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Preventive Drug Coverage
Your employer has elected to include a Preventive Drug The drugs listed below are grouped into broad categories. coverage feature with your prescription benefit plan. Below is Each category includes an alphabetical list of drugs. Generic the list of medications available under your Preventive Drug drugs are available for many of the brands noted on this list. coverage. The actual cost of the medication will be applied You are encouraged to use generic drugs.
toward the preventive benefit offered by your employer, • generic drugs are listed in bold, lower-case type.
allowing you to receive coverage even if you have not met your deductible. Benefits will be provided in accordance with • brand drugs are listed in all CAPITAL LETTERS. U.S. Department of the Treasury and Internal Revenue Service g brand drug names followed by a “g” means generic
(IRS) guidance with Health Spending Accounts (HSAs) and qualified High Deductible Health Plans (HDHPs). This list will be reviewed periodically and is subject to change.
a n t i h y P e r t e n s i v e s
Cartia xt
ACCUPRIL g
ACCURETIC g
CATAPRES g
acebutolol
ISOPTIN SR g
chlorothiazide
isradipine
ADALAT CC g
chlorthalidone
KERLONE g
ALDACTAZIDE g
clonidine
labetalol
ALDACTONE g
ALDORIL g
CORGARD g
amiloride/hydrochlorothiazide
CORZIDE g
lisinopril
lisinopril/hydrochlorothiazide
LOPRESSOR HCT g
atenolol
DEMADEX g
LOTENSIN g
atenolol/chlorthalidone
LOTENSIN HCT g
Diltia xt
diltiazem
benazepril
diltiazem er
benazepril/hydrochlorothiazide
MAXZIDE g
MAXZIDE-25 g
BETAPACE g
doxazosin
methyldopa
BETAPACE AF g
DYAZIDE g
methyldopa/hydrochlorothiazide
betaxolol
metolazone
metoprolol
bisoprolol
metoprolol/hydrochlorothiazide
bisoprolol/hydrochlorothiazide
enalapril
BLOCADREN g
enalapril/hydrochlorothiazide
bumetanide
felodipine er
MICROZIDE g
fosinopril
MINIPRESS g
fosinopril/hydrochlorothiazide
furosemide
minoxidil
CALAN SR g
CAPOTEN g
guanfacine
MONOPRIL g
CAPOZIDE g
hydralazine
MONOPRIL HCT g
captopril
captopril/hydrochlorothiazide
hydrochlorothiazide
nicardipine
CARDENE g
nifediac CC
nifedical xl
CARDIZEM g
indapamide
nifedipine
CARDIZEM CD g
INDERAL g
nifedipine er
CARDURA g
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of Blue Cross and Blue Shield Association.
pindolol
Dentall 1100 Plus
PLENDIL g
DESOGEN g
prazosin g
enpresse
ethedent
PRINIVIL g
fluorabon
PRINZIDE g
fluor-a-day
PROCARDIA g
jolivette
fluoritab
PROCARDIA XL g
flura-drops
propranolol
GEL-KAM g
propranolol/hydrochlorothiazide
just for kids
quinapril
karidium
quinapril/hydrochlorothiazide
quinaretic
LEVLITE g
karigel-n
lozi-flur
LO/OVRAL g
SECTRAL g
LOESTRIN g
neutragard advanced
LOESTRIN FE g
OMNIIGEL g
low-ogestrel
OMNII MED DENTAL g
sotalol (af)
Perfect Choice brush-on
spironolactone
microgestin
Perio med
spironolactone/hydrochlorothiazide
microgestin fe
Pharmaflur
MIRCETTE g
MODICON g
PREVIDENT RINSE g
taztia xt
mononessa
PREVIDENT 5000 PLUS g
TENORETIC g
PREVIDENT FLUORIDE g
NORDETTE g
terazosin g
NORINYL g
sf 5000 Plus
sodium fluoride
stannous fluoride
THERA-FLUR-N g
ORTHO MICRONOR g
ORTHO TRI-CYCLEN g
l i P i D - l o w e r i n g
torsemide
ORTHO-CEPT g
triamterene/hydrochlorothiazide
ORTHO-CYCLEN g
ORTHO-NOVUM g
cholestyramine
cholestyramine light
VASERETIC g
COLESTID g
VASOTEC g
verapamil
Previfem
fenofibrate
verapamil er
reclipsen
gemfibrozil
VERELAN g
ZAROXOLYN g
sprintec
TRI-LEVLEN g
LOFIBRA g
ZESTORETIC g
trinessa
ZESTRIL g
TRI-NORINYL g
lovastatin
TRIPHASIL g
MEVACOR g
C o n t r a C e P t i v e s
tri-Previfem
tri-sprintec
PRAVACHOL g
aranelle
pravastatin
Prevalite
BREVICON g
QUESTRAN g
f l u o r i D e s u P P l e m e n t s
QUESTRAN LIGHT g
Cavirinse
simvastatin
Cryselle
Controlrx
Denta 5000 Plus
DEMULEN g
Dentagel
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of Blue Cross and Blue Shield Association.
Prenatal-u
o s t e o P o r o s i s
PRIMACARE ONE
ultra natalcare
vinate gt
vinate ii
BONIVA
DIDRONEL g
s m o k i n g C e s s at i o n
etidronate
buproban
bupropion sr
nicotine patch
fortical
MIACALCIN g
w e i g h t l o s s
ADIPEX-P g
P e D i at r i C v i ta m i n s
BONTRIL PDM g
w / f l u o r i D e
chewable multivitamins/fluoride/iron
chewable multivite w/fluoride
diethylpropion
multiple vitamins/fluoride
diethylpropion er
multivitamin drops/fluoride
multivitamin drops/fluoride/iron
multivitamins/fluoride/iron
phendimetrazine
POLY-VI-FLOR g
phendimetrazine er
POLY-VI-FLOR/IRON g
phentermine hCl
TRI-VI-FLOR g
vitamins a/d/c/fluoride
P r e n ata l v i ta m i n s
advanced natalcare
advanced-rf natalcare
Cal-nate
CENOGEN ULTRA g
CITRACAL PRENATAL RX g
Duet tabs
DUET DHA
ICAR PRENATAL COMBO PACK
nataCaps
natafort
natalCare glosstabs
natalCare Plus
natatab fa
natatab rx
NATELLE
NATELLE PREFER
NOVANATAL g
nutrinate
nutrispire
OPTINATE
PRECARE
PRECARE CONCEIVE
PRECARE PRENATAL
PREMESIS RX
Prenatal formula 3
Prenatal mr 90 fe
Prenatal mtr/selenium
Prenatal Plus
Prenatal rx 1
Prenatal-h

Prime therapeutics llC is the pharmacy benefit manager for blue Cross and blue shield of texas.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of Blue Cross and Blue Shield Association.
44164-0906 PRIME THER APEUTICS LLC (41722-E)

Source: http://www.flowserveflex.com/pdfs/PreventiveDrugList.pdf

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