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Cleveland Clinic Employee Health Plan Maintenance List July 2021

Prescription Drug Coverage Maintenance are prescriptions commonly used to treat conditions that are considered chronic or long- term. These conditions commonly require regular, daily use of (s). Examples of maintenance drugs are those used to treat asthma, , disease, and high pressure. The prescription listed below are considered maintenance medications. Members covered under the EHP 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 Accolate () Incruse Ellipta (umeclidinium ) 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] /Seizure Disorders Arnuity Ellipta (fluticasone furoate) Perforomist (formoterol) Banzel () Asmanex Twisthaler (mometasone) Pulmicort Flexhaler, Respules (budesonide) Briviact () 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 () Dilantin () Brovana solution for inhalation (arformoterol) Spiriva Respimat (tiotropium) Equetro () Combivent (ipratropium and albuterol) Symbicort (budesonide and formoterol) Felbatol () Cromolyn (cromolyn) Theo-24 (theophylline) Gabitril () Daliresp (roflumilast) Trelegy Ellipta (fluticasone furote, umeclidinium, Gralise () Dulera (mometasone and formoterol) and vilanterol) Horizant () DuoNeb (ipratropium and albuterol) Tudorza Pressair (aclidinium) Keppra, Keppra XR () Elixophylline Elixir (theophylline) Utibron (indacaterol/glycopyrrolate) Lamictal, Lamictal XR () Flovent HFA, Flovent Diskus (fluticasone) VoSpire ER (albuterol) Lyrica () Foradil Aerolizer (formoterol) Yupelri (revefenacin inhalation solution) Neurontin (gabapentin) Grasetek (timothy grass pollen allergen extract) Mysoline () 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 ( tartrate) Peganone () Artane (trihexyphenidyl) Sectral () Phenytek (phenytoin) Azilect (rasagiline) Tenormin () Potiga (ezogabine) Cogentin (benztropine) Toprol XL (metoprolol succinate) Qudexy XR () Comtan (entacapone) Trandate (labetalol) Stavzor (valproic acid) Eldepryl (selegiline) Visken () Tegretol, Tegretol-XR (carbamazepine) Lodosyn (carbidopa) Zebeta () Topamax (topiramate) Mirapex, Mirapex ER (pramipexole) Blood Modifiers Trileptal () Neupro transdermal patch (rotigotine) Aggrenox ( and dipyridamole) Trokendi XR (topiramate) Parcopa (carbidopa and levodopa) Agrylin (anagrelide) Vimpat () Parlodel () Brilinta (ticagrelor) Zarontin () Requip, Requip XL (ropinirole) Effient (prasugrel) Zonegran () Sinemet, Sinemet CR (carbidopa and levodopa) Persantine (dipyridamole) Antidepressants Stalevo (levodopa, carbidopa and entacapone) Plavix (clopidogrel) Celexa (citalopram) Tasmar (tolcapone) Pletal () Cymbalta (duloxetine) Xadago () Ticlid (ticlopidine) Desyrel (trazodone) CARDIOVASCULAR AGENTS Trental (pentoxifylline) Effexor, Effexor XR (venlafaxine) Blockers Emsam transdermal patches (selegiline) ACE Inhibitors Zelapar (selegiline) Calan, Calan SR (, verapamil SR) Fetzima (levomilnacipran) Cardene SR () Khedezla (desvenlafaxine) Aceon (perindopril erbumine) Accupril (quinapril) Cardizem, Cardizem CD, Cardizem SR (, Lexapro (escitalopram) diltiazem CD, diltiazem SR) Ludiomil (maprotiline) Altace (ramipril) Capoten (captopril) Cartia XT (diltiazem) Parnate (tranylcypromine) Dilacor XR (diltiazem) Paxil, Paxil CR () Lotensin (benazepril) Mavik (trandolapril) DynaCirc CR () Pexeva (paroxetine) Norvasc () Pristiq (desvenlafaxine) Monopril (fosinopril) Prinivil () Plendil () Prozac () Sular () Remeron (mirtazapine) Univasc (moexipril) Savella (milnacipran) Vasotec (enalapril) Combinations Serzone () II Antagonists Accuretic (quinapril and ) 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 () 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 () Teveten (eprosartan) Capozide (captopril and hydrochlorothiazide) Caplyta (lumateperone) Clorpres ( and chlorthalidone) Fanapt (iloperidone) Anti-arrhythmics Corzide ( and ) Geodon (ziprasidone) Betapace () Diovan HCT (valsartan and hydrochlorothiazide) Invega (paliperidone) Codarone () Edarbyclor (azilsartan/chlorthalidone) Latuda (lurasidone) Lanoxin () Exforge (amlodipine and valsartan) , Lithobid (lithium) Multaq () Exforge HCT (amlodipine, valsartan, Loxitane (loxapine) Mexitil () hydrochlorothiazide) Navane (thiothixene) Norpace, Norpace CR () Hyzaar (losartan and hydrochlorothiazide) Rexulti (brexpiprazole) Rythmol, Rythmol SR () Lotensin HCT (benazepril and Risperdal, Risperdal M-Tab (risperidone) gluconate hydrochlorothiazide) Saphris (asenapine) Quinidine sulfate Lotrel (amlodipine and benazepril) Secuado (asenapine) Tambocor () Micardis HCT (telmisartan and Seroquel, Seroquel XR (quetiapine) Beta Blockers hydrochlorothiazide) Vraylar (cariprazine) Blocadren () Monopril-HCT (fosinopril and Zyprexa, Zyprexa Zydis (olanzapine) Bystolic (nebivolol) hydrochlorothiazide) Attention Deficit Hyperactivity Disorder (ADHD) Coreg, Coreg CR () Prinzide (lisinopril and hydrochlorothiazide) Intuniv (guanfacine) Corgard (nadolol) Tarka (trandolapril and verapamil) Kapvay (clonidine) Inderal () Tekamlo (aliskiren and amlodipine) Strattera () Kerlone () 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) • Lancets Tribenzor (olmesartan, amlodipine, Tekturna (aliskiren) • Needles purchased separately hydrochlorothiazide) Tenex (guanfacine) • Syringes Twynsta Vasodilan (isoxsuprine) • Test strips Uniretic (moexipril and hydrochlorothiazide) Actoplus Met ( and ) Valturna (aliskiren and valsartan) CANCER Actos (pioglitazone) Vaseretic (enalapril and hydrochlorothiazide) Nolvadex (tamoxifen) Adlyxin () Ziac (bisoprolol and hydrochlorothiazide) Rheumatrex () Admelog ( human lispro) Afrezza (insulin human) Aldactazide (hydrochlorothiazide and CONTRACEPTION Amaryl () ) Amethyst (ethinyl estradiol and levonorgestrel) Apidra (insulin human glulisine) Aldactone (spironolactone) Apri (ethinyl estradiol and desoge strel) Avandamet ( and metformin) Bumex () Aranelle (ethinyl estradiol and norethindrone) Avandaryl (rosiglitazone and glimepiride) Demadex (torsemide) Aviane (ethinyl estradiol and levonorgestrel) Avandia (rosiglitazone) Diuril () Azurette (ethinyl estradiol and ) Basaglar (insulin human glargine) Dyazide ( and hydrochlorothiazide) Balziva (ethinyl estradiol and norethindrone) Bydureon () Dyrenium (triamterene) Briellyn (ethinyl estradiol and norethindrone) Byetta (exenatide) Edecrin (ethacrynic acid) Camila (norethindrone) Diabinese () HydroDiuril (hydrochlorothiazide) Cryselle (ethinyl estradiol and norgestrel) Duetact (pioglitazone and glimepiride) Inspra () Cyclessa (ethinyl estradiol and desogestrel) Farxiga () Lasix () Enpresse-28 (ethinyl estradiol and levonorgestrel) Fiasp (insulin human aspart) Lozol () Errin (norethindrone) Glucotrol, Glucotrol XL () Midamor () Estrostep Fe (ethinyl estradiol and norethindrone) Glucovance (glyburide and metformin) Thalitone (chlorthalidone) Gianvi (ethinyl estradiol and drospirenone) Glumetza (metformin) Zaroxolyn () Introvale (ethinyl estradiol and levonorgestrel) Glyset () Jinteli (ethinyl estradiol and norethindrone) Glyxambi (/) High Jolessa (ethinyl estradiol and levonorgestrel) Humalog (human insulin) Antara () Junel (ethinyl estradiol and norethindrone) Humalog Mix (insulin human lispro Advicor ( and lovastatin) Junel FE (ethinyl estradiol and norethindrone) NPL/lispro) Colestid () Kariva (ethinyl estradiol and desogestrel) Humulin (human insulin) Crestor () Leena (ethinyl estradiol and norethindrone) Humulin R U-500 (insulin human regular) Epanova (omega-3-carboxylic acids) Lessina (ethinyl estradiol and levonorgestrel) Invokamet (/metformin) Fibricor (fenofibric acid) Levora (ethinyl estradiol and levonorgestrel) Invokamet XR (canagliflozin/metformin) Lescol, Lescol XL () Lo Loestrin Fe (ethinyl estradiol and Invokana (canagliflozin) Lipitor () norethindrone) Jardiance (empagliflozin) Livalo () Low-Ogestrel (ethinyl estradiol and norgestrel) Janumet ( and metformin) Lopid () Lutera (ethinyl estradiol and levonorgestrel) Januvia (sitagliptin) Lovaza (omega-3-acid ethyl esters) Lybrel (ethinyl estradiol and levonorgestrel) Jentadueto (linagliptin and metformin) Mevacor (lovastatin) Microgest (ethinyl estradiol and norethindrone) Juvisync (sitagliptin and ) Niaspan (niacin) Microgestin (ethinyl estradiol and norethindrone) Kazano (/metformin) Nikita (pitavastatin) Natazia (estradiol and dienogest) Kombiglyze (/metformin) Pravachol () Necon (ethinyl estradiol and norethindrone) Lantus (insulin human glargine) Simcor (niacin and simvastatin) Norinyl (ethinyl estradiol and norethindrone) Levemir (insulin human detemir) TriCor (fenofibrate) Nortrel (ethinyl estradiol and norethindrone) Meaglip (glipizide and metformin) TriLipix (fenofibric acid) NuvaRing (ethinyl estradiol and etonogestrel) Micronase (glyburide) Vascepa (icosapent ethyl) Ocella (ethinyl estradiol and drospirenone) Nesina (alogliptin) Vytorin ( and simvastatin) Ortho Evra (ethinyl estradiol and ) Novolin (human insulin) Welchol () Ovcon (ethinyl estradiol and norethindrone) Novolog (human insulin) Zetia (ezetimibe) Portia (ethinyl estradiol and levonorgestrel) Novolog Mix (insulin human aspart NPL/aspart) Zocor (simvastatin) Quasense (ethinyl estradiol and levonorgestrel) Onglyza (saxagliptin) Zypitamag (pitavastatin) Reclipsen (ethinyl estradiol and desogestrel) Orinase ()PrandiMet ( Miscellaneous Cardiovascular Drugs Seasonique (ethinyl estradiol and levonorgestrel) and metformin) Aldomet (methyldopa) Sprintec (ethinyl estradiol and norgestimate) Oseni (alogliptin/pioglitazone) Apresoline () Tri-Legest Fe (ethinyl estradiol and norethindrone) Ozempic () BiDil (isosorbide dinitrate and hydralazine) TriNessa (ethinyl estradiol and norgestimate) Prandin (repaglinide) Catapres (clonidine) Tri-Sprintec (ethinyl estradiol and norgestimate) Precose () Corlanor () Trivora (ethinyl estradiol and levonorgestrel) Qtern (dapagliflozin/saxagliptin) Elmiron (pentosan polysulfate ) Velivet (ethinyl estradiol and desogestrel) Rybelsus (semaglutide) Minipress (prazosin) Yaz (ethinyl estradiol and drospirenone) Segluromet (/metformin) (minoxidil) Zovia (ethinyl estradiol and ethynodiol diacetate) Soliqua (insulin human glargine/ lixisenatide) Ranexa () Starlix () 3 Maintenance Drug List (continued)

DIABETES (cont.) GOUT OSTEOPOROSIS Steglatro (ertugliflozin) ColBenemid ( and probenecid) Actonel (risedronate) Steglujan (ertugliflozin/sitagliptin) Duzallo (lesinurad/allopurinol) Boniva (ibandronate) tablets Synjardy (empagliflozin/metformin) Uloric (febuxostat) Evista (raloxifene) Synjardy XR (empagliflozin/metformin) Zurampic (lesinurad) Fortical (calcitonin) Symlin () Zyloprim (allopurinol) Fosamax (alendronate) Tanzeum () Miacalcin (calcitonin) Toujeo () HORMONE REPLACEMENT Pancreatic Enzymes Tolinase () AND METABOLIC DRUGS Creon (pancrelipse) Tradjenta (linagliptin) Activella (estradiol and norethindrone) Pancreaze (pancrelipse) Tresiba (insulin human degludec) Alora (estradiol) Pertzye (pancrelipse) Trijardy XR (empaglifloziln/linagliptin/ Angeliq (drospirenone and estradiol) Zenpep (pancrelipse) metformin Armour Thyroid (thyroid) Trulicity () Bijuva (estradiol/) PANCREATIC ENZYMES Victoza () Carnitor (levocarnitine) Creon (pancrelipse) Xigduo XR (dapagliflozin/metformin) Cenestin (conjugated estrogens) Pancreaze (pancrelipse) Xultophy (/liraglutide) ClimaraPro (estradiol/levonorgestrel)CombiPatch Pertzye (pancrelipse) (estradiol/norethindrone) Zenpep (pancrelipse) Covaryx, Covaryx HS (esterified estrogens and Alphagan P () methyltestosterone) ULCER/REFLUX DISEASE Azopt () Cytomel (liothyronine) Carafate (sucralfate) Betagan () DepoProvera (medroxyprogesterone acetate) Cytotec (misoprostol) Betimol (timolol) Divigel (estradiol) Betoptic-S (betaxolol) MISCELLANEOUS Duavee (conjugated estrogens/bazedoxifene) Actigall (ursodiol) Combigan (brimonidine and timolol) EEMT, EEMT HS (esterified estrogens and Cosopt, Cosopt PF ( and timolol) Apriso (mesalamine) methyltestosterone) Asacol HD (mesalamine) Isopto (carbachol) Enjuvia (conjugated estrogens) Isopto Carpine () Azulfidine (sulfasalazine) Estrace (estradiol) Brisdelle (paroxetine mesylate) Istalol (timolol) Estraderm (estradiol) Lumigan () Buspar () Estring (estradiol) Calphron (calcium acetate) Ocupress () Femhrt (ethinyl estradiol and norethindrone) OptiPranolol () Cuvposa (glycopyrrolate) Florinef (fludrocortisone) Delzicol (mesalamine) Phospholine Iodide ( iodide) Levoxyl () Pilopine HS (pilocarpine) Diamox, Diamox Sequels () Menest (esterified estrogens) Dipentum (olsalazine) Rhopressa () Ogen (estropipate) Timoptic, Timoptic XE (timolol) Eliphos (calcium acetate) Prefest (estradiol/norgestimate) Evoxac (cevimeline) Travatan Z () Premarin (conjugated estrogens) Trusopt (dorzolamide) Fosrenol (lanthanum) Premphase (conjugated estrogens/ Gastrocrom (cromolyn) Xalatan () medroxyprogesterone) Zioptan () Giazo (balsalazide) Prempro (conjugated estrogens and Lialda (mesalamine) medroxyprogesterone) Librax (chlordiazepoxide/clidinium) GENITOURINARY Prometrium (progesterone) Enlarged Prostate (BPH)/Urinary Motegrity (prucalopride) Propylthiouracil (propylthiouracil) Nascobal (cyanocobalamin) Antispasmodics Synthroid (levothyroxine) Avodart (dutasteride) Neptazane () Tapazole (methimazole) Orap () Cardura () Thyrolar (liotrix) Cardura XL (doxazosin) Otrexup (methotrexate injection) Vagifem (estradiol vaginal inserts) Pentasa (mesalamine) Detrol, Detrol LA () Vivelle-Dot (estradiol) Ditropan, Ditropan XL (oxybutynin) PhosLo (calcium acetate) Enablex () IRRITABLE BOWEL SYNDROME Phoslyra (calcium acetate) Flomax (tamsulosin) Renagel (sevelamer) Amitiza (lubiprostone) Renvela (sevelamer) Hytrin (terazosin) Lotronex (alosetron) Jalyn (dutasteride and tamsulosin) Ridura (auranofin) Myrbetriq (mirabegron) MUSCLE SPASMS Rocaltrol (calcitriol) Oxytrol transdermal patches (oxybutynin) Salagen (pilocarpine) Lioresal () Vitamin D (ergocalciferol) Proscar () Zanaflex (tizanidine) Uroxatral (alfuzosin) Xenazine (tetrabenazine) Rapaflo () Sanctura, Sanctura XR (trospium) Toviaz (fesoterodine) Urispas (flavoxate) Vesicare ()

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