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AL 2019 Rx90 Maintenance by Alpha Standard Member List Finalv3

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AL 2019 Rx90 Maintenance by Alpha Standard Member List Finalv3 Prescription Drug Maintenance List Effective January 1, 2019 Below is the list of medications available for the Prescription Listing of oral contraceptives: Oral contraceptives are a Drug Maintenance List. This list is subject to change without part of this list and are included in the benefit. Please note, due notice. Please refer to your benefit to find out if the Prescription to the large number of brand names, this list may not reflect all Drug Maintenance List applies to your plan. available brands. Please note, generic drugs are available for many of the brand- name drugs listed. Some products noted as generics may not have generics for every strength. ADALAT CC – nifedipine tab er 24hr 30 mg ABILIFY – aripiprazole tab 2 mg ADALAT CC – nifedipine tab er 24hr 60 mg ABILIFY – aripiprazole tab 5 mg ADALAT CC – nifedipine tab er 24hr 90 mg ABILIFY – aripiprazole tab 10 mg ADLYXIN – lixisenatide soln pen-injector 20 mcg/0.2ml ABILIFY – aripiprazole tab 15 mg (100 mcg/ml) ABILIFY – aripiprazole tab 20 mg ADVAIR DISKUS – fluticasone-salmeterol aer powder ba ABILIFY – aripiprazole tab 30 mg 100-50 mcg/dose acarbose tab 25 mg (Precose) ADVAIR DISKUS – fluticasone-salmeterol aer powder ba acarbose tab 50 mg (Precose) 250-50 mcg/dose acarbose tab 100 mg (Precose) ADVAIR DISKUS – fluticasone-salmeterol aer powder ba ACCOLATE – zafirlukast tab 10 mg 500-50 mcg/dose ACCOLATE – zafirlukast tab 20 mg ADVAIR HFA – fluticasone-salmeterol inhal aerosol ACCUPRIL – quinapril hcl tab 5 mg 45-21 mcg/act ACCUPRIL – quinapril hcl tab 10 mg ADVAIR HFA – fluticasone-salmeterol inhal aerosol ACCUPRIL – quinapril hcl tab 20 mg 115-21 mcg/act ACCUPRIL – quinapril hcl tab 40 mg ADVAIR HFA – fluticasone-salmeterol inhal aerosol ACCURETIC – quinapril-hydrochlorothiazide tab 10-12.5 mg 230-21 mcg/act ACCURETIC – quinapril-hydrochlorothiazide tab 20-12.5 mg AEROSPAN – flunisolide hfa inhal aerosol 80 mcg/act ACCURETIC – quinapril-hydrochlorothiazide tab 20-25 mg AGGRENOX – aspirin-dipyridamole cap er 12hr 25-200 mg acebutolol hcl cap 200 mg (Sectral) AGRYLIN – anagrelide hcl cap 0.5 mg acebutolol hcl cap 400 mg (Sectral) AIRDUO RESPICLICK 113/14 – fluticasone-salmeterol ACEON – perindopril erbumine tab 4 mg aer powder ba 113-14 mcg/act ACEON – perindopril erbumine tab 8 mg AIRDUO RESPICLICK 232/14 – fluticasone-salmeterol acetazolamide tab 125 mg aer powder ba 232-14 mcg/act acetazolamide tab 250 mg AIRDUO RESPICLICK 55/14 – fluticasone-salmeterol acetazolamide cap er 12hr 500 mg (Diamox) aer powder ba 55-14 mcg/act ACIPHEX – rabeprazole sodium ec tab 20 mg ALDACTAZIDE – spironolactone & hydrochlorothiazide tab ACIPHEX SPRINKLE – rabeprazole sodium capsule sprinkle 25-25 mg dr 5 mg ALDACTAZIDE – spironolactone & hydrochlorothiazide tab ACIPHEX SPRINKLE – rabeprazole sodium capsule sprinkle 50-50 mg dr 10 mg ALDACTONE – spironolactone tab 25 mg ACTIGALL – ursodiol cap 300 mg ALDACTONE – spironolactone tab 50 mg ACTIVELLA – estradiol & norethindrone acetate tab ALDACTONE – spironolactone tab 100 mg 0.5-0.1 mg alendronate sodium tab 5 mg ACTIVELLA – estradiol & norethindrone acetate tab alendronate sodium tab 10 mg 1-0.5 mg alendronate sodium tab 35 mg ACTONEL – risedronate sodium tab 5 mg alendronate sodium tab 70 mg (Fosamax) ACTONEL – risedronate sodium tab 35 mg ALENDRONATE SODIUM – alendronate sodium oral soln ACTONEL – risedronate sodium tab 150 mg 70 mg/75ml ACTOPLUS MET – pioglitazone hcl-metformin hcl tab alfuzosin hcl tab er 24hr 10 mg (Uroxatral) 15-500 mg allopurinol tab 100 mg (Zyloprim) ACTOPLUS MET – pioglitazone hcl-metformin hcl tab allopurinol tab 300 mg (Zyloprim) 15-850 mg ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) ACTOPLUS MET XR – pioglitazone hcl-metformin hcl tab er ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) 24hr 15-1000 mg ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) ACTOPLUS MET XR – pioglitazone hcl-metformin hcl tab er ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab 24hr 30-1000 mg 12.5-500 mg ACTOS – pioglitazone hcl tab 15 mg (base equiv) ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab ACTOS – pioglitazone hcl tab 30 mg (base equiv) 12.5-1000 mg ACTOS – pioglitazone hcl tab 45 mg (base equiv) Generic Drugs = bold Brand Drugs = CAPITAL LETTERS Product names listed are the property of their respected owners. 3160-ALPHA © Prime Therapeutics LLC 06/18 Page 1 of 24 ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab amlodipine besylate-atorvastatin calcium tab 5-80 mg 12.5-15 mg (Caduet) ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab amlodipine besylate-atorvastatin calcium tab 10-10 mg 12.5-30 mg (Caduet) ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab amlodipine besylate-atorvastatin calcium tab 10-20 mg 12.5-45 mg (Caduet) ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab amlodipine besylate-atorvastatin calcium tab 10-40 mg 25-15 mg (Caduet) ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab amlodipine besylate-atorvastatin calcium tab 10-80 mg 25-30 mg (Caduet) ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab amlodipine besylate-benazepril hcl cap 2.5-10 mg 25-45 mg amlodipine besylate-benazepril hcl cap 5-10 mg ALORA – estradiol td patch twice weekly 0.025 mg/24hr (Lotrel) ALORA – estradiol td patch twice weekly 0.05 mg/24hr amlodipine besylate-benazepril hcl cap 5-20 mg ALORA – estradiol td patch twice weekly 0.075 mg/24hr (Lotrel) ALORA – estradiol td patch twice weekly 0.1 mg/24hr amlodipine besylate-benazepril hcl cap 5-40 mg alosetron hcl tab 0.5 mg (base equiv) (Lotronex) amlodipine besylate-benazepril hcl cap 10-20 mg alosetron hcl tab 1 mg (base equiv) (Lotronex) (Lotrel) ALPHAGAN P – brimonidine tartrate ophth soln 0.1% amlodipine besylate-benazepril hcl cap 10-40 mg ALPHAGAN P – brimonidine tartrate ophth soln 0.15% (Lotrel) ALTACE – ramipril cap 1.25 mg amlodipine besylate-olmesartan medoxomil tab ALTACE – ramipril cap 2.5 mg 5-20 mg (Azor) ALTACE – ramipril cap 5 mg amlodipine besylate-olmesartan medoxomil tab ALTACE – ramipril cap 10 mg 5-40 mg (Azor) ALTOPREV – lovastatin tab er 24hr 20 mg amlodipine besylate-olmesartan medoxomil tab ALTOPREV – lovastatin tab er 24hr 40 mg 10-20 mg (Azor) ALTOPREV – lovastatin tab er 24hr 60 mg amlodipine besylate-olmesartan medoxomil tab ALVESCO – ciclesonide inhal aerosol 80 mcg/act 10-40 mg (Azor) ALVESCO – ciclesonide inhal aerosol 160 mcg/act amlodipine besylate-valsartan tab 5-160 mg (Exforge) amantadine hcl cap 100 mg amlodipine besylate-valsartan tab 5-320 mg (Exforge) amantadine hcl syrup 50 mg/5ml amlodipine besylate-valsartan tab 10-160 mg (Exforge) amantadine hcl tab 100 mg amlodipine besylate-valsartan tab 10-320 mg (Exforge) AMARYL – glimepiride tab 1 mg amlodipine-valsartan-hydrochlorothiazide tab AMARYL – glimepiride tab 2 mg 5-160-12.5 mg (Exforge hct) AMARYL – glimepiride tab 4 mg amlodipine-valsartan-hydrochlorothiazide tab amiloride hcl tab 5 mg 5-160-25 mg (Exforge hct) amiloride & hydrochlorothiazide tab 5-50 mg amlodipine-valsartan-hydrochlorothiazide tab amiodarone hcl tab 100 mg 10-160-12.5 mg (Exforge hct) amiodarone hcl tab 200 mg (Cordarone) amlodipine-valsartan-hydrochlorothiazide tab amiodarone hcl tab 400 mg 10-160-25 mg (Exforge hct) AMITIZA – lubiprostone cap 8 mcg amlodipine-valsartan-hydrochlorothiazide tab AMITIZA – lubiprostone cap 24 mcg 10-320-25 mg (Exforge hct) amlodipine besylate tab 2.5 mg (base equivalent) anagrelide hcl cap 0.5 mg (Agrylin) (Norvasc) anagrelide hcl cap 1 mg amlodipine besylate tab 5 mg (base equivalent) ANASPAZ – hyoscyamine sulfate tab disint 0.125 mg (Norvasc) ANDRODERM – testosterone td patch 24hr 2 mg/24hr amlodipine besylate tab 10 mg (base equivalent) ANDRODERM – testosterone td patch 24hr 4 mg/24hr (Norvasc) ANDROGEL – testosterone td gel 25 mg/2.5gm (1%) amlodipine besylate-atorvastatin calcium tab ANDROGEL – testosterone td gel 50 mg/5gm (1%) 2.5-10 mg (Caduet) ANDROGEL – testosterone td gel 20.25 mg/1.25gm (1.62%) ANDROGEL – testosterone td gel 40.5 mg/2.5gm (1.62%) amlodipine besylate-atorvastatin calcium tab ANDROGEL PUMP – testosterone td gel 20.25 mg/act (1.62%) 2.5-20 mg (Caduet) ANGELIQ – drospirenone-estradiol tab 0.25-0.5 mg amlodipine besylate-atorvastatin calcium tab ANGELIQ – drospirenone-estradiol tab 0.5-1 mg 2.5-40 mg (Caduet) ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba amlodipine besylate-atorvastatin calcium tab 62.5-25 mcg/inh 5-10 mg (Caduet) ANTARA – fenofibrate micronized cap 30 mg amlodipine besylate-atorvastatin calcium tab 5-20 mg ANTARA – fenofibrate micronized cap 90 mg (Caduet) APLENZIN – bupropion hbr tab er 24hr 174 mg amlodipine besylate-atorvastatin calcium tab 5-40 mg APLENZIN – bupropion hbr tab er 24hr 348 mg (Caduet) APLENZIN – bupropion hbr tab er 24hr 522 mg Generic Drugs = bold Brand Drugs = CAPITAL LETTERS Product names listed are the property of their respected owners. 3160-ALPHA © Prime Therapeutics LLC 08/17 Page 2 of 24 APRISO – mesalamine cap er 24hr 0.375 gm atenolol tab 50 mg (Tenormin) ARCAPTA NEOHALER – indacaterol maleate inhal powder cap atenolol tab 100 mg (Tenormin) 75 mcg (base equiv) atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) ARICEPT – donepezil hydrochloride tab 5 mg atenolol & chlorthalidone tab 100-25 mg ARICEPT – donepezil hydrochloride tab 10 mg (Tenoretic 100) ARICEPT – donepezil hydrochloride tab 23 mg atomoxetine hcl cap 10 mg (base equiv) (Strattera) aripiprazole oral solution 1 mg/ml atomoxetine hcl cap 18 mg (base equiv) (Strattera) aripiprazole tab 2 mg (Abilify) atomoxetine hcl cap 25 mg (base equiv) (Strattera) aripiprazole tab 5 mg
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