THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME
ANAPHYLAXIS
THERAPY
ANAPHYLAXIS THERAPY
AGENTS
EPINEPHRINE
AUVI-Q*, EPINEPHRINE, EPIPEN,
EPIPEN 2-PAK, EPIPEN JR, EPIPEN
JR 2-PAK, SYMJEPI*
ANTICOAGULANTS /
ANTIPLATELET
ANTICOAGULANTS,COU
MARIN TYPE
WARFARIN SODIUM JANTOVEN, WARFARIN SODIUM
DIRECT FACTOR XA
INHIBITORS
APIXABAN ELIQUIS*
RIVAROXABAN XARELTO*
BETRIXABAN MALEATE BEVYXXA*
EDOXABAN TOSYLATE SAVAYSA*
HEPARIN AND RELATED
PREPARATIONS
DALTEPARIN
SODIUM,PORCINE
FRAGMIN*
ENOXAPARIN SODIUM ENOXAPARIN SODIUM, LOVENOX
FONDAPARINUX SODIUM ARIXTRA, FONDAPARINUX SODIUM
PLATELET
AGGREGATION
INHIBITORS
ASPIRIN/ DIPYRIDAMOLE
AGGRENOX, ASPIRIN-
DIPYRIDAMOLE ER
CILOSTAZOL CILOSTAZOL
CLOPIDOGREL BISULFATE CLOPIDOGREL, PLAVIX
DIPYRIDAMOLE DIPYRIDAMOLE
PRASUGREL HCL EFFIENT, PRASUGREL HCL
MedImpact Safe Harbor Preventative Drug List
This list includes medications identified as those most likely to qualify as “preventive” based on the U.S.
Department of Treasury Department/ IRS guidance. This list may not include all medications considered
preventive or every health condition for which a preventive drug may be prescribed. At this time, neither
MedImpact nor your health plan can guarantee which medications will satisfy U.S. Treasury Department
definition for preventative safe harbor medications.
Please also note:
--- Utilization management (ie. prior authorization, step therapy, and quantity limits) may apply to listed
medications based on benefit design
--- Use of generics may be required depending on plan design
--- Some strengths or dosage forms may not be included
--- Certain products or therapeutic categories may not be covered
--- Brand and generic status may not be current due to the changes and drug availability in the market
--- This list is subject to change without prior notice
--- Regardless of their appearance in this document, please contact member services at the number on your
prescription benefits card should you have any questions regarding coverage
Effective October 1, 2020
*Available as Brand Only
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