CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A
HSA Preventive Drug List
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Lists medications and diabetic supplies designated as preventive under certain HSA-eligible and Transitional Blue HSA plans offered by Blue Cross Blue Shield - North Carolina; applies to members of employer/group and Individual-Under 65 High Deductible Health Plans that include the HSA Preventive Drug coverage feature.
Policy Summary
PayerBlue Cross Blue Shield - North Carolina
PolicyHSA Preventive Drug List
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionVerify with the member's plan whether a generic must be tried before dispensing a brand drug and consult benefit materials or the plan website for coverage details.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
20+drug categories listed
100+individual line-items
2026-01-01effective date
NCapplicability
14+antihypertensive entries
Coverage and Preventive Drug List
Coverage stance and usage
Preventive coverage applies as a feature of certain HSA-eligible and Transitional Blue HSA plans; verify plan-level requirements.
Preventive coverage is available as an HSA Preventive Drug coverage feature for some employer/group plans and the Individual-Under 65 High Deductible Health Plans (ACA Bronze HSA-Eligible and Transitional Blue Options HSA).
Benefits are provided in accordance with U.S. Department of the Treasury and IRS guidance for HSAs and qualified HDHPs; the actual cost of the medication is applied toward the preventive benefit even if the deductible has not been met.
Coverage details, including whether a generic must be tried before a brand product, vary by plan — verify benefit materials and the plan website for current information.
Preventive drug list entries
Medications and strengths included on the preventive drug list for specified conditions:
High blood pressure (selected entries)
- terazosin hcl cap 2 mg; terazosin hcl cap 5 mg; terazosin hcl cap 10 mg
- torsemide tab 5 mg; torsemide tab 10 mg; torsemide tab 20 mg; torsemide tab 100 mg
- trandolapril tab 1 mg; trandolapril tab 2 mg; trandolapril tab 4 mg
- triamterene & hydrochlorothiazide cap 37.5-25 mg; triamterene & hydrochlorothiazide tab 37.5-25 mg; triamterene & hydrochlorothiazide tab 75-50 mg
High cholesterol (selected entries)
- atorvastatin calcium tab 10 mg; atorvastatin calcium tab 20 mg; atorvastatin calcium tab 40 mg; atorvastatin calcium tab 80 mg (Lipitor)
- ezetimibe tab 10 mg (Zetia); ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg (Vytorin)
- fenofibrate micronized cap 67 mg; fenofibrate micronized cap 134 mg; fenofibrate micronized cap 200 mg; gemfibrozil tab 600 mg (Lopid); icosapent ethyl cap 0.5 gm (Vascepa)
Osteoporosis (selected entries)
- alendronate sodium tab 10 mg; alendronate sodium tab 35 mg; alendronate sodium tab 70 mg (Fosamax)
- ibandronate sodium tab 150 mg (base equivalent); risedronate sodium tab 30 mg; risedronate sodium tab 35 mg (Actonel); risedronate sodium tab 150 mg (Actonel)
- calcitonin (salmon) nasal soln 200 unit/act; raloxifene hcl tab 60 mg (Evista)
Respiratory (selected entries)
- acetylcysteine inhal soln 10%; acetylcysteine inhal soln 20%
- ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act; ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act; ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act
- albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) (Proventil hfa); albuterol sulfate soln nebu 0.083% (2.5 mg/3 ml); albuterol sulfate soln nebu 0.5% (5 mg/ml); albuterol sulfate soln nebu 0.63 mg/3 ml; albuterol sulfate soln nebu 1.25 mg/3 ml; albuterol sulfate syrup 2 mg/5 ml; albuterol sulfate tab 2 mg; albuterol sulfate tab 4 mg
Medication & Supply Coding Tables
Anti-coagulants/Anti-plateletsNDCCovered
| anagrelide hcl cap 0.5 mg | anagrelide hcl cap 0.5 mg (Agrylin) |
| anagrelide hcl cap 1 mg | anagrelide hcl cap 1 mg |
| aspirin-dipyridamole cap er 12hr 25-200 mg | aspirin-dipyridamole cap er 12hr 25-200 mg |
| cilostazol tab 50 mg | cilostazol tab 50 mg |
| cilostazol tab 100 mg | cilostazol tab 100 mg |
| clopidogrel bisulfate tab 75 mg | clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) |
| clopidogrel bisulfate tab 300 mg | clopidogrel bisulfate tab 300 mg (base equiv) |
| dabigatran etexilate mesylate cap 75 mg | dabigatran etexilate mesylate cap 75 mg (etexilate base eq) (Pradaxa) |
| dabigatran etexilate mesylate cap 110 mg | dabigatran etexilate mesylate cap 110 mg (etexilate base eq) (Pradaxa) |
| dabigatran etexilate mesylate cap 150 mg | dabigatran etexilate mesylate cap 150 mg (etexilate base eq) (Pradaxa) |
1–10 of 28
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Diabetes medications & suppliesNDCCovered
| Insulin FIASP - insulin aspart (with niacinamide) inj 100 unit/ml | Insulin FIASP - insulin aspart (with niacinamide) inj 100 unit/ml |
| HUMALOG - insulin lispro inj soln 100 unit/ml | HUMALOG - insulin lispro inj soln 100 unit/ml |
| INSULIN GLARGINE-YFGN - insulin glargine-yfgn inj 100 unit/ml | INSULIN GLARGINE-YFGN - insulin glargine-yfgn inj 100 unit/ml |
| LANTUS - insulin glargine inj 100 unit/ml | LANTUS - insulin glargine inj 100 unit/ml |
| NOVOLOG - insulin aspart inj soln 100 unit/ml | NOVOLOG - insulin aspart inj soln 100 unit/ml |
| HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj 500 unit/ml | HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj 500 unit/ml |
| Oral diabetes products (e.g., metformin hcl tab 500 mg) | Oral diabetes medications including metformin and others as listed (examples: metformin hcl tab 500 mg, acarbose tab 25 mg, glimepiride tab 1 mg) |
High blood pressureNDCCovered
| acebutolol hcl cap 200 mg | acebutolol hcl cap 200 mg |
| amlodipine besylate tab 5 mg | amlodipine besylate tab 5 mg (Norvasc) |
| amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg | amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg (Exforge hct) |
| atenolol tab 25 mg | atenolol tab 25 mg (Tenormin) |
| benazepril hcl tab 5 mg | benazepril hcl tab 5 mg |
| candesartan cilexetil tab 4 mg | candesartan cilexetil tab 4 mg (Atacand) |
| captopril tab 12.5 mg | captopril tab 12.5 mg |
| clonidine hcl tab 0.3 mg | clonidine hcl tab 0.3 mg |
| diltiazem hcl tab 30 mg | diltiazem hcl tab 30 mg (Cardizem) |
| enalapril maleate tab 2.5 mg | enalapril maleate tab 2.5 mg (Vasotec) |
1–10 of 30
1/3
AntihypertensivesNDCCovered
| terazosin hcl cap 2 mg | terazosin hcl cap 2 mg (base equivalent) |
| terazosin hcl cap 5 mg | terazosin hcl cap 5 mg (base equivalent) |
| terazosin hcl cap 10 mg | terazosin hcl cap 10 mg (base equivalent) |
| torsemide tab 5 mg | torsemide tab 5 mg |
| torsemide tab 10 mg | torsemide tab 10 mg |
| torsemide tab 20 mg | torsemide tab 20 mg |
| torsemide tab 100 mg | torsemide tab 100 mg |
| trandolapril tab 1 mg | trandolapril tab 1 mg |
| trandolapril tab 2 mg | trandolapril tab 2 mg |
| trandolapril tab 4 mg | trandolapril tab 4 mg |
1–10 of 13
1/2
Lipid-lowering agentsNDCCovered
| atorvastatin calcium tab 10 mg | atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) |
| atorvastatin calcium tab 20 mg | atorvastatin calcium tab 20 mg (base equivalent) (Lipitor) |
| atorvastatin calcium tab 40 mg | atorvastatin calcium tab 40 mg (base equivalent) (Lipitor) |
| atorvastatin calcium tab 80 mg | atorvastatin calcium tab 80 mg (base equivalent) (Lipitor) |
| ezetimibe tab 10 mg | ezetimibe tab 10 mg (Zetia) |
| fenofibrate micronized cap 67 mg | fenofibrate micronized cap 67 mg |
| icosapent ethyl cap 0.5 gm | icosapent ethyl cap 0.5 gm (Vascepa) |
Osteoporosis agentsNDCCovered
| alendronate sodium tab 10 mg | alendronate sodium tab 10 mg |
| alendronate sodium tab 35 mg | alendronate sodium tab 35 mg |
| alendronate sodium tab 70 mg | alendronate sodium tab 70 mg (Fosamax) |
| calcitonin (salmon) nasal soln 200 unit/act | calcitonin (salmon) nasal soln 200 unit/act |
| ibandronate sodium tab 150 mg | ibandronate sodium tab 150 mg (base equivalent) |
| raloxifene hcl tab 60 mg | raloxifene hcl tab 60 mg (Evista) |
| risedronate sodium tab 30 mg | risedronate sodium tab 30 mg |
| risedronate sodium tab 35 mg | risedronate sodium tab 35 mg (Actonel) |
| risedronate sodium tab 150 mg | risedronate sodium tab 150 mg (Actonel) |
Respiratory agentsNDCCovered
| acetylcysteine inhal soln 10% | acetylcysteine inhal soln 10% |
| acetylcysteine inhal soln 20% | acetylcysteine inhal soln 20% |
| ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act | ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act |
| ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act | ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act |
| ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act | ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act |
| AIRSUPRA - albuterol-budesonide inhalation aerosol 90-80 mcg/act | AIRSUPRA - albuterol-budesonide inhalation aerosol 90-80 mcg/act |
| albuterol sulfate inhal aero 108 mcg/act | albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) (Proventil hfa) |
| albuterol sulfate soln nebu 0.083% | albuterol sulfate soln nebu 0.083% (2.5 mg/3 ml) |
| albuterol sulfate soln nebu 0.5% | albuterol sulfate soln nebu 0.5% (5 mg/ml) |
| albuterol sulfate soln nebu 0.63 mg/3 ml | albuterol sulfate soln nebu 0.63 mg/3 ml (base equiv) |
1–10 of 14
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Provider and Member Actions
Documentation Required
Confirm generic-first/plan coverage before dispensing
Verify with the member’s specific plan whether a generic must be tried before dispensing a brand-name preventive medication; refer to the member’s benefit materials and the plan website for current coverage details.
- Check plan-level requirements for generic-first or step edits prior to filling a brand product.
- Use the member’s benefit materials and plan website as the definitive source for coverage and any changes.
Note
Antihypertensive medications and strengths (preventive list)
The preventive list includes the following antihypertensive medications and strengths as shown on the HSA Preventive Drug List.
- acebutolol hcl cap 200 mg; acebutolol hcl cap 400 mg
- amiloride hcl tab 5 mg; amiloride & hydrochlorothiazide tab 5-50 mg
- amlodipine (various combination products) including amlodipine-valsartan-hydrochlorothiazide 5-160-25 mg and 10-160-12.5 mg
- candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg and 32-12.5 mg
- clonidine hcl tab 0.3 mg; clonidine td patch weekly 0.1 mg/24hr and 0.2 mg/24hr
- enalapril maleate tabs 2.5 mg, 5 mg, 10 mg
- fosinopril sodium tab 20 mg and 40 mg (and combination fosinopril-hydrochlorothiazide formulations)
- losartan potassium & hydrochlorothiazide tab 50-12.5 mg and 100-12.5 mg
- metolazone tab 5 mg and 10 mg; metoprolol combination products
- olmesartan medoxomil tab 40 mg and olmesartan combinations (Benicar HCT, Tribenzor)
- terazosin hcl cap 2 mg, 5 mg, 10 mg
- torsemide tab 5 mg, 10 mg, 20 mg, 100 mg
- trandolapril tab 1 mg, 2 mg, 4 mg
- triamterene & hydrochlorothiazide cap/tab 37.5-25 mg and tab 75-50 mg
- valsartan tabs 40 mg, 80 mg
Note
Lipid‑lowering medications and strengths (preventive list)
The preventive list includes the following lipid-lowering (high-cholesterol) medications and strengths as shown on the HSA Preventive Drug List.
- atorvastatin calcium tabs 10 mg, 20 mg, 40 mg, 80 mg (Lipitor)
- cholestyramine light powder 4 gm/dose (Questran light); cholestyramine powder 4 gm/dose (Questran)
- colesevelam hcl tab 625 mg (Welchol)
- colestipol hcl granules 5 gm and granule packets 5 gm; colestipol hcl tab 1 gm (Colestid)
- ezetimibe tab 10 mg (Zetia)
- ezetimibe-simvastatin tabs 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg (Vytorin)
- fenofibrate micronized caps 67 mg, 134 mg, 200 mg; fenofibrate tabs 48 mg, 54 mg, 145 mg, 160 mg (Tricor)
- gemfibrozil tab 600 mg (Lopid)
- icosapent ethyl cap 0.5 gm (Vascepa)
Note
Osteoporosis medications and strengths (preventive list)
The preventive list includes the following osteoporosis medications and strengths as shown on the HSA Preventive Drug List.
- alendronate sodium tab 10 mg; alendronate sodium tab 35 mg; alendronate sodium tab 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 tab 30 mg; risedronate sodium tab 35 mg; risedronate sodium tab 150 mg (Actonel)
Note
Respiratory medications and strengths (preventive list)
The preventive list includes an extensive range of respiratory medications (inhalers, nebulizer solutions, combination controller/reliever products and strengths) as shown on the HSA Preventive Drug List.
- acetylcysteine inhalation solution 10% and 20%
- ADVAIR HFA fluticasone‑salmeterol inhal aerosol 45-21, 115-21, 230-21 mcg/act
- AIRSUPRA albuterol‑budesonide inhalation aerosol 90-80 mcg/act
- albuterol sulfate inhaler 108 mcg/act (90 mcg base equiv) and nebulizer solutions 0.083% (2.5 mg/3 ml), 0.5% (5 mg/ml), 0.63 mg/3 ml, 1.25 mg/3 ml; albuterol syrup and tablets
- ANORO ELLIPTA umeclidinium‑vilanterol 62.5-25 mcg/act
- arformoterol tartrate solution nebu 15 mcg/2 ml (Brovana)
- ARNUITY ELLIPTA (fluticasone furoate) 50 mcg/act, 100 mcg/act, 200 mcg/act
- ASMANEX HFA/TWISTHALER mometasone furoate formulations
- BREO ELLIPTA fluticasone furoate‑vilanterol 50-25, 100-25, 200-25 mcg/act
- BREZTRI AEROSPHERE budesonide‑glycopyrrolate‑formoterol 160-9-4.8 mcg/act
- budesonide inhalation suspension 0.25 mg/2 ml (Pulmicort)
Definitions and Formatting Notes
HSA Preventive Drug coverage
DefinitionHSA Preventive Drug coverage feature: Preventive medications covered before the deductible under certain employer/group and Individual-Under-65 High Deductible Health Plans (ACA Bronze HSA-Eligible and Transitional Blue Options HSA). Benefits provided in accordance with U.S. Treasury and IRS HSA/HDHP guidance.
ApplicabilityApplies to some employer/group plans and Individual-Under-65 HDHP plans offered by Blue Cross Blue Shield of North Carolina; verify plan-level requirements.
Benefit effectThe actual cost of the medication is applied toward the preventive benefit, allowing coverage even if the deductible has not been met.
Member actionCheck benefit materials and the plan website for current information and any plan-specific rules.
Provider actionVerify with the member’s plan whether a generic must be tried before filling a brand version.
Formatting / coverage note
Generic formattingGeneric prescription drugs are shown in lower-case boldface type; most generics are followed by a reference brand in parentheses.
Brand formattingBrand prescription drugs are shown in CAPITAL LETTERS followed by the generic name.
Reference brandsReference brands shown in parentheses may not themselves be covered; check the member’s benefit.
Availability noteGeneric medicines are available for many brand-name drugs listed but may not be available in all strengths.
Antihypertensives (preventive list)
Covered membersNC members enrolled in applicable BCBSNC HSA-eligible or Transitional Blue HSA plans are eligible for the preventive antihypertensive formulations listed.
Example agentsAntihypertensive entries include terazosin (2 mg, 5 mg, 10 mg), torsemide (5, 10, 20, 100 mg), trandolapril (1, 2, 4 mg).
Combination productsIncluded diuretic/combo products such as triamterene & hydrochlorothiazide (37.5-25 mg, 75-50 mg) are on the preventive list.
VerificationConfirm plan-specific coverage and whether generics or reference brands are required or preferred.
Respiratory agents (preventive list)
ScopeRespiratory medications on the preventive list include inhalers, nebulizer solutions, combination inhalers, and controller/reliever formulations.
Inhalers / combination productsExamples include ADVAIR HFA (fluticasone-salmeterol) in multiple strengths and AIRSUPRA (albuterol-budesonide) combination inhaler.
Short-acting bronchodilatorsAlbuterol formulations listed: albuterol sulfate inhalation aerosol (108 mcg/act; 90 mcg base equiv), oral tabs (2 mg, 4 mg), syrup, and multiple nebulizer solutions (0.083% 2.5 mg/3 ml; 0.5% 5 mg/ml; 0.63 mg/3 ml; 1.25 mg/3 ml).
MucolyticsAcetylcysteine inhalation solutions (10% and 20%) are included.
Policy Summary
PayerBlue Cross Blue Shield - North Carolina
PolicyHSA Preventive Drug List
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateJan 1, 2026
Next Review Date
Key ActionVerify with the member's plan whether a generic must be tried before dispensing a brand drug and consult benefit materials or the plan website for coverage details.
SourceLink
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