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Maintenance Drug List

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Maintenance Drug List MedImpact Safe Harbor Preventative Drug List This list includes medications identified as those most likely to qualify as “preventive” based on the U.S. Department of Treasury Department IRS guidance. This list may not include all medications considered preventive or every health condition for which a preventive drug may be prescribed. At this time, neither MedImpact nor your health plan can guarantee which medications will satisfy U.S. Treasury Department definition for preventative safe harbor medications. Please also note: --- Utilization management (ie. prior authorization, step therapy, and quantity limits) may apply to listed medications based on benefit design --- Use of generics may be required depending on plan design --- Some strengths or dosage forms may not be included --- Certain products or therapeutic categories may not be covered --- Brand and generic status may not be current due to the changes and drug availability in the market --- This list is subject to change without prior notice --- Regardless of their appearance in this document, please contact member services at the number on your prescription benefits card should you have any questions regarding coverage THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME ANAPHYLAXIS ANAPHYLAXIS THERAPY EPINEPHRINE EPINEPHRINE, AUVI-Q*, EPIPEN*, THERAPY AGENTS EPIPEN JR*, SYMJEPI* ANTICOAGULANTS ANTICOAGULANTS,COU WARFARIN SODIUM COUMADIN, WARFARIN SODIUM, ANTIPLATELET MARIN TYPE JANTOVEN DIRECT FACTOR XA APIXABAN ELIQUIS* INHIBITORS RIVAROXABAN XARELTO* BETRIXABAN MALEATE BEVYXXA* EDOXABAN TOSYLATE SAVAYSA* HEPARIN AND RELATED DALTEPARIN FRAGMIN* PREPARATIONS SODIUM,PORCINE ENOXAPARIN SODIUM LOVENOX, ENOXAPARIN SODIUM FONDAPARINUX SODIUM ARIXTRA, FONDAPARINUX SODIUM PLATELET AGGREGATION ASPIRIN DIPYRIDAMOLE AGGRENOX, ASPIRIN- INHIBITORS DIPYRIDAMOLE ER CILOSTAZOL CILOSTAZOL CLOPIDOGREL BISULFATE PLAVIX, CLOPIDOGREL DIPYRIDAMOLE DIPYRIDAMOLE PRASUGREL HCL EFFIENT, PRASUGREL HCL TICAGRELOR BRILINTA* Effective July 1, 2020 *Available as Brand Only 1 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME VORAPAXAR SULFATE ZONTIVITY* SICKLE CELL ANEMIA HYDROXYUREA DROXIA*, SIKLOS* AGENTS GLUTAMINE ENDARI* THROMBIN DABIGATRAN ETEXILATE PRADAXA* INHIBITORS,SELECTIVE,DI MESYLATE RECT, & REVERSIBLE ASTHMA AND COPD ANTICHOLINERGICS, TIOTROPIUM BROMIDE SPIRIVA*, SPIRIVA RESPIMAT* ORALLY INHALED LONG ACTING UMECLIDINIUM BROMIDE INCRUSE ELLIPTA* GLYCOPYRROLATE LONHALA MAGNAIR REFILL* NEB.ACCESSORIES GLYCOPYRROL NEBULIZER LONHALA MAGNAIR STARTER* ACCESSOR GLYCOPYRROLATE SEEBRI NEOHALER* ACLIDINIUM BROMIDE TUDORZA PRESSAIR* REVEFENACIN YUPELRI* BETA-ADRENERGIC ALBUTEROL SULFATE ALBUTEROL SULFATE, PROAIR AGENTS, INHALED, HFA*, PROAIR RESPICLICK*, SHORT ACTING VENTOLIN HFA*, ALBUTEROL SULFATE HFA, PROAIR DIGIHALER*, PROVENTIL HFA LEVALBUTEROL HCL XOPENEX, XOPENEX CONCENTRATE, LEVALBUTEROL CONCENTRATE, LEVALBUTEROL HCL LEVALBUTEROL TARTRATE LEVALBUTEROL TARTRATE HFA, XOPENEX HFA BETA-ADRENERGIC FORMOTEROL FUMARATE PERFOROMIST* AGENTS, ORALLY INHALED,LONG ACTING SALMETEROL XINAFOATE SEREVENT DISKUS* ARFORMOTEROL BROVANA* TARTRATE Effective July 1, 2020 *Available as Brand Only 2 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME BETA-ADRENERGIC AND BUDESONIDE SYMBICORT*, BUDESONIDE- GLUCOCORTICOID FORMOTEROL FUMARATE FORMOTEROL FUMARATE COMBINATIONS FLUTICASONE VILANTEROL BREO ELLIPTA* MOMETASONE DULERA* FORMOTEROL FLUTICASONE PROPION ADVAIR HFA*, ADVAIR DISKUS, SALMETEROL AIRDUO RESPICLICK, FLUTICASONE- SALMETEROL, WIXELA INHUB GLUCOCORTICOIDS, BECLOMETHASONE QVAR REDIHALER* ORALLY INHALED DIPROPIONATE BUDESONIDE BUDESONIDE, PULMICORT, PULMICORT FLEXHALER* FLUTICASONE FUROATE ARNUITY ELLIPTA* FLUTICASONE ARMONAIR RESPICLICK*, FLOVENT PROPIONATE DISKUS*, FLOVENT HFA* CICLESONIDE ALVESCO* MOMETASONE FUROATE ASMANEX*, ASMANEX HFA* LEUKOTRIENE RECEPTOR MONTELUKAST SODIUM SINGULAIR, MONTELUKAST ANTAGONISTS SODIUM ZAFIRLUKAST ACCOLATE, ZAFIRLUKAST MAST CELL STABILIZERS, CROMOLYN SODIUM CROMOLYN SODIUM, ORALLY INHALED GASTROCROM, CROMOLYN SODIUM ANTICHOLINERGIC, IPRATROPIUM BROMIDE ATROVENT HFA*, IPRATROPIUM ORALLY INHALED SHORT BROMIDE ACTING BETA-ADRENERGIC INDACATEROL MALEATE ARCAPTA NEOHALER* AGENTS, INHALED, ULTRA-LONG ACTING OLODATEROL HCL STRIVERDI RESPIMAT* BETA-ADRENERGIC AND UMECLIDINIUM BRM ANORO ELLIPTA* ANTICHOLINERGIC VILANTEROL TR COMBINATIONS Effective July 1, 2020 *Available as Brand Only 3 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME GLYCOPYRROLATE BEVESPI AEROSPHERE* FORMOTEROL FUM IPRATROPIUM ALBUTEROL COMBIVENT RESPIMAT*, SULFATE IPRATROPIUM-ALBUTEROL ACLIDINIUM BROM DUAKLIR PRESSAIR* FORMOTEROL FUM TIOTROPIUM BR STIOLTO RESPIMAT* OLODATEROL HCL INDACATEROL UTIBRON NEOHALER* GLYCOPYRROLATE BETA-ADRENERGIC- FLUTICASONE UMECLIDIN TRELEGY ELLIPTA* ANTICHOLINERGIC- VILANTER GLUCOCORT, INHALED PHOSPHODIESTERASE-4 ROFLUMILAST DALIRESP* (PDE4) INHIBITORS GLUCOCORTICOIDS PREDNISONE PREDNISONE, PREDNISONE INTENSOL*, RAYOS* BEHAVIORAL HEALTH SELECTIVE SEROTONIN CITALOPRAM CELEXA, CITALOPRAM HBR - ANTIDEPRESSANTS REUPTAKE INHIBITOR HYDROBROMIDE (SSRIS) ESCITALOPRAM OXALATE LEXAPRO, ESCITALOPRAM OXALATE FLUVOXAMINE MALEATE FLUVOXAMINE MALEATE, FLUVOXAMINE MALEATE ER PAROXETINE HCL PAXIL*, PAXIL CR, PAROXETINE ER, PAXIL, PAROXETINE HCL, PAROXETINE CR SERTRALINE HCL ZOLOFT, SERTRALINE HCL FLUOXETINE HCL FLUOXETINE HCL, PROZAC, SARAFEM, FLUOXETINE DR ST. JOHN'S WORT ST. JOHN'S WORT PAROXETINE MESYLATE PEXEVA* SSRI & 5HT1A PARTIAL VILAZODONE HCL VIIBRYD* AGONIST ANTIDEPRESSANT SSRI & SEROTONIN VORTIOXETINE TRINTELLIX* RECEPTOR MODULATOR HYDROBROMIDE ANTIDEPRESSANT Effective July 1, 2020 *Available as Brand Only 4 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME CANCER ANTINEOPLASTIC ANASTROZOLE ARIMIDEX, ANASTROZOLE PREVENTION AROMATASE INHIBITORS EXEMESTANE AROMASIN, EXEMESTANE CARDIOVASCULAR ACE INHIBITOR CALCIUM AMLODIPINE BESYLATE LOTREL, AMLODIPINE BESYLATE- CHANNEL BLOCKER BENAZEPRIL BENAZEPRIL COMBINATION TRANDOLAPRIL TARKA, TRANDOLAPRIL-VERAPAMIL VERAPAMIL HCL ER PERINDOPRIL ARG PRESTALIA* AMLODIPINE BES ACE INHIBITOR THIAZIDE BENAZEPRIL LOTENSIN HCT, BENAZEPRIL- & THIAZIDE-LIKE HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE DIURETIC CAPTOPRIL CAPTOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE ENALAPRIL VASERETIC, ENALAPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE FOSINOPRIL FOSINOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE LISINOPRIL ZESTORETIC, LISINOPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE QUINAPRIL ACCURETIC, QUINAPRIL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE ALPHA BETA- CARVEDILOL COREG, CARVEDILOL ADRENERGIC BLOCKING AGENTS CARVEDILOL PHOSPHATE COREG CR, CARVEDILOL ER LABETALOL HCL LABETALOL HCL ANGIOTEN.RECEPTR AMLODIPINE VALSARTAN EXFORGE HCT, AMLODIPINE- ANTAG. CAL.CHANL BLKR HCTHIAZID VALSARTAN-HCTZ THIAZIDE CB Effective July 1, 2020 *Available as Brand Only 5 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME OLMESARTAN TRIBENZOR, OLMESARTAN- AMLODIPIN HCTHIAZID AMLODIPINE-HCTZ ANGIOTENSIN RECEPTOR AZILSARTAN MED EDARBYCLOR* ANTAG. THIAZIDE CHLORTHALIDONE DIURETIC COMB CANDESARTAN ATACAND HCT, CANDESARTAN- HYDROCHLOROTHIAZID HYDROCHLOROTHIAZID IRBESARTAN AVALIDE, IRBESARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE LOSARTAN HYZAAR*, LOSARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE OLMESARTAN BENICAR HCT, OLMESARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE TELMISARTAN MICARDIS HCT, TELMISARTAN- HYDROCHLOROTHIAZID HYDROCHLOROTHIAZID VALSARTAN DIOVAN HCT, VALSARTAN- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE ANGIOTENSIN RECEPTOR AMLODIPINE BES AZOR, AMLODIPINE-OLMESARTAN ANTGNST & OLMESARTAN MED CALC.CHANNEL BLOCKR AMLODIPINE BESYLATE EXFORGE, AMLODIPINE- VALSARTAN VALSARTAN TELMISARTAN TWYNSTA, TELMISARTAN- AMLODIPINE AMLODIPINE ANTIHYPERTENSIVES, BENAZEPRIL HCL LOTENSIN, BENAZEPRIL HCL ACE INHIBITORS CAPTOPRIL CAPTOPRIL ENALAPRIL MALEATE VASOTEC, ENALAPRIL MALEATE, EPANED* FOSINOPRIL SODIUM FOSINOPRIL SODIUM LISINOPRIL PRINIVIL, ZESTRIL, LISINOPRIL, QBRELIS* MOEXIPRIL HCL MOEXIPRIL HCL PERINDOPRIL ERBUMINE PERINDOPRIL ERBUMINE Effective July 1, 2020 *Available as Brand Only 6 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME QUINAPRIL HCL ACCUPRIL, QUINAPRIL HCL RAMIPRIL ALTACE, RAMIPRIL TRANDOLAPRIL TRANDOLAPRIL ANTIHYPERTENSIVES, AZILSARTAN MEDOXOMIL EDARBI* ANGIOTENSIN RECEPTOR ANTAGONIST CANDESARTAN CILEXETIL ATACAND, CANDESARTAN CILEXETIL EPROSARTAN MESYLATE EPROSARTAN MESYLATE IRBESARTAN AVAPRO, IRBESARTAN LOSARTAN POTASSIUM COZAAR, LOSARTAN POTASSIUM OLMESARTAN BENICAR, OLMESARTAN MEDOXOMIL MEDOXOMIL TELMISARTAN MICARDIS, TELMISARTAN VALSARTAN DIOVAN, VALSARTAN BETA-ADRENERGIC ACEBUTOLOL HCL ACEBUTOLOL HCL BLOCKING AGENTS ATENOLOL TENORMIN, ATENOLOL BETAXOLOL HCL BETAXOLOL HCL BISOPROLOL FUMARATE BISOPROLOL FUMARATE METOPROLOL SUCCINATE TOPROL XL, KAPSPARGO SPRINKLE*, METOPROLOL SUCCINATE METOPROLOL TARTRATE LOPRESSOR, METOPROLOL TARTRATE NADOLOL CORGARD, NADOLOL NEBIVOLOL HCL BYSTOLIC* PINDOLOL PINDOLOL PROPRANOLOL HCL INDERAL LA, HEMANGEOL*, INDERAL XL*, INNOPRAN XL*, PROPRANOLOL HCL, PROPRANOLOL HCL ER SOTALOL HCL BETAPACE, BETAPACE AF, SORINE, SOTALOL, SOTALOL AF, SOTYLIZE* TIMOLOL MALEATE TIMOLOL MALEATE PENBUTOLOL SULFATE LEVATOL* Effective July 1, 2020 *Available as Brand Only 7 of 15 THERAPEUTIC AREA DRUG CLASS GENERIC NAME BRAND NAME BETA-ADRENERGIC ATENOLOL TENORETIC 100, TENORETIC 50, BLOCKING AGENTS CHLORTHALIDONE ATENOLOL-CHLORTHALIDONE THIAZIDE & RELATED BISOPROLOL ZIAC, BISOPROLOL- HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE METOPROLOL SU DUTOPROL* HYDROCHLOROTHIAZ METOPROLOL LOPRESSOR HCT, METOPROLOL-
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