Maintenance Drug List January 2020

Maintenance drugs are medications prescribed for chronic, long‐term conditions and are taken on a regular, recurring basis. Examples of chronic conditions that may require maintenance drugs are: high blood pressure, high cholesterol, and diabetes.

HAP has developed a list of drugs classified as "maintenance drugs" based on the most prevalent chronic health conditions in our member population. Drugs placed on the Maintenance Drug List are well‐established medications that have proven safety and efficacy and are considered first‐line therapy options for the treatment of common chronic conditions.

The list refers to the most common dosage forms and strengths of a product. Less common forms or strengths of a listed product may not be covered under the maintainance drug list. The majority of these drugs are now available as generic drugs.

How are Drugs Approved to be on the Maintenance Drug List? Many of the medications that you may be taking on a regular basis will not be classified as a maintenance drug on our Maintenance Drug List. HAP uses a committee of physicians, nurses, and pharmacists to determine which drugs are to be placed on our Maintenance Drug List. All requests for adding drugs to this list are thoroughly reviewed by the committee and a determination is made to add a drug to the Maintenance Drug List.

How are Maintenance Drugs Dispensed? Up to a 90‐day supply is covered for drugs listed on the HAP Maintenance Drug List if filled at an eligible 90‐Day HAP retail pharmacy or by using the Pharmacy Advantage Home Delivery Service. Most major chains and many independent pharmacies are in the HAP 90‐Day network. Typically the charge for a 90‐day supply is two retail copays but individual plans may vary.

Drugs that are not listed on the maintenance drug list will be limited to 30‐day supply at retail pharmacies.

In order to fill a 90‐day prescription, the physician must write the prescription for a 90‐day supply.

PRODUCT ROUTE PRODUCT ROUTE

acebutolol Oral amlodipine Oral acetazolamide Oral amlodipine benazepril Oral adapalene External amlodipine besylate‐olmesartan Oral medoxomil ADVAIR Inhalation amlodipine besylate‐valsartan Oral albuterol Oral amlodipine‐valsartan‐ Oral alendronate Oral hydrochlorothiazide alfuzosin Oral amphetamine‐dextroamphetamine Oral allopurinol Oral anastrozole Oral alprazolam Oral aripiprazole Oral amantadine Oral aspirin Oral amiloride Oral aspirin‐dipyridamole (AGGRENOX) Oral amiloride hydrochlorothiazide Oral atenolol Oral amiodarone Oral atenolol‐chlorthalidone Oral amitriptyline Oral atorvastatin Oral

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 1 of 7 The listing may change from time to time. PRODUCT ROUTE PRODUCT ROUTE

azathioprine Oral carvedilol Oral azelastine Nasal celecoxib Oral baclofen Oral cetirizine Oral balsalazide disodium Oral chlorothiazide Oral beclomethasone dipropionate Inhalation chlorpropamide Oral benazepril Oral chlorthalidone Oral benazepril‐hydrochlorothiazide Oral cholestyramine Oral benztropine Oral cholestyramine light Oral betamethasone External citalopram Oral betaxolol Ophthalmic clonazepam Oral betaxolol Oral clonidine Oral bethanechol Oral clonidine Transderm bisoprolol fumarate Oral clonidine (adhd) Oral bisoprolol‐hydrochlorothiazide Oral clopidogrel Oral brimonidine tartrate (0.15% SOLUTION) Ophthalmic colchicine Oral bromocriptine Oral colchicine w/ probenecid Oral budesonide Oral colesevelam (WELCHOL) Oral budesonide (inhalation) Inhalation colestipol Oral bumetanide Oral COMBIGAN Ophthalmic bupropion Oral COMBIVENT RESPIMAT Inhalation bupropion ER Oral contraceptives (generic, max 3 cycles) Oral bupropion SR Oral cyclobenzaprine Oral bupropion XL Oral cyclosporine Oral buspirone Oral cyclosporine (NEORAL) Oral BYSTOLIC Oral cyclosporine modified Oral cabergoline Oral desloratadine Oral calcitriol Oral desmopressin acetate Oral candesartan cilexetil Oral diazepam Oral captopril Oral diclofenac Oral captopril‐hydrochlorothiazide Oral diclofenac Ophthalmic carbamazepine Oral dicyclomine Oral carbamazepine ER Oral digoxin Oral carbidopa/levodopa Oral diltiazem Oral carteolol Ophthalmic diltiazem ER Oral

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 2 of 7 The listing may change from time to time. PRODUCT ROUTE PRODUCT ROUTE

dipyridamole Oral fludrocortisone acetate Oral disopyramide phosphate Oral fluoxetine Oral disulfiram Oral fluphenazine Oral divalproex Oral flurbiprofen Oral dorzolamide‐timolol maleate Ophthalmic flurbiprofen Ophthalmic doxazosin Oral fluvoxamine maleate Oral doxepin Oral folic acid Oral duloxetine Oral fosinopril Oral duoneb Inhalation fosinopril‐hydrochlorothiazide Oral dutasteride Oral furosemide Oral ELIQUIS Oral gabapentin Oral enalapril maleate Oral gemfibrozil Oral enalapril‐hydrochlorothiazide Oral glimepiride Oral ENTRESTO Oral glipizide Oral eplerenone Oral glipizide ER Oral estradiol Transderm glipizide XL Oral estradiol Oral glipizide‐metformin Oral estradiol/noreth AC Transderm glyburide Oral estradiol‐norethindrone acetate Oral glyburide micronized Oral estrogen & methyltestosterone Oral glyburide‐metformin Oral estrogens,conjugated Oral glycopyrrolate Oral estrogens,esterified Oral guanfacine Oral estropipate Oral guanfacine (adhd) Oral etodolac Oral hydralazine Oral ezetimibe Oral hydralazine/hydrochlorothiazide Oral ezetimibe‐simvastatin (VYTORIN) Oral hydrochlorothiazide Oral famotidine Oral hydroxyzine Oral felodipine ER Oral hyoscyamin (OSCIMIN) Oral fenofibrate Oral ibandronate Oral fenofibrate nanocrystallized Oral ibuprofen Oral fenofibrate,micronized Oral imipramine Oral fenofibric acid Oral indapamide Oral finasteride Oral insulin needles and syringes flecainide acetate Oral ipratropium bromide (nasal) Nasal

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 3 of 7 The listing may change from time to time. PRODUCT ROUTE PRODUCT ROUTE

irbesartan Oral losartan Oral irbesartan‐hydrochlorothiazide Oral losartan‐hydrochlorothiazide Oral isoniazid Oral lovastatin Oral isosorbide dinitrate Oral LUMIGAN (max 7.5ml) Ophthalmic isosorbide dinitrate Sublingual LYRICA Oral isosorbide mononitrate Oral meclizine Oral isradipine Oral medroxyprogesterone Oral JANUMET Oral meloxicam Oral JANUMET XR Oral memantine Oral JANUVIA Oral mercaptopurine Oral labetalol Oral mesalamine Rectal lactic acid (ammonium lactate) External mesalamine Oral lactulose Oral metaproterenol Oral lamotrigine Oral metformin Oral lansoprazole Oral metformin ER Oral LANTUS methazolamide Oral LANTUS SOLOSTAR methenamine Oral latanoprost (XALATAN max 7.5ml) Ophthalmic methimazole Oral leflunomide Oral methocarbamol Oral letrozole Oral methyclothiazide Oral leucovorin calcium Oral methyldopa Oral levalbuterol Inhalation methyldopa‐hydrochlorothiazide Oral levetiracetam Oral methylphenidate Oral levobunolol Ophthalmic metipranolol Ophthalmic levocetirizine dihydrochloride Oral metoclopramide Oral levonorgestrel‐ethinyl estradiol (91‐day) Oral metolazone Oral levothyroxine Oral metoprolol succinate (TOPROL XL) Oral liothyronine Oral metoprolol tartrate Oral liotrix Oral metoprolol‐hydrochlorothiazide Oral lisinopril Oral mexiletine Oral lisinopril‐hydrochlorothiazide Oral midodrine Oral lithium carbonate Oral minoxidil Oral loperamide Oral mirtazapine Oral loratadine Oral moexipril Oral

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 4 of 7 The listing may change from time to time. PRODUCT ROUTE PRODUCT ROUTE

moexipril‐hydrochlorothiazide Oral olopatadine Ophthalmic montelukast Oral omega‐3‐acid ethyl esters Oral MULTAQ Oral omeprazole (Rx only) Oral multivitamins (generic Rx only) Oral orphenadrine citrate Oral mycophenolate Oral oxandrolone Oral nabumetone Oral oxcarbazepine Oral nadolol Oral oxybutynin Oral nadolol‐bendroflumethiazide Oral oxybutynin chloride Oral naltrexone Oral oxybutynin chloride ER Oral naproxen Oral pantoprazole Oral nefazodone Oral paroxetine Oral niacin Oral PENTASA Oral niacin er Oral pentoxifylline Oral nicardipine Oral perindopril erbumine Oral nicotine Transderm phenobarbital Oral nifedipine Oral phenytoin Oral nifedipine ER Oral phenytoin extended Oral nisoldipine Oral pilocarpine Oral nitroglycerin Transderm pilocarpine Ophthalmic nitroglycerin Sublingual pindolol Oral nitroglycerin Oral pioglitazone Oral nitroglycerin patch Transderm pioglitazone‐metformin Oral nizatidine Oral potassium chloride Oral norelgestromin‐ethinyl estradiol Transderm potassium gluconate Oral norethindrone acetate‐ethinyl estradiol Oral PRADAXA Oral norgestimate‐ethinyl estradiol (triphasic) Oral pramipexole dihydrochloride Oral nortriptyline Oral prasugrel (EFFIENT) Oral NOVOLIN N pravastatin Oral NOVOLIN R prazosin Oral NOVOLOG FLEXPEN prednisolone Ophthalmic NOVOLOG MIX 70/30 PREFILLED prednisone Oral FLEXPEN prednisone intensol Oral NOVOLOG PENFILL PREMARIN Vaginal olmesartan medoxomil Oral PREMPHASE (max 3 cycles) Oral

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 5 of 7 The listing may change from time to time. PRODUCT ROUTE PRODUCT ROUTE

PREMPRO (max 3 cycles) Oral SPIRIVA HANDIHALER Oral prenatal vitamins (generic Rx only) Oral SPIRIVA RESPIMAT Inhalation primidone Oral spironolact/hydrochlorothiazid Oral probenecid Oral spironolactone Oral progesterone Oral STIOLTO RESPIMAT Inhalation propafenone Oral sucralfate Oral propranolol Oral sulfasalazine Oral propranolol hydrochlorothiazide Oral sulfasalazine DR Oral propylthiouracil Oral sulindac Oral quetiapine fumarate Oral sumatriptan Oral quinapril‐hydrochlorothiazide Oral SYMBICORT Inhalation quinidine Oral tacrolimus Oral rabeprazole Oral tamoxifen citrate Oral raloxifene Oral tamsulosin Oral ramipril Oral TEKTURNA Oral RANEXA Oral telmisartan Oral ranitidine Oral temazepam Oral rasagiline Oral terazosin Oral repaglinide Oral terbutaline Oral reserpine Oral theophylline Oral rifampin Oral theophylline anhydrous Oral risedronate Oral thyroid Oral risperidone Oral timolol Oral ropinirole Oral tolazamide Oral rosuvastatin Oral tolbutamide Oral salsalate Oral tolterodine tartrate Oral SAVELLA Oral topiramate Oral selegiline Oral torsemide Oral SEREVENT DISKUS Inhalation TOUJEO SOLOSTAR sertraline Oral tramadol Oral sildenafil citrate 20 mg Oral trandolapril Oral simvastatin Oral trandolapril‐verapamil Oral sodium citrate Oral travoprost (TRAVATAN Z 7.5ml) Oral sotalol Oral trazodone Oral

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 6 of 7 The listing may change from time to time. PRODUCT ROUTE PRODUCT ROUTE

triamterene Oral triamterene‐hydrochlorothiazide Oral trifluoperazine Oral trihexyphenidyl Oral ursodiol Oral valproic acid Oral valsartan hct (DIOVAN HCT) Oral venlafaxine Oral venlafaxine ER (capsules) Oral verapamil Oral verapamil ER Oral VESICARE Oral VIMPAT Oral VYVANSE Oral warfarin Oral XARELTO Oral zafirlukast Oral zaleplon Oral ziprasidone Oral zolpidem tartrate Oral zonisamide Oral

Generic products are listed in lower case letters, brand name products are listed in CAPITAL letters For some generic products Brand name is listed in parentheses. This is for information purposes only . When a generic product is available, the prescriptions will be filled with FDA approved “A” rated generic. If a generic is not available, brand product will be covered at your applicable brand copay. Some of the drugs on the Maintenance drug list may be subject to additional plan coverage rules. Some formulations of a listed drug may not be covered as maintenance drug . Page 7 of 7 The listing may change from time to time.