reserpine Prevention of Cardiovascular Disease
REVEAL TEST STRIP Prevention of Diabetes‐Related Complications
RIGHTEST GL300 LANCETS Prevention of Diabetes‐Related Complications
RIGHTEST GS100 TEST STRIPS Prevention of Diabetes‐Related Complications
RIGHTEST GS300 TEST STRIPS Prevention of Diabetes‐Related Complications
RIGHTEST GS550 TEST STRIPS Prevention of Diabetes‐Related Complications
rimantadine hcl Prevention of Infections
RIOMET Prevention of Diabetes‐Related Complications
risedronate sodium Prevention of Osteoporosis
risedronate sodium dr Prevention of Osteoporosis
R‐NATAL OB Prevention of Prenatal Complications
rosuvastatin calcium Prevention of Cardiovascular Disease
ROTARIX Prevention of Infections
ROTATEQ Prevention of Infections
rulavite dha Prevention of Prenatal Complications
SAFESNAP INSULIN SYRINGE Prevention of Diabetes‐Related Complications
SAFETY LANCETS Prevention of Diabetes‐Related Complications
SAFETY SEAL LANCETS Prevention of Diabetes‐Related Complications
SAFETYGLIDE INSULIN SYRINGE Prevention of Diabetes‐Related Complications
SAFETYGLIDE SYRINGE Prevention of Diabetes‐Related Complications
SAFETY‐LET Prevention of Diabetes‐Related Complications
SAVAYSA Prevention of Cardiovascular Disease
SECTRAL Prevention of Cardiovascular Disease
SEEBRI NEOHALER Prevention of Asthma‐Related Complications
SELECT‐OB Prevention of Prenatal Complications
SELECT‐OB + DHA Prevention of Prenatal Complications
se‐natal 19 Prevention of Prenatal Complications
SEREVENT DISKUS Prevention of Asthma‐Related Complications
se‐tan dha Prevention of Prenatal Complications
simvastatin Prevention of Cardiovascular Disease
SINGLE‐LET Prevention of Diabetes‐Related Complications
SINGULAIR Prevention of Asthma‐Related Complications
SMART SENSE Prevention of Diabetes‐Related Complications
SMART SENSE LANCETS Prevention of Diabetes‐Related Complications
SMART SENSE TEST STRIPS Prevention of Diabetes‐Related Complications
SMARTDIABETES VANTAGE Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
SMARTDIABETES XPRES Prevention of Diabetes‐Related Complications
SMARTEST LANCET Prevention of Diabetes‐Related Complications
SMARTEST TEST Prevention of Diabetes‐Related Complications
sodium fluoride Prevention of Childhood Diseases
SOFT TOUCH Prevention of Diabetes‐Related Complications
SOLIQUA 100‐33 Prevention of Diabetes‐Related Complications
SOLUS V2 Prevention of Diabetes‐Related Complications
SOLUS V2 LANCETS Prevention of Diabetes‐Related Complications
SOLUS V2 TEST STRIPS Prevention of Diabetes‐Related Complications
SPIRIVA Prevention of Asthma‐Related Complications
SPIRIVA RESPIMAT Prevention of Asthma‐Related Complications
spironolactone Prevention of Cardiovascular Disease
spironolactone‐hctz Prevention of Cardiovascular Disease
STARLIX Prevention of Diabetes‐Related Complications
STERILANCE TL Prevention of Diabetes‐Related Complications
STIOLTO RESPIMAT Prevention of Asthma‐Related Complications
STRIVERDI RESPIMAT Prevention of Asthma‐Related Complications
SULAR Prevention of Cardiovascular Disease
SUPER THIN LANCETS Prevention of Diabetes‐Related Complications
SURE COMFORT Prevention of Diabetes‐Related Complications
SURE COMFORT INSULIN SYRINGE Prevention of Diabetes‐Related Complications
SURE COMFORT LANCETS Prevention of Diabetes‐Related Complications
SURE EDGE TEST STRIPS Prevention of Diabetes‐Related Complications
SURECHEK TEST STRIPS Prevention of Diabetes‐Related Complications
SURE‐FINE PEN NEEDLES Prevention of Diabetes‐Related Complications
SURE‐JECT INSULIN SYRINGE Prevention of Diabetes‐Related Complications
SURE‐LANCE Prevention of Diabetes‐Related Complications
SURE‐TEST EASYPLUS MINI Prevention of Diabetes‐Related Complications
SURE‐TOUCH Prevention of Diabetes‐Related Complications
SYMBICORT Prevention of Asthma‐Related Complications
SYMLINPEN 120 Prevention of Diabetes‐Related Complications
SYMLINPEN 60 Prevention of Diabetes‐Related Complications
SYNJARDY Prevention of Diabetes‐Related Complications
SYNJARDY XR Prevention of Diabetes‐Related Complications
TANZEUM Prevention of Diabetes‐Related Complications
TARKA Prevention of Cardiovascular Disease
taron‐bc Prevention of Prenatal Complications
taron‐c dha Prevention of Prenatal Complications
taron‐prex prenatal Prevention of Prenatal Complications
taztia xt Prevention of Cardiovascular Disease
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
TECHLITE LANCETS Prevention of Diabetes‐Related Complications
TECHLITE PEN NEEDLE Prevention of Diabetes‐Related Complications
TEKAMLO Prevention of Cardiovascular Disease
TEKTURNA Prevention of Cardiovascular Disease
TEKTURNA HCT Prevention of Cardiovascular Disease
TELCARE Prevention of Diabetes‐Related Complications
telmisartan Prevention of Cardiovascular Disease
telmisartan‐amlodipine Prevention of Cardiovascular Disease
telmisartan‐hydrochlorothiazide Prevention of Cardiovascular Disease
TENEX Prevention of Cardiovascular Disease
TENIVAC Prevention of Infections
TENORETIC 100 Prevention of Cardiovascular Disease
TENORETIC 50 Prevention of Cardiovascular Disease
TENORMIN Prevention of Cardiovascular Disease
terbutaline sulfate Prevention of Asthma‐Related Complications
TERUMO INSULIN SYRINGE Prevention of Diabetes‐Related Complications
TEST N'GO Prevention of Diabetes‐Related Complications
TEST STRIPS Prevention of Diabetes‐Related Complications
TETANUS DIPHTHERIA TOXOIDS Prevention of Infections
tetanus toxoid adsorbed Prevention of Infections
TEVETEN Prevention of Cardiovascular Disease
TEVETEN HCT Prevention of Cardiovascular Disease
THEO‐24 Prevention of Asthma‐Related Complications
theochron Prevention of Asthma‐Related Complications
theophylline Prevention of Asthma‐Related Complications
theophylline anhydrous Prevention of Asthma‐Related Complications
THIN LANCETS Prevention of Diabetes‐Related Complications
THINPRO INSULIN SYRINGE Prevention of Diabetes‐Related Complications
thrivite 19 Prevention of Prenatal Complications
THRIVITE RX Prevention of Prenatal Complications
TIAZAC Prevention of Cardiovascular Disease
ticlopidine hcl Prevention of Cardiovascular Disease
timolol maleate Prevention of Cardiovascular Disease
TL FOLATE Prevention of Prenatal Complications
tl‐care dha Prevention of Prenatal Complications
tl‐select Prevention of Prenatal Complications
TL‐SELECT DHA Prevention of Prenatal Complications
tolazamide Prevention of Diabetes‐Related Complications
tolbutamide Prevention of Diabetes‐Related Complications
TOPCARE CLICKFINE Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
TOPCARE ULTRA COMFORT Prevention of Diabetes‐Related Complications
TOPCARE UNIVERSAL1 LANCET Prevention of Diabetes‐Related Complications
TOPCARE UNIVERSAL1 THIN LANCET Prevention of Diabetes‐Related Complications
TOPROL XL Prevention of Cardiovascular Disease
TOUJEO SOLOSTAR Prevention of Diabetes‐Related Complications
TRADJENTA Prevention of Diabetes‐Related Complications
TRANDATE Prevention of Cardiovascular Disease
trandolapril Prevention of Cardiovascular Disease
trandolapril‐verapamil er Prevention of Cardiovascular Disease
TRELEGY ELLIPTA Prevention of Asthma‐Related Complications
TRESIBA FLEXTOUCH U‐100 Prevention of Diabetes‐Related Complications
TRESIBA FLEXTOUCH U‐200 Prevention of Diabetes‐Related Complications
triadvance Prevention of Prenatal Complications
triamterene‐hctz Prevention of Cardiovascular Disease
triamterene‐hydrochlorothiazide Prevention of Cardiovascular Disease
TRIBENZOR Prevention of Cardiovascular Disease
TRICARE Prevention of Prenatal Complications
TRICARE PRENATAL Prevention of Prenatal Complications
TRICARE PRENATAL COMPLEAT Prevention of Prenatal Complications
TRICARE PRENATAL DHA ONE Prevention of Prenatal Complications
TRICARE PRENATAL WITH DHA Prevention of Prenatal Complications
TRICOR Prevention of Cardiovascular Disease
TRIGLIDE Prevention of Cardiovascular Disease
triklo Prevention of Cardiovascular Disease
TRILIPIX Prevention of Cardiovascular Disease
trinatal gt Prevention of Prenatal Complications
trinatal rx 1 Prevention of Prenatal Complications
trinate Prevention of Prenatal Complications
triple‐vitamin w‐fluoride Prevention of Childhood Diseases
TRISTART DHA Prevention of Prenatal Complications
tri‐tabs dha Prevention of Prenatal Complications
triveen‐duo dha Prevention of Prenatal Complications
triveen‐one Prevention of Prenatal Complications
triveen‐prx rnf Prevention of Prenatal Complications
tri‐vitamin with fluoride Prevention of Childhood Diseases
TRUE METRIX GLUCOSE TEST STRIP Prevention of Diabetes‐Related Complications
TRUEPLUS INSULIN SYRINGE Prevention of Diabetes‐Related Complications
TRUEPLUS KETONE TEST STRIPS Prevention of Diabetes‐Related Complications
TRUEPLUS LANCETS Prevention of Diabetes‐Related Complications
TRUEPLUS PEN NEEDLE Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
TRUETEST TEST STRIPS Prevention of Diabetes‐Related Complications
TRUETRACK SMART SYSTEM Prevention of Diabetes‐Related Complications
TRUETRACK TEST STRIP Prevention of Diabetes‐Related Complications
TRULICITY Prevention of Diabetes‐Related Complications
TRUMENBA Prevention of Infections
trust natal dha Prevention of Prenatal Complications
TUDORZA PRESSAIR Prevention of Asthma‐Related Complications
TWINRIX Prevention of Infections
TWYNSTA Prevention of Cardiovascular Disease
ULTICARE Prevention of Diabetes‐Related Complications
ULTICARE INSULIN SYRINGE Prevention of Diabetes‐Related Complications
ULTICARE PEN NEEDLE Prevention of Diabetes‐Related Complications
ULTILET BASIC Prevention of Diabetes‐Related Complications
ULTILET CLASSIC Prevention of Diabetes‐Related Complications
ULTILET INSULIN SYRINGE Prevention of Diabetes‐Related Complications
ULTILET LANCETS Prevention of Diabetes‐Related Complications
ULTILET PEN NEEDLE Prevention of Diabetes‐Related Complications
ULTILET SAFETY Prevention of Diabetes‐Related Complications
ULTIMA Prevention of Diabetes‐Related Complications
ultimatecare one Prevention of Prenatal Complications
ultimatecare one nf Prevention of Prenatal Complications
ULTRA COMFORT Prevention of Diabetes‐Related Complications
ULTRA THIN LANCETS Prevention of Diabetes‐Related Complications
ULTRA THIN PLUS Prevention of Diabetes‐Related Complications
ULTRA THIN PLUS LANCETS Prevention of Diabetes‐Related Complications
ULTRALANCE Prevention of Diabetes‐Related Complications
ULTRA‐THIN II Prevention of Diabetes‐Related Complications
ULTRATLC LANCETS Prevention of Diabetes‐Related Complications
ULTRATRAK Prevention of Diabetes‐Related Complications
ULTRATRAK ULTIMATE Prevention of Diabetes‐Related Complications
UNIFINE PENTIPS Prevention of Diabetes‐Related Complications
UNIFINE PENTIPS PLUS Prevention of Diabetes‐Related Complications
UNILET COMFORTOUCH Prevention of Diabetes‐Related Complications
UNILET EXCELITE Prevention of Diabetes‐Related Complications
UNILET EXCELITE II Prevention of Diabetes‐Related Complications
UNILET GP LANCET Prevention of Diabetes‐Related Complications
UNILET LANCETS Prevention of Diabetes‐Related Complications
UNIRETIC Prevention of Cardiovascular Disease
UNISTIK 3 Prevention of Diabetes‐Related Complications
UNISTIK 3 EXTRA Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
UNISTIK CZT Prevention of Diabetes‐Related Complications
UNISTIK SAFETY Prevention of Diabetes‐Related Complications
UNISTIK TOUCH Prevention of Diabetes‐Related Complications
UNISTRIP1 Prevention of Diabetes‐Related Complications
UNIVASC Prevention of Cardiovascular Disease
UNIVERSAL 1 Prevention of Diabetes‐Related Complications
UTIBRON NEOHALER Prevention of Asthma‐Related Complications
valsartan Prevention of Cardiovascular Disease
valsartan‐hydrochlorothiazide Prevention of Cardiovascular Disease
VANISHPOINT Prevention of Diabetes‐Related Complications
VAQTA Prevention of Infections
VARIVAX VACCINE Prevention of Infections
VASERETIC Prevention of Cardiovascular Disease
VASOTEC Prevention of Cardiovascular Disease
vemavite‐prx 2 Prevention of Prenatal Complications
vena‐bal dha Prevention of Prenatal Complications
venatal‐fa Prevention of Prenatal Complications
VENTOLIN HFA Prevention of Asthma‐Related Complications
verapamil er Prevention of Cardiovascular Disease
verapamil er pm Prevention of Cardiovascular Disease
verapamil hcl Prevention of Cardiovascular Disease
verapamil sr Prevention of Cardiovascular Disease
VERELAN Prevention of Cardiovascular Disease
VERELAN PM Prevention of Cardiovascular Disease
VICTORY Prevention of Diabetes‐Related Complications
VICTOZA 2‐PAK Prevention of Diabetes‐Related Complications
VICTOZA 3‐PAK Prevention of Diabetes‐Related Complications
vinate care Prevention of Prenatal Complications
vinate ii Prevention of Prenatal Complications
vinate one Prevention of Prenatal Complications
vinate‐m Prevention of Prenatal Complications
virt nate Prevention of Prenatal Complications
virt‐advance Prevention of Prenatal Complications
virt‐bal dha Prevention of Prenatal Complications
virt‐bal dha plus Prevention of Prenatal Complications
virt‐c dha Prevention of Prenatal Complications
virt‐care one Prevention of Prenatal Complications
virt‐nate Prevention of Prenatal Complications
virt‐nate dha Prevention of Prenatal Complications
virt‐pn Prevention of Prenatal Complications
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
DRUG NAME DRUG CLASSIFICATION
virt‐pn dha Prevention of Prenatal Complications
virt‐pn plus Prevention of Prenatal Complications
virt‐select Prevention of Prenatal Complications
virt‐vite gt Prevention of Prenatal Complications
VITAFOL GUMMIES Prevention of Prenatal Complications
VITAFOL NANO Prevention of Prenatal Complications
VITAFOL ULTRA Prevention of Prenatal Complications
VITAFOL‐OB Prevention of Prenatal Complications
VITAFOL‐OB+DHA Prevention of Prenatal Complications
VITAFOL‐ONE Prevention of Prenatal Complications
VITAMEDMD ONE RX Prevention of Prenatal Complications
VITAMEDMD PLUS RX Prevention of Prenatal Complications
VITAMEDMD REDICHEW RX Prevention of Prenatal Complications
vitamins a,c,d and fluoride Prevention of Childhood Diseases
VITAPEARL Prevention of Prenatal Complications
VITATRUE Prevention of Prenatal Complications
VOCAL POINT Prevention of Diabetes‐Related Complications
vol‐nate Prevention of Prenatal Complications
vol‐plus Prevention of Prenatal Complications
vol‐tab rx Prevention of Prenatal Complications
VOSPIRE ER Prevention of Asthma‐Related Complications
VP CH ULTRA Prevention of Prenatal Complications
vp‐ch plus Prevention of Prenatal Complications
vp‐ch‐pnv Prevention of Prenatal Complications
vp‐era ob plus Prevention of Prenatal Complications
vp‐ggr‐b6 Prevention of Prenatal Complications
vp‐heme ob Prevention of Prenatal Complications
vp‐heme one Prevention of Prenatal Complications
VP‐PNV‐DHA Prevention of Prenatal Complications
VYTORIN Prevention of Cardiovascular Disease
warfarin sodium Prevention of Cardiovascular Disease
WAVESENSE JAZZ Prevention of Diabetes‐Related Complications
WAVESENSE PRESTO Prevention of Diabetes‐Related Complications
WELCHOL Prevention of Cardiovascular Disease
XARELTO Prevention of Cardiovascular Disease
XIGDUO XR Prevention of Diabetes‐Related Complications
XOPENEX Prevention of Asthma‐Related Complications
XOPENEX CONCENTRATE Prevention of Asthma‐Related Complications
XOPENEX HFA Prevention of Asthma‐Related Complications
XULTOPHY 100‐3.6 Prevention of Diabetes‐Related Complications
Key: BRAND medications are listed in UPPER CASE and generics in lower case.
04HQ1393 R011/17 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and is incorporated as Louisiana Health Service & Indemnity Company.
OGB Pelican HSA 775 CDHP Maintenance/Preventive Care Drug List
DRUG NAME DRUG CLASSIFICATION
zafirlukast Prevention of Asthma‐Related Complications
ZAROXOLYN Prevention of Cardiovascular Disease
zatean‐ch Prevention of Prenatal Complications
zatean‐pn Prevention of Prenatal Complications
zatean‐pn dha Prevention of Prenatal Complications
zatean‐pn plus Prevention of Prenatal Complications
ZEBETA Prevention of Cardiovascular Disease
ZESTORETIC Prevention of Cardiovascular Disease
ZESTRIL Prevention of Cardiovascular Disease
ZETIA Prevention of Cardiovascular Disease
ZIAC Prevention of Cardiovascular Disease
zileuton er Prevention of Asthma‐Related Complications
zingiber Prevention of Prenatal Complications
ZOCOR Prevention of Cardiovascular Disease
ZOSTAVAX Prevention of Infections
ZYFLO Prevention of Asthma‐Related Complications
ZYFLO CR Prevention of Asthma‐Related Complications