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~:NGs�-��h�8X�������4g���v�F.Ӈ���V��7�+���L��]o2gL�YJ�5�H��i)x�.���a���1έ�g����SV��[��X��H#��iq�`��$�Z�L�6D�ZP,�b����la��j��_-G�MlO\h'�yy�J�ă�A�7���J�ƍ�H%�B�D�{�T���-�g���Y�������oS�{ “preventive,” and you or your doctor may be asked by us to provide medical records showing that the drug you’re taking is being used for prevention. Below is the list of medications available under your HSA Preventive Drug coverage. Remember, if you improperly classify the drug, it may result in adverse tax consequences so please be sure to take the confirming step to properly classify your claim. 0 HSA Preventive Drug List Effective January 1, 2020 Your employer has elected to include an HSA Preventive Drug coverage feature with your prescription benefit plan. %%EOF h�bbd```b``6��7�d/�d���j`2��(�d����" (?���p���i7��N�`` The HSA Preventive Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. fd�R�V�(}�="=�*�%Ĭ�A�H2�:�Pi�t� ��_�y�\��Z�a�a��᭢s�騴M��Rj].���^���Rq��*��JX��KrZ�d�wЋu{̧�{��l�Rd���c��|4� h�m��� h\���5ei_�o���[��y�o��ʬ��.����.��A.!����BaKh�aF&�DH���DO��,���2&b�! 225 0 obj <>stream Medica Health Savings Account (HSA) Preventive Drug List (01/01/2020) Certain health plans provide a specific benefit for preventive outpatient drugs that are considered maintenance drugs used to treat common disease states. �8��ȝ��;$�@����6H����] {3K;K C?�VFf_�lf��L[ބ�E����3������f�H�30��n�]������ff`���e`腨e�` �� The reimbursable amount is limited to the excess … The actual cost of the medication will be applied toward the preventive benefit offered by your employer, allowing you …

REMEMBER: Just because a drug is on the list, doesn’t always … CVS Caremark® makes no representations regarding its compliance with applicable legal requirements. 176 0 obj <> endobj The items and services chosen for identified chronic conditions are limited, and other common chronic conditions have been left off the list.

are sometimes eligible for reimbursement with a flexible spending account (FSA), health savings account (HSA) and a health reimbursement arrangement (HRA) with a Letter of Medical Necessity (LMN) from a physician. The Preventive Therapy Drug List should be modified as necessary or desired by the plan sponsor based on the advice of the plan sponsor’s counsel. For drugs on the preventive drug list, you pay only the generic, brand formulary, or brand non-formulary coinsurance percentage described in your plan summary. Additional Standard HSA Preventive Drug List Effective January 1, 2020 Your employer has elected to include an HAS Preventive Drug coverage feature with your prescription benefit plan. %PDF-1.7 %���� This list is periodically reviewed and updated to ensure that the drugs listed meet the criteria for inclusion. h�bbd```b``�"^�HFk09D���H�H�HX�L��,Z`�L��3`r"�d|kb�[���׃M0��10120� ���8d��� Y/w endstream endobj 180 0 obj <>stream %PDF-1.6 %���� h�b```a``6����� ���� 331 0 obj <>/Filter/FlateDecode/ID[<135CDF3B76BBAA4BAFD58FA5DEAB4273><414F4A1911394C4BA08E998BBD3FB22F>]/Index[312 51]/Info 311 0 R/Length 100/Prev 266885/Root 313 0 R/Size 363/Type/XRef/W[1 3 1]>>stream 106-39859A 062717 h�b```c``����� � Ā B,@Q�- �!�L�k{�J20t �h K;S �% �2`�d~��jvr1�`�˚ĻF,��]Kg�ť6̞>. 205 0 obj <>/Filter/FlateDecode/ID[<15E4D596E558A09C2132755B9AE5A702><55F755FC52A45448945BD339D7C89594>]/Index[176 50]/Info 175 0 R/Length 125/Prev 160356/Root 177 0 R/Size 226/Type/XRef/W[1 3 1]>>stream endstream endobj startxref

[X)�lO忿��ɒ���B�{���%��3�ܣ�LX*��1)8�N��k�R�`!/RhF�p�$^QŒ� �e�FgϤW(eA��B���) ��L���b*��ƒ0g���I[���adp0�c��#N0cĀ������{{�,��|�?#���W�8��M��d������`΁���! 106-1038894B 080120 High Deductible Health Plan (HDHP) - Health Savings Account (HSA) Preventive Therapy Drug List (08/01/20) ANTI-INFECTIVES phenobarbital ANTIRETROVIRAL AGENTS DESCOVY The expanded list of preventive care for items and services to manage chronic conditions is a welcome development for employers and health policy advocates looking to increase HSA-qualified HDHP participation. endstream endobj 177 0 obj <>/Metadata 13 0 R/Outlines 21 0 R/PageLabels 172 0 R/Pages 174 0 R/StructTreeRoot 41 0 R/Type/Catalog/ViewerPreferences<>>> endobj 178 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 2/Tabs/S/Type/Page>> endobj 179 0 obj <>stream

312 0 obj <> endobj federal rules permit certain preventive drugs to be paid without being subject to the plan’s deductible. 362 0 obj <>stream H�d��N�J ��=�e����l !���sQ����tQ���� �ϭ�-�������-��xx[��s~�=�o���q�__��w�����p��2����{����{ޞ��n/�?~{}���O/����K/�_���V������奿���|8~Y}x|��tx�_o>�

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