HSA Preventive Drug List
Spending Accounts (HSAs) and qualified High Deductible
Your employer has elected to include an HSA Preventive
Health Plans (HDHPs). This list will be reviewed periodically
Drug coverage feature with your prescription benefit plan.
Below is the list of medications available under your HSA
Preventive Drug coverage. The actual cost of the medication
The drugs listed below are grouped into broad categories.
will be applied toward the preventive benefit offered by your
Each category includes an alphabetical list of drugs. Generic
employer, allowing you to receive coverage even if you have
drugs are available for many of the brands noted on this list.
not met your deductible. Benefits will be provided in
accordance with U.S. Department of the Treasury and
Internal Revenue Service (IRS) guidance with Health
Bozeman School District #7 Briellyn clopidogrel Cryselle Previfem Cyclafem 1/35, 7/7/7 Reclipsen Emoquette Sprintec warfarin Enpresse Tri-Legest Fe Trinessa -Cervical Caps- Gildess Fe 1/20, 1.5/30 Junel 1/20, 1.5/30 Tri-Previfem Junel Fe 1/20, 1.5/30 Tri-Sprintec Kelnor 1/35 Levora 0.15/30 Wymzya Fe Zenchent levonorgestrel Zenchent Fe Next Choice Low-Ogestrel Zovia 1/35E Marlissa Microgestin 1/20, 1.5/30 Microgestin Fe 1/20, 1.5/30 Amethia Lo AMETHYST Mononessa Camrese Lo Introvale Necon 0.5/35, 1/35, 7/7/7 levonorgestrel/ethinyl estradiol medroxyprogesterone acetate norgestimate/ethinyl estradiol norgestrel/ethinyl estradiol Quasense Altavera Nortrel 0.5/35, 1/35, 7/7/7 Alyacen 1/35, 7/7/7 Aranelle Orsythia Azurette Jolivette
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available
3160-C Prime Therapeutics LLC 07/11 Product names listed are the property of their respected owners.
norethindrone chlorothiazide chlorthalidone 25, 50 mg clonidine acarbose chlorpropamide diltiazem diltiazem ext-release acebutolol acetazolamide glimepiride acetazolamide ext-release doxazosin glipizide glipizide ext-release glipizide/metformin amiloride amiloride/hydrochlorothiazide amlodipine enalapril enalapril/hydrochlorothiazide amlodipine/benazepril eplerenone eprosartan glyburide micronized glyburide, generics of Micronase atenolol felodipine ext-release glyburide/metformin atenolol/chlorthalidone fosinopril fosinopril/hydrochlorothiazide furosemide soln, 10 mg/mL; tabs benazepril guanfacine benazepril/hydrochlorothiazide hydralazine hydrochlorothiazide caps; tabs, betaxolol indapamide bisoprolol bisoprolol/hydrochlorothiazide metformin bumetanide metformin ext-release irbesartan nateglinide irbesartan/hydrochlorothiazide captopril labetalol captopril/hydrochlorothiazide 25-25, 50-25 mg lisinopril lisinopril/hydrochlorothiazide losartan losartan/hydrochlorothiazide carvedilol
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available
3160-C Prime Therapeutics LLC 07/11 Product names listed are the property of their respected owners.
triamterene/hydrochlorothiazide etidronate 400 mg methazolamide methyldopa ibandronate metolazone metoprolol succinate ext-release verapamil metoprolol tartrate verapamil ext-release metoprolol/hydrochlorothiazide minoxidil moexipril moexipril/hydrochlorothiazide nadolol/bendroflumethiazide albuterol nicardipine albuterol ext-release nifedipine ext-release atorvastatin nimodipine cholestyramine nisoldipine ext release 8.5, 17, cholestyramine light colestipol budesonide inhal susp, 0.25, fenofibrate perindopril 0.5 mg/2 mL fenofibrate micronized prazosin cromolyn sodium inhal soln fluvastatin gemfibrozil propranolol ext-release propranolol tabs dyphylline/guaifenesin epinephrine inj quinapril quinapril/hydrochlorothiazide ramipril lovastatin ipratropium inhal soln ipratropium/albuterol inhal soln sotalol AF levalbuterol spironolactone spironolactone/hydrochloro- pravastatin thiazide simvastatin terazosin terbutaline alendronate theophylline ext-release torsemide calcitonin-salmon trandolapril
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available
3160-C Prime Therapeutics LLC 07/11 Product names listed are the property of their respected owners.
zafirlukast
Generic Drugs = bold Brand Drugs = CAPITAL LETTERS ** = generic available
3160-C Prime Therapeutics LLC 07/11 Product names listed are the property of their respected owners.
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