CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

HSA Preventive Drug List

Lists prescription drugs that may be covered as preventive medications under certain HSA-qualified and high-deductible health plans administered by Blue Cross Blue Shield - North Carolina; applies to members whose employer/group or individual-under-65 plans include this HSA Preventive Drug coverage feature.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyHSA Preventive Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionVerify with the member's plan whether a generic must be tried before dispensing a brand and check benefit materials or the plan website for coverage details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCapplicable state

2024-01-01effective date shown

3therapeutic categories shown

~100+medications listed

20+broad categories

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

General coverage guidance

Covered when ALL of the following are met:

The drug appears on the HSA Preventive Drug List administered by Blue Cross Blue Shield - North Carolina.

The member's specific plan includes the HSA Preventive Drug coverage feature or equivalent preventive benefit for HSA‑qualified/high‑deductible plans.

Benefits are applied in accordance with U.S. Department of the Treasury and IRS guidance for HSAs and qualified HDHPs.

Verify benefit and any utilization conditions (for example, whether a generic must be tried before a brand) with the member's plan; refer to plan benefit materials and the plan website for current coverage details.

Deductible exception for listed drugs

Applicable deductible treatment when the plan includes the HSA Preventive Drug feature:

Medications on this HSA Preventive Drug List may be applied toward the preventive benefit and covered even if the member has not met their deductible, when the member's plan includes this feature.

Coverage and application prior to meeting the deductible will be provided in accordance with Treasury and IRS guidance for HSAs and qualified HDHPs.

Formulary lists

The following formulary-style lists identify drugs designated for HSA preventive coverage when the member's plan includes the feature. No additional utilization management criteria are specified in this excerpt.

Lipid medications: See lipid-lowering agents list (e.g., cholestyramine; colesevelam; colestipol; ezetimibe; ezetimibe-simvastatin; fenofibrate formulations; gemfibrozil; icosapent ethyl; lovastatin; niacin ER; pravastatin; rosuvastatin; simvastatin; VASCEPA icosapent ethyl).

Osteoporosis medications: See osteoporosis agents list (e.g., alendronate 10 mg/35 mg/70 mg; calcitonin (salmon) nasal; ibandronate 150 mg; raloxifene 60 mg; risedronate formulations including immediate- and delayed-release).

Respiratory medications: See respiratory agents list (extensive list including inhaled bronchodilators, inhaled corticosteroids, combination inhalers, leukotriene modifiers, theophyllines, inhaled antimuscarinics, phosphodiesterase inhibitors, and others such as ADVAIR HFA, albuterol formulations, BREO ELLIPTA, DULERA, FLUTICASONE/SALMETEROL products, SPIRIVA, SYMBICORT, TRELEGY ELLIPTA, etc.).

Coding and Drug Lists

Drug list (no CPT/HCPCS/ICD codes included)mixed

List contains drug names and strengths (no billing or procedure codes provided in this document segment).

Lipid medicationsmixedCovered

cholestyramine powder 4 gm/dose	(Questran)
colesevelam hcl packet for susp 3.75 gm	(Welchol)
colesevelam hcl tab 625 mg	(Welchol)
colestipol hcl granules 5 gm	(Colestid flavored)
colestipol hcl granule packets 5 gm	(Colestid flavored)
colestipol hcl tab 1 gm	(Colestid)
ezetimibe tab 10 mg	(Zetia)
ezetimibe-simvastatin tab 10-10 mg	(Vytorin)
ezetimibe-simvastatin tab 10-20 mg	(Vytorin)
ezetimibe-simvastatin tab 10-40 mg	(Vytorin)

1–10 of 41

1/5

Osteoporosis medicationsmixedCovered

alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
alendronate sodium tab 70 mg	(Fosamax)
calcitonin (salmon) nasal soln 200 unit/act
ibandronate sodium tab 150 mg	(base equivalent)
raloxifene hcl tab 60 mg	(Evista)
risedronate sodium tab 5 mg
risedronate sodium tab 30 mg
risedronate sodium tab 35 mg	(Actonel)
risedronate sodium tab 150 mg	(Actonel)

1–10 of 11

1/2

inv-08: Plan-level deductible exception

Policy summaryMedications on this HSA Preventive Drug List may be applied toward the preventive benefit and covered even if the member has not met their deductible when the member's plan includes the HSA Preventive Drug coverage feature.

ApplicabilitySome employer/group plans and all Individual-Under 65 plans may include this feature; check the member's plan documents for eligibility and applicability.

AuthorityBenefits are provided in accordance with U.S. Department of the Treasury and IRS guidance for HSAs and qualified HDHPs.

Member instructionsVerify with your plan whether a generic must be tried before filling a brand and refer to benefit materials and the plan website for current coverage details.

Provider Actions and Guidance

Prior Authorization

Benefit verification / formulary guidance

Verify plan-level coverage and formulary rules before prescribing or dispensing. The policy instructs providers to "please verify with your plan if a generic drug must be tried before filling a brand version of a drug" and to refer to the member's benefit materials and the plan website for current coverage details. Also note that listed drugs "may be applied toward the preventive benefit and covered even if the member has not met their deductible" when the member's plan includes the HSA Preventive Drug feature and in accordance with Treasury/IRS guidance.

Check the member's specific plan benefits and formulary prior to dispensing.
Confirm whether a generic trial (step through a generic) is required before a brand product will be covered.
If the member's plan includes the HSA Preventive Drug feature, the drug cost may be applied to the preventive benefit even if the deductible has not been met.

Documentation Required

Lipid agents list (drugs enumerated)

Definitions

inv-14: HSA Preventive Drug coverage feature (medications covered prior to deductible per Treasury/IRS guidance)

Feature descriptionHSA Preventive Drug coverage feature allows listed medications to be covered prior to the member meeting their deductible when the member's plan includes this feature and in accordance with Treasury/IRS guidance.

Plan typesSome employer/group plans and all Individual-Under 65 plans may include this feature; coverage depends on the member's specific plan benefits.

Where to confirmVerify benefit applicability on the plan website and in the member's benefit materials; publication subject to change.

inv-15: Generic and brand notation (formatting conventions)

Generic formatting conventionGeneric prescription drugs are shown in lower-case boldface type; most generics are followed by a reference brand in parentheses.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyHSA Preventive Drug List

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionVerify with the member's plan whether a generic must be tried before dispensing a brand and check benefit materials or the plan website for coverage details.

SourceLink

On This Page

inv-09: (unnamed key_value item)

Documented itemList entries include specific lipid agents and strengths such as ezetimibe 10 mg; simvastatin 5, 10, 20, 40, 80 mg; rosuvastatin 5, 10, 20, 40 mg; fenofibrate formulations (67, 134, 200 mg; 48, 54, 145, 160 mg); gemfibrozil 600 mg; icosapent ethyl (Vascepa) 0.5 gm and 1 gm.

Category coverageThis block corresponds to formulary entries for lipid-lowering medications included on the HSA Preventive Drug List.

Reference noteBrand and generic names are shown per list formatting (e.g., VASCEPA - icosapent ethyl cap 0.5 gm shown as brand then generic).

Use the listed lipid agents when assessing preventive drug coverage. The policy lists specific lipid-lowering medications including cholestyramine, colesevelam, colestipol, ezetimibe (and ezetimibe-simvastatin combinations), multiple fenofibrate formulations, gemfibrozil, icosapent ethyl (VASCEPA), lovastatin, niacin ER, pravastatin, rosuvastatin (Crestor), and simvastatin (Zocor).

cholestyramine powder 4 gm/dose (Questran)
colesevelam hcl packet for susp 3.75 gm (Welchol); colesevelam hcl tab 625 mg (Welchol)
colestipol hcl granules and tablets (Colestid)
ezetimibe 10 mg (Zetia); ezetimibe-simvastatin (Vytorin) 10-10, 10-20, 10-40, 10-80 mg
fenofibrate micronized caps 67, 134, 200 mg; fenofibrate tabs 48, 54, 145, 160 mg (Tricor)
gemfibrozil 600 mg (Lopid)
icosapent ethyl 0.5 gm and 1 gm (VASCEPA)
lovastatin 10, 20, 40 mg
niacin ER 500, 750, 1000 mg (antihyperlipidemic)
pravastatin 10, 20, 40, 80 mg
rosuvastatin 5, 10, 20, 40 mg (Crestor)
simvastatin 5, 10, 20, 40, 80 mg (Zocor)

Documentation Required

Osteoporosis agents list (drugs enumerated)

Refer to the osteoporosis agent list when verifying preventive coverage. The policy enumerates bisphosphonates and related agents including alendronate, ibandronate, risedronate (multiple formulations), calcitonin (salmon) nasal solution, and raloxifene (Evista).

alendronate sodium tabs 10 mg, 35 mg, 70 mg (Fosamax)
calcitonin (salmon) nasal solution 200 unit/act
ibandronate sodium tab 150 mg (base equivalent)
raloxifene hcl tab 60 mg (Evista)
risedronate sodium tabs 5 mg, 30 mg, 35 mg (Actonel), 150 mg; risedronate delayed release 35 mg (Atelvia)

Documentation Required

Respiratory agents list (drugs enumerated)

Use the respiratory medication list for plan-level preventive coverage checks. The policy provides an extensive enumerated list of inhaled bronchodilators, inhaled corticosteroids, combination inhalers, leukotriene modifiers, phosphodiesterase inhibitors, theophyllines, antimuscarinics, and others (e.g., ADVAIR HFA, albuterol formulations, BREO ELLIPTA, DULERA, FLUTICASONE-SALMETEROL products, roflumilast, tiotropium products, TRELEGY ELLIPTA).

Examples include ADVAIR HFA; albuterol inhalation and nebulized solutions; ANORO ELLIPTA; ARNUITY ELLIPTA; ASMANEX HFA/TWISTHALER; BREO ELLIPTA; BREZTRI AEROSPHERE; budesonide (Pulmicort); COMBIVENT RESPIMAT; DULERA; multiple fluticasone-salmeterol (Advair) formulations
Other included agents: ipratropium, levalbuterol nebulizer solutions, montelukast (Singulair), QVAR REDIHALER, roflumilast (Daliresp), SEREVENT DISKUS, SPIRIVA products, SYMBICORT, TRELEGY ELLIPTA, VENTOLIN HFA, theophylline formulations, zafirlukast (Accolate)

Brand formatting convention

Brand prescription drugs are shown in capital letters followed by the generic name.

Availability noteGeneric medicines are available for many brand-name drugs listed but may not be available in all strengths; reference brands may not be covered—check benefits.

inv-16: Lipid agents list (name-brand and generic, formulations/strengths)

Representative agentsezetimibe 10 mg; ezetimibe-simvastatin combination (10-10, 10-20, 10-40, 10-80 mg); simvastatin (5, 10, 20, 40, 80 mg); rosuvastatin (5, 10, 20, 40 mg); lovastatin (10, 20, 40 mg); pravastatin (10, 20, 40, 80 mg).

Fibrate agentsfenofibrate micronized caps 67, 134, 200 mg; fenofibrate tabs 48, 54, 145, 160 mg; gemfibrozil tab 600 mg.

Other lipid agentscholestyramine powder 4 gm; colesevelam HCl packets 3.75 gm and tabs 625 mg; colestipol granules and tablets; niacin ER 500, 750, 1000 mg; icosapent ethyl (Vascepa) 0.5 gm and 1 gm; lovastatin and pravastatin strengths as listed.

inv-17: Osteoporosis agents list (agents by formulation/strength)

Included agentsalendronate sodium tablets 10 mg, 35 mg, 70 mg; risedronate sodium tablets 5 mg, 30 mg, 35 mg, 150 mg; risedronate delayed release 35 mg; ibandronate sodium tab 150 mg; raloxifene HCl 60 mg; calcitonin (salmon) nasal solution 200 unit/act.

Formulation/strength detailEntries specify tablet strengths and include both daily and weekly/monthly dosing formulations where applicable (e.g., alendronate 70 mg).

Category noteThese osteoporosis agents are listed for potential preventive coverage under applicable HSA-qualified plans; check member benefits for applicability.

inv-18: Respiratory agents list (agents by formulation/strength)

Representative respiratory agentsAlbuterol inhalers and nebulizer solutions; combination inhalers such as fluticasone-salmeterol (ADVAIR HFA) in multiple strengths; fluticasone furoate-vilanterol (BREO ELLIPTA); budesonide inhalation suspension; ipratropium-albuterol (COMBIVENT RESPIMAT); mometasone-formoterol (DULERA).

Additional inhaled therapiesInhaled corticosteroids and long-acting bronchodilators in multiple strengths and delivery forms (HFA aerosol, dry powder, inhalation suspension) as listed across document chunks.

Other respiratory agentsAcetylcysteine inhalation solutions 10% and 20%; levalbuterol nebulizer solutions; roflumilast tablets (Daliresp); tiotropium (SPIRIVA) and other long-acting antimuscarinics; theophylline oral formulations.