Maintenance Medications List Precision Formulary

Quality Driven and Cost-Conscious Medications As the pharmacy benefit manager for your benefit plan, Magellan Rx Management strives to offer you access to a broad choice of medications at a reasonable price.

The Maintenance Medication List is a subset of products included within your plan’s preferred, or formulary, medication list, that are used to treat chronic conditions requiring ongoing treatment with medication.

Mandatory 90-Day supply at retail or mail A 90-day supply is mandatory upon the third fill of a Tier 1 or Tier 2 maintenance medication. You’ll be allowed two 30 day fills within 90 days before being required to obtain 90 days through mail order or at a participating pharmacy location. Mandatory 90 requirement does not apply to medications on Tier 3, Tier 4 or Tier 5.

How to get a 90-day supply Call 352-265-0405 to get a 90 day through Shands Pharmacy (In person or by mail!)

Call 877-276-9360 to get a 90 day through Walgreens Mail Order

To locate a retail pharmacy, visit magellanrx.com or contact customer service at the toll-free member phone number on your benefit plan ID card.

To check the cost of a medication, refer to your benefit handbook or contact customer service at the toll-free member phone number on your benefit plan ID card.

Money Saving Generics If you have questions or would like additional information on the GatorCare Maintenance Medication List, please contact customer service at the toll-free member phone number on your ID card or visit gatorcare.org.

A list of covered maintenance medications begins on the next page. Medications are listed both alphabetically and by therapeutic category. They are indicated by:

Generics: Lower case italic. For example, acarbose

Brands: Capitalized and not italics. For example, Abilify

*This maintenance medication list is subject to change and does not guarantee coverage.

For a current listing of covered medications, visit the Formulary Lookup Tool. magellanrx.com 2020 Maintenance Medication List Alphabetical Listings

A bisoprolol fumarate/ D escitalopram oxalate hydrochlorothiazide esomeprazole magnesium acamprosate calcium Brilinta darifenacin hydrobromide esomeprazole strontium acarbose bromocriptine mesylate Depakote Er estradiol acebutolol hcl bumetanide Depakote Sprinkle estradiol/norethindrone acetate acetazolamide bupropion hcl desipramine hcl Estring Actoplus Met Xr buspirone hcl desmopressin acetate estropipate acyclovir Bystolic desogestrel-ethinyl estradiol ethinyl estradiol/drospirenone albuterol sulfate desogestrel-ethinyl estradiol/ethinyl ethosuximide alendronate sodium estradiol C ethynodiol diacetate-ethinyl alfuzosin hcl desvenlafaxine estradiol cabergoline amantadine hcl desvenlafaxine fumarate etidronate disodium calcitonin,salmon,synthetic amiloride hcl desvenlafaxine succinate exemestane calcitriol amiloride hcl/hydrochlorothiazide dicyclomine hcl ezetimibe calcium acetate amiodarone hcl digoxin ezetimibe/simvastatin amitriptyline hcl candesartan cilexetil Dilantin amlodipine besylate candesartan cilexetil/ Dilantin-125 hydrochlorothiazide F amlodipine besylate/atorvastatin diltiazem hcl calcium captopril dipyridamole famciclovir amlodipine besylate/benazepril captopril/hydrochlorothiazide disopyramide phosphate famotidine hcl Carafate disulfiram felbamate amlodipine besylate/olmesartan carbamazepine medoxomil divalproex sodium felodipine carbidopa amlodipine besylate/valsartan Divigel fenofibrate nanocrystallized carbidopa/levodopa amlodipine besylate/valsartan/ donepezil hcl fenofibric acid (choline) hydrochlorothiazide carbidopa/levodopa/entacapone doxazosin mesylate finasteride amoxapine carvedilol doxepin hcl flavoxate hcl anagrelide hcl cevimeline hcl drospirenone/ethinyl estradiol/ flecainide acetate anastrozole chlorothiazide levomefolate calcium fludrocortisone acetate Apriso chlorpromazine hcl Duavee fluoxetine hcl aripiprazole chlorpropamide duloxetine hcl fluphenazine hcl aspirin/dipyridamole chlorthalidone dutasteride flutamide atenolol cholestyramine (with sugar) dutasteride/tamsulosin hcl fluvastatin sodium atenolol/chlorthalidone cholestyramine/aspartame fluvoxamine maleate atorvastatin calcium cilostazol folic acid Avandia cimetidine fosinopril sodium azathioprine citalopram hydrobromide E fosinopril sodium/ Climara Pro hydrochlorothiazide clomipramine hcl B enalapril maleate furosemide clonidine enalapril maleate/ hydrochlorothiazide benazepril hcl clonidine hcl entacapone G benazepril hcl/hydrochlorothiazide clopidogrel bisulfate colestipol hcl eplerenone benztropine mesylate gabapentin Creon eprosartan mesylate betaxolol hcl galantamine hbr cyanocobalamin (vitamin b-12) ergocalciferol (vitamin d2) bicalutamide gemfibrozil ergoloid mesylates bisoprolol fumarate glimepiride

magellanrx.com 2 | 2020 Magellan Rx Management, LLC. All rights reserved. GatorCare_MRX1218_0220 glipizide levetiracetam N perphenazine/amitriptyline hcl glipizide/metformin hcl levocarnitine (with sugar) phenelzine sulfate glyburide levonorgestrel/ethinyl estradiol and nadolol Phenytek ethinyl estradiol glyburide,micronized nadolol/bendroflumethiazide phenytoin levonorgestrel-ethinyl estradiol glyburide/metformin hcl Natazia phenytoin sodium extended levothyroxine sodium glycopyrrolate nateglinide pilocarpine hcl Linzess guanfacine hcl nefazodone hcl pimozide liothyronine sodium niacin pindolol lipase/protease/amylase nicardipine hcl pioglitazone hcl H lisinopril nifedipine pioglitazone hcl/glimepiride lisinopril/hydrochlorothiazide haloperidol nisoldipine pioglitazone hcl/metformin hcl lithium carbonate haloperidol lactate Nitro-Bid potassium bicarbonate/citric acid lithium citrate hydralazine hcl nitroglycerin potassium chloride losartan potassium hydrochlorothiazide nizatidine potassium citrate losartan potassium/ hydrocortisone norelgestromin/ethinyl estradiol pramipexole di-hcl hydrochlorothiazide hydroxyurea norethindrone pravastatin sodium lovastatin norethindrone acetate prazosin hcl loxapine succinate norethindrone acetate-ethinyl Premarin I estradiol Premphase M norethindrone acetate-ethinyl ibandronate sodium estradiol/ferrous fumarate Prempro imipramine hcl prenatal vit no.80/iron carb,bisgl/ maprotiline hcl norethindrone-ethinyl estradiol methylfolate gluc/dss/dha imipramine pamoate medroxyprogesterone acetate norethindrone-ethinyl estradiol/ prenatal vits no.12/iron,carb/folic indapamide ferrous fumarate megestrol acetate acid/docusate/omega-3 Invokamet norgestimate-ethinyl estradiol memantine hcl primidone Invokamet Xr norgestrel-ethinyl estradiol Menest progesterone, micronized Invokana Norpace Cr mesalamine propafenone hcl irbesartan nortriptyline hcl metaproterenol sulfate propranolol hcl irbesartan/hydrochlorothiazide metformin hcl propranolol hcl/hydrochlorothiazide isosorbide dinitrate methazolamide O propylthiouracil isosorbide mononitrate methimazole protriptyline hcl isoxsuprine hcl olanzapine methotrexate sodium pyridostigmine bromide isradipine olanzapine/fluoxetine hcl methyclothiazide olmesartan medoxomil methyldopa olmesartan medoxomil/amlodipine Q J methyldopa/hydrochlorothiazide besylate/hydrochlorothiazide metolazone olmesartan medoxomil/ quetiapine fumarate Janumet metoprolol succinate hydrochlorothiazide quinapril hcl Janumet Xr metoprolol tartrate omega-3 acid ethyl esters quinapril hcl/hydrochlorothiazide Januvia metoprolol tartrate/ omeprazole quinidine gluconate Jardiance hydrochlorothiazide omeprazole/sodium bicarbonate quinidine sulfate Jentadueto mexiletine hcl oxcarbazepine Jentadueto Xr miglitol oxybutynin chloride minoxidil R mirtazapine L P rabeprazole sodium moexipril hcl raloxifene hcl labetalol hcl moexipril hcl/hydrochlorothiazide paliperidone ramipril lactulose molindone hcl pantoprazole sodium ranitidine hcl lamotrigine montelukast sodium paroxetine hcl rasagiline mesylate Lanoxin pentoxifylline repaglinide lansoprazole perindopril erbumine repaglinide/metformin hcl letrozole perphenazine riluzole

magellanrx.com 3 | 2020 Magellan Rx Management, LLC. All rights reserved. GatorCare_MRX1218_0220 risedronate sodium triamterene/hydrochlorothiazide risperidone trifluoperazine hcl rivastigmine tartrate trihexyphenidyl hcl ropinirole hcl trimipramine maleate rosuvastatin calcium trospium chloride

S U selegiline hcl ursodiol sertraline hcl simvastatin V sodium fluoride sotalol hcl valacyclovir hcl spironolactone valganciclovir hcl spironolactone/hydrochlorothiazide valproic acid (as sodium salt) (valproate sodium) sucralfate valsartan sulfasalazine valsartan/hydrochlorothiazide Synjardy venlafaxine hcl Synjardy Xr verapamil hcl Synthroid vitamin b complex no.3/folic acid/ ascorbic acid(vitc)/biotin T tamoxifen citrate Z tamsulosin hcl zafirlukast telmisartan Zarontin telmisartan/amlodipine besylate Zenpep telmisartan/hydrochlorothiazide zileuton terazosin hcl ziprasidone hcl terbutaline sulfate Zonegran theophylline anhydrous zonisamide thioridazine hcl thiothixene thyroid,pork tiagabine hcl ticlopidine hcl timolol maleate tolazamide tolbutamide tolcapone tolterodine tartrate Topamax topiramate torsemide Tradjenta trandolapril trandolapril/verapamil hcl tranylcypromine sulfate trazodone hcl Trexall

magellanrx.com 4 | 2020 Magellan Rx Management, LLC. All rights reserved. GatorCare_MRX1218_0220 Therapeutic entacapone BLOOD DISORDER CARDIOVASCULAR pramipexole di-hcl pentoxifylline ergoloid mesylates Category pramipexole di-hcl isoxsuprine hcl rasagiline mesylate BHP ropinirole hcl alfuzosin hcl CONTRACEPTIVES ALZHEIMER'S THERAPY ropinirole hcl dutasteride desogestrel-ethinyl estradiol memantine hcl selegiline hcl dutasteride/tamsulosin hcl desogestrel-ethinyl estradiol/ethinyl tolcapone estradiol finasteride trihexyphenidyl hcl drospirenone/ethinyl estradiol/ AMYOTROPHIC LATERAL Rapaflo levomefolate calcium SCLEROSIS AGENTS silodosin ethinyl estradiol/drospirenone riluzole ANTIPLATELET DRUGS tamsulosin hcl ethynodiol diacetate-ethinyl estradiol anagrelide hcl levonorgestrel/ethinyl estradiol and aspirin/dipyridamole ethinyl estradiol ANTICONVULSANTS CANCER Brilinta levonorgestrel-ethinyl estradiol carbamazepine anastrozole cilostazol Natazia Carbatrol bicalutamide clopidogrel bisulfate norelgestromin/ethinyl estradiol Depakote Er exemestane dipyridamole norethindrone Depakote Sprinkle Fareston Effient norethindrone acetate-ethinyl Dilantin flutamide prasugrel hcl estradiol Dilantin-125 hydroxyurea ticlopidine hcl norethindrone acetate-ethinyl divalproex sodium letrozole estradiol/ferrous fumarate ethosuximide methotrexate sodium norethindrone-ethinyl estradiol felbamate ANTIVIRALS tamoxifen citrate norethindrone-ethinyl estradiol/ ferrous fumarate gabapentin acyclovir toremifene citrate norgestimate-ethinyl estradiol Gabitril famciclovir Trexall norgestrel-ethinyl estradiol lamotrigine valacyclovir hcl Nuvaring levetiracetam valganciclovir hcl oxcarbazepine CARDIAC DRUGS amiodarone hcl Phenytek DIABETES ASTHMA Cordarone phenytoin acarbose albuterol sulfate Corlanor phenytoin sodium extended Actoplus Met Xr metaproterenol sulfate digoxin primidone Avandamet montelukast sodium Dilatrate-sr Tegretol Xr Avandaryl terbutaline sulfate disopyramide phosphate tiagabine hcl Avandia theophylline anhydrous flecainide acetate Topamax chlorpropamide theophylline anhydrous Isordil topiramate glimepiride theophylline anhydrous isosorbide dinitrate valproic acid (as sodium salt) glipizide (valproate sodium) zafirlukast isosorbide mononitrate glipizide/metformin hcl Zarontin zileuton Lanoxin glyburide Zonegran mexiletine hcl zonisamide glyburide,micronized Nitro-bid AUTONOMIC DRUGS glyburide/metformin hcl Nitro-dur cevimeline hcl Invokamet ANTIPARKINSON DRUGS nitroglycerin donepezil hcl Invokamet Xr amantadine hcl Norpace cr galantamine hbr Invokana benztropine mesylate Mestinon propafenone hcl Janumet bromocriptine mesylate pilocarpine hcl quinidine gluconate Janumet Xr carbidopa pyridostigmine bromide quinidine sulfate Januvia carbidopa/levodopa rivastigmine tartrate Ranexa Jardiance carbidopa/levodopa ranolazine er Jentadueto carbidopa/levodopa/entacapone

magellanrx.com 5 | 2020 Magellan Rx Management, LLC. All rights reserved. GatorCare_MRX1218_0220 Jentadueto Xr potassium citrate hydrochlorothiazide prazosin hcl metformin hcl Renvela Bystolic propranolol hcl miglitol sodium fluoride candesartan cilexetil propranolol hcl/ hydrochlorothiazide nateglinide candesartan cilexetil/ hydrochlorothiazide quinapril hcl pioglitazone hcl GASTROINTESTINAL captopril quinapril hcl/hydrochlorothiazide pioglitazone hcl/glimepiride Amitiza captopril/hydrochlorothiazide ramipril pioglitazone hcl/metformin hcl Apriso carvedilol reserpine repaglinide Canasa clonidine sotalol hcl repaglinide/metformin hcl Carafate clonidine hcl telmisartan Synjardy cimetidine diltiazem hcl telmisartan/amlodipine besylate Synjardy Xr Creon doxazosin mesylate telmisartan/hydrochlorothiazide tolazamide dicyclomine hcl enalapril maleate terazosin hcl tolbutamide esomeprazole magnesium enalapril maleate/ timolol maleate Tradjenta hydrochlorothiazide esomeprazole strontium trandolapril eprosartan mesylate famotidine trandolapril/verapamil hcl felodipine DIABETIC SUPPLIES glycopyrrolate valsartan fosinopril sodium Lancets lactulose valsartan/hydrochlorothiazide fosinopril sodium/ Needles lansoprazole verapamil hcl hydrochlorothiazide Pen Needles Lialda guanfacine hcl Syringes Linzess hydralazine hcl Test Strips lipase/protease/amylase HIGH BLOOD PRESSURE/ irbesartan CHOLESTEROL mesalamine irbesartan/hydrochlorothiazide amlodipine besylate/atorvastatin nizatidine calcium DIURETICS isradipine omega-3 acid ethyl esters acetazolamide labetalol hcl omeprazole amiloride hcl lisinopril HIGH CHOLESTEROL omeprazole/sodium bicarbonate amiloride hcl/hydrochlorothiazide lisinopril/hydrochlorothiazide atorvastatin calcium pantoprazole sodium bumetanide losartan potassium cholestyramine (with sugar) rabeprazole sodium chlorothiazide losartan potassium/ cholestyramine/aspartame ranitidine hcl hydrochlorothiazide chlorthalidone colestipol hcl sucralfate methyldopa eplerenone ezetimibe sulfasalazine methyldopa/hydrochlorothiazide furosemide ezetimibe/simvastatin ursodiol metoprolol succinate hydrochlorothiazide fenofibrate nanocrystallized Zenpep metoprolol tartrate indapamide fenofibric acid (choline) lanthanum carbonate metoprolol tartrate/ hydrochlorothiazide fluvastatin sodium methazolamide HIGH BLOOD PRESSURE minoxidil gemfibrozil methyclothiazide acebutolol hcl moexipril hcl lovastatin metolazone amlodipine besylate moexipril hcl/hydrochlorothiazide niacin sevelamer carbonate amlodipine besylate/benazepril hcl nadolol pravastatin sodium spironolactone amlodipine besylate/olmesartan rosuvastatin calcium medoxomil nadolol/bendroflumethiazide spironolactone/ simvastatin hydrochlorothiazide amlodipine besylate/valsartan nicardipine hcl Welchol torsemide amlodipine besylate/valsartan/ nifedipine hydrochlorothiazide triamterene/hydrochlorothiazide nisoldipine atenolol olmesartan medoxomil HORMONES atenolol/chlorthalidone olmesartan medoxomil/amlodipine cabergoline DIURETICS besylate/hydrochlorothiazide benazepril hcl calcitonin,salmon,synthetic calcium acetate benazepril hcl/hydrochlorothiazide olmesartan medoxomil/ hydrochlorothiazide Climara Pro Fosrenol betaxolol hcl perindopril erbumine desmopressin acetate potassium bicarbonate/citric acid bisoprolol fumarate pindolol Divigel potassium chloride bisoprolol fumarate/

magellanrx.com 6 | 2020 Magellan Rx Management, LLC. All rights reserved. GatorCare_MRX1218_0220 Duavee citalopram hydrobromide propylthiouracil Enjuvia clomipramine hcl Synthroid Estrace desipramine hcl thyroid,pork estradiol desvenlafaxine estradiol/norethindrone acetate desvenlafaxine fumarate URINARY Estring desvenlafaxine succinate flavoxate hcl estropipate doxepin hcl Gelnique fludrocortisone acetate duloxetine hcl oxybutynin chloride hydrocortisone escitalopram oxalate solifenacin succinate medroxyprogesterone acetate fluoxetine hcl tolterodine tartrate Menest fluphenazine hcl trospium chloride norethindrone acetate fluvoxamine maleate Vesicare norethindrone acetate-ethinyl haloperidol estradiol haloperidol lactate Premarin imipramine hcl VITAMINS Premphase imipramine pamoate calcitriol Prempro lithium carbonate cyanocobalamin (vitamin b-12) progesterone, micronized lithium citrate ergocalciferol (vitamin d2) loxapine succinate folic acid IMMUNOSUPPRESSANTS maprotiline hcl vitamin b complex no.3/folic acid/ ascorbic acid(vitc)/biotin azathioprine mirtazapine molindone hcl nefazodone hcl MISCELLANEOUS nortriptyline hcl acamprosate calcium olanzapine disulfiram olanzapine/fluoxetine hcl levocarnitine (with sugar) paliperidone megestrol acetate paroxetine hcl perphenazine OSTEOPOROSIS perphenazine/amitriptyline hcl alendronate sodium phenelzine sulfate darifenacin hydrobromide pimozide etidronate disodium protriptyline hcl ibandronate sodium quetiapine fumarate raloxifene hcl risperidone risedronate sodium Seroquel Xr sertraline hcl thioridazine hcl PRE-NATAL VITAMINS thiothixene prenatal vit no.80/iron carb,bisgl/ methylfolate gluc/dss/dha tranylcypromine sulfate prenatal vits no.12/iron,carb/folic trazodone hcl acid/docusate/omega-3 trifluoperazine hcl trimipramine maleate venlafaxine hcl PSYCHOTHERAPEUTIC DRUGS ziprasidone hcl amitriptyline hcl amoxapine aripiprazole PSYCHOTHERAPEUTIC DRUGS bupropion hcl levothyroxine sodium buspirone hcl liothyronine sodium chlorpromazine hcl methimazole