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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.

Source: http://www.bsd7.org/UserFiles/Servers/Server_112418/File/2013%20Bozeman%20School%20HSA%20Preventive%20Drug%20List.pdf

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