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Cleveland Clinic Employee Health Plan Maintenance Drug List July 2021

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Cleveland Clinic Employee Health Plan Maintenance Drug List July 2021 Cleveland Clinic Employee Health Plan Maintenance Drug List July 2021 Prescription Drug Coverage Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long- term. These conditions commonly require regular, daily use of medication(s). Examples of maintenance drugs are those used to treat asthma, diabetes, heart disease, and high blood pressure. The prescription medications listed below are considered maintenance medications. Members covered under the EHP Prescription Drug Benefit can obtain the first fill of any of these medications at any Cleveland Clinic/Akron General Pharmacy, CVS store pharmacy, or CVS/caremark™. Refills of the medications listed below must be obtained at a Cleveland Clinic Pharmacy, Cleveland Clinic Home Delivery Pharmacy, or through the CVS/caremark Mail Service in order to be covered. In addition, those maintenance medications that are highlighted in red must be refilled for three month supplies at a Cleveland Clinic Pharmacy, Cleveland Clinic Home Delivery Pharmacy, or through the CVS/caremark Mail Service in order to be covered. Please note that this list does not guarantee coverage and is subject to change. Each maintenance medication is listed by its brand or trade name, followed in parentheses by its generic name. CVS/caremark is a trademark of CVSHealth Inc. Maintenance Drug List ASTHMA/RESPIRATORY ASTHMA/RESPIRATORY (cont.) CENTRAL NERVOUS SYSTEM Accolate (zafirlukast) Incruse Ellipta (umeclidinium bromide) Alzheimer’s Disease Advair HFA, Advair Diskus (fluticasone and Lonhala Magnair (glycopyrrolate) Aricept (donepezil) salmeterol) Lufyllin (dyphylline) Hydergine (ergoloid mesylates) AirDuo (fluticasone and salmeterol) Metaproterenol tablets, syrup (metaproterenol) Namenda XR (memantine extended-release) Albuterol tablets, solution for inhalation, Odactra (house dust mite allergen extract) Razadyne, Razadyne ER (galantamine) syrup (albuterol) Oralair (grass mixed pollen allergen extract) Exelon (rivastigmine) Alvesco (ciclesonide) Palforzia [peanut (arachis hypogaea) allergen Namenda (memantine) Arcapta Neohaler (indacaterol) powder-dnfp] Anticonvulsants/Seizure Disorders Arnuity Ellipta (fluticasone furoate) Perforomist (formoterol) Banzel (rufinamide) Asmanex Twisthaler (mometasone) Pulmicort Flexhaler, Respules (budesonide) Briviact (brivaracetam) Atrovent HFA, nasal spray, solution for QVAR (beclomethasone) Celontin (methsuximide) inhalation (ipratropium) Ragwitek (ragweed pollen allergen extract) Depakene (valproic acid) Bevespi Aerosphere (glycopyrrolate/formoterol) Seebri Neohaler (glycopyrrolate) Depakote, Depakote ER, Depakote Breo Ellipta (fluticasone/vilanterol) Serevent Diskus (salmeterol) Sprinkle (divalproex) Brethine (terbutaline) Singulair (montelukast) Dilantin (phenytoin) Brovana solution for inhalation (arformoterol) Spiriva Respimat (tiotropium) Equetro (carbamazepine) Combivent (ipratropium and albuterol) Symbicort (budesonide and formoterol) Felbatol (felbamate) Cromolyn (cromolyn) Theo-24 (theophylline) Gabitril (tiagabine) Daliresp (roflumilast) Trelegy Ellipta (fluticasone furote, umeclidinium, Gralise (gabapentin) Dulera (mometasone and formoterol) and vilanterol) Horizant (gabapentin enacarbil) DuoNeb (ipratropium and albuterol) Tudorza Pressair (aclidinium) Keppra, Keppra XR (levetiracetam) Elixophylline Elixir (theophylline) Utibron (indacaterol/glycopyrrolate) Lamictal, Lamictal XR (lamotrigine) Flovent HFA, Flovent Diskus (fluticasone) VoSpire ER (albuterol) Lyrica (pregabalin) Foradil Aerolizer (formoterol) Yupelri (revefenacin inhalation solution) Neurontin (gabapentin) Grasetek (timothy grass pollen allergen extract) Mysoline (primidone) 1 Maintenance Drug List (continued) CENTRAL NERVOUS SYSTEM CENTRAL NERVOUS SYSTEM CARDIOVASCULAR AGENTS (cont.) (cont.) (cont.) Beta Blockers (cont.) Anticonvulsants/Seizure Disorders (cont.) Parkinson’s Disease Lopressor (metoprolol tartrate) Peganone (ethotoin) Artane (trihexyphenidyl) Sectral (acebutolol) Phenytek (phenytoin) Azilect (rasagiline) Tenormin (atenolol) Potiga (ezogabine) Cogentin (benztropine) Toprol XL (metoprolol succinate) Qudexy XR (topiramate) Comtan (entacapone) Trandate (labetalol) Stavzor (valproic acid) Eldepryl (selegiline) Visken (pindolol) Tegretol, Tegretol-XR (carbamazepine) Lodosyn (carbidopa) Zebeta (bisoprolol) Topamax (topiramate) Mirapex, Mirapex ER (pramipexole) Blood Modifiers Trileptal (oxcarbazepine) Neupro transdermal patch (rotigotine) Aggrenox (aspirin and dipyridamole) Trokendi XR (topiramate) Parcopa (carbidopa and levodopa) Agrylin (anagrelide) Vimpat (lacosamide) Parlodel (bromocriptine) Brilinta (ticagrelor) Zarontin (ethosuximide) Requip, Requip XL (ropinirole) Effient (prasugrel) Zonegran (zonisamide) Sinemet, Sinemet CR (carbidopa and levodopa) Persantine (dipyridamole) Antidepressants Stalevo (levodopa, carbidopa and entacapone) Plavix (clopidogrel) Celexa (citalopram) Tasmar (tolcapone) Pletal (cilostazol) Cymbalta (duloxetine) Xadago (safinamide) Ticlid (ticlopidine) Desyrel (trazodone) CARDIOVASCULAR AGENTS Trental (pentoxifylline) Effexor, Effexor XR (venlafaxine) Calcium Channel Blockers Emsam transdermal patches (selegiline) ACE Inhibitors Zelapar (selegiline) Calan, Calan SR (verapamil, verapamil SR) Fetzima (levomilnacipran) Cardene SR (nicardipine) Khedezla (desvenlafaxine) Aceon (perindopril erbumine) Accupril (quinapril) Cardizem, Cardizem CD, Cardizem SR (diltiazem, Lexapro (escitalopram) diltiazem CD, diltiazem SR) Ludiomil (maprotiline) Altace (ramipril) Capoten (captopril) Cartia XT (diltiazem) Parnate (tranylcypromine) Dilacor XR (diltiazem) Paxil, Paxil CR (paroxetine) Lotensin (benazepril) Mavik (trandolapril) DynaCirc CR (isradipine) Pexeva (paroxetine) Norvasc (amlodipine) Pristiq (desvenlafaxine) Monopril (fosinopril) Prinivil (lisinopril) Plendil (felodipine) Prozac (fluoxetine) Sular (nisoldipine) Remeron (mirtazapine) Univasc (moexipril) Savella (milnacipran) Vasotec (enalapril) Combinations Serzone (nefazodone) Angiotensin II Receptor Antagonists Accuretic (quinapril and hydrochlorothiazide) Symbyax (olanzapine and fluoxetine) Atacand (candesartan) Amturnide (aliskiren, amlodipine, and Trintellix (vortioxetine) Avapro (irbesartan) hydrochlorothiazide) Viibryd (vilazodone) Benicar (olmesartan) Atacand HCT (candesartan and Wellbutrin, Wellbutrin SR, Wellbutrin XL Cozaar (losartan) hydrochlorothiazide) (bupropion) Diovan (valsartan) Avalide (irbesartan and hydrochlorothiazide) Zoloft (sertraline) Edarbi (azilsartan) Azor (amlodipine and olmesartan) Entresto (sacubitril/valsartan) Benicar HCT (olmesartan and Antipsychotics and Mood Stabilizers hydrochlorothiazide) Abilify (aripiprazole) Micardis (telmisartan) Teveten (eprosartan) Capozide (captopril and hydrochlorothiazide) Caplyta (lumateperone) Clorpres (clonidine and chlorthalidone) Fanapt (iloperidone) Anti-arrhythmics Corzide (nadolol and bendroflumethiazide) Geodon (ziprasidone) Betapace (sotalol) Diovan HCT (valsartan and hydrochlorothiazide) Invega (paliperidone) Codarone (amiodarone) Edarbyclor (azilsartan/chlorthalidone) Latuda (lurasidone) Lanoxin (digoxin) Exforge (amlodipine and valsartan) Lithium, Lithobid (lithium) Multaq (dronedarone) Exforge HCT (amlodipine, valsartan, Loxitane (loxapine) Mexitil (mexiletine) hydrochlorothiazide) Navane (thiothixene) Norpace, Norpace CR (disopyramide) Hyzaar (losartan and hydrochlorothiazide) Rexulti (brexpiprazole) Rythmol, Rythmol SR (propafenone) Lotensin HCT (benazepril and Risperdal, Risperdal M-Tab (risperidone) Quinidine gluconate hydrochlorothiazide) Saphris (asenapine) Quinidine sulfate Lotrel (amlodipine and benazepril) Secuado (asenapine) Tambocor (flecainide) Micardis HCT (telmisartan and Seroquel, Seroquel XR (quetiapine) Beta Blockers hydrochlorothiazide) Vraylar (cariprazine) Blocadren (timolol) Monopril-HCT (fosinopril and Zyprexa, Zyprexa Zydis (olanzapine) Bystolic (nebivolol) hydrochlorothiazide) Attention Deficit Hyperactivity Disorder (ADHD) Coreg, Coreg CR (carvedilol) Prinzide (lisinopril and hydrochlorothiazide) Intuniv (guanfacine) Corgard (nadolol) Tarka (trandolapril and verapamil) Kapvay (clonidine) Inderal (propranolol) Tekamlo (aliskiren and amlodipine) Strattera (atomoxetine) Kerlone (betaxolol) Tekturna HCT (aliskiren and hydrochlorothiazide) Levatol (penbutolol) Tenoretic (atenolol and chlorthalidone) 2 Maintenance Drug List (continued) CARDIOVASCULAR AGENTS (cont.) CARDIOVASCULAR AGENTS (cont.) DIABETES Combinations (cont.) Miscellaneous Cardiovascular Drugs (cont.) Diabetic Supplies: Teveten HCT (eprosartan and hydrochlorothiazide) Reserpine (reserpine) • Lancets Tribenzor (olmesartan, amlodipine, Tekturna (aliskiren) • Needles purchased separately hydrochlorothiazide) Tenex (guanfacine) • Syringes Twynsta Vasodilan (isoxsuprine) • Test strips Uniretic (moexipril and hydrochlorothiazide) Actoplus Met (pioglitazone and metformin) Valturna (aliskiren and valsartan) CANCER Actos (pioglitazone) Vaseretic (enalapril and hydrochlorothiazide) Nolvadex (tamoxifen) Adlyxin (lixisenatide) Ziac (bisoprolol and hydrochlorothiazide) Rheumatrex (methotrexate) Admelog (insulin human lispro) Diuretics Afrezza (insulin human) Aldactazide (hydrochlorothiazide and CONTRACEPTION Amaryl (glimepiride) spironolactone) Amethyst (ethinyl estradiol and levonorgestrel) Apidra (insulin human glulisine) Aldactone (spironolactone) Apri (ethinyl estradiol and desoge strel) Avandamet (rosiglitazone and metformin) Bumex (bumetanide) Aranelle (ethinyl estradiol and norethindrone) Avandaryl (rosiglitazone
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