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2018 Gundersen Health Plan Drug Formulary Maintenance List

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2018 Gundersen Health Plan Drug Formulary Maintenance List 2018 Gundersen Health Plan Drug Formulary Maintenance List *Our plan uses a national drug database to define a list of drugs that are considered maintenance medications. This list is subject to change at any time due to the dynamic changes occurring within the pharmacy industry, such as additions and removals of drugs from the market. ACAMPROSATE CALCIUM APTENSIO XR BISOPROLOL ACARBOSE APTIOM FUMARATE/HYDROCHLORO ACEBUTOLOL HCL ARCAPTA NEOHALER THIAZIDE ACETAZOLAMIDE ARIPIPRAZOLE BREO ELLIPTA ACYCLOVIR ARMODAFINIL BRILINTA ADVAIR DISKUS ARMOUR THYROID BRIMONIDINE TARTRATE ADVAIR HFA ARNUITY ELLIPTA BRINTELLIX AFREZZA ASMANEX BRIVIACT AGGRENOX ASMANEX HFA BROMOCRIPTINE ALBUTEROL SULFATE ASPIRIN/DIPYRIDAMOLE MESYLATE ALENDRONATE SODIUM ATENOLOL BROVANA ALFUZOSIN HCL ATENOLOL/CHLORTHALIDO BUDESONIDE ALLOPURINOL NE BUMETANIDE ALORA ATOMOXETINE HCL BUPRENORPHINE ALPHAGAN P ATORVASTATIN CALCIUM HCL/NALOXONE HCL ALVESCO ATROPINE SULFATE BUPROPION HCL AMANTADINE HCL ATROVENT HFA BUSPIRONE HCL AMILORIDE HCL AURYXIA BYDUREON AMILORIDE AVANDIA BYDUREON PEN HCL/HYDROCHLOROTHIAZID AZATHIOPRINE BYETTA E AZELASTINE HCL BYSTOLIC AMINOCAPROIC ACID AZILECT BYVALSON AMIODARONE HCL AZOPT CABERGOLINE AMITIZA BACLOFEN CALCITONIN,SALMON,SYNT AMITRIPTYLINE HCL BALCOLTRA HETIC AMLODIPINE BESYLATE BANZEL CALCITRIOL AMLODIPINE BENAZEPRIL HCL CALCIUM ACETATE BESYLATE/BENAZEPRIL HCL BENAZEPRIL CANASA AMOXAPINE HCL/HYDROCHLOROTHIAZID CANDESARTAN CILEXETIL AMOXICILLIN E CANDESARTAN ANAGRELIDE HCL BENZTROPINE MESYLATE CILEXETIL/HYDROCHLOROT ANASTROZOLE BETAXOLOL HCL HIAZIDE ANDROGEL BETIMOL CAPTOPRIL ANGELIQ BETOPTIC S CAPTOPRIL/HYDROCHLORO ANORO ELLIPTA BEVESPI AEROSPHERE THIAZIDE APIDRA BICALUTAMIDE CARAFATE APIDRA SOLOSTAR BIMATOPROST CARBAMAZEPINE APRISO BISOPROLOL FUMARATE CARBIDOPA CARBIDOPA/LEVODOPA CORLANOR DEXTROAMPHETAMINE CARBIDOPA/LEVODOPA/ENT COUMADIN SULF- ACAPONE CREON SACCHARATE/AMPHETAMIN CARNITOR CRESTOR E SULF-ASPARTATE CARNITOR SF CROMOLYN SODIUM DEXTROAMPHETAMINE CARTEOLOL HCL CUVPOSA SULFATE CARVEDILOL CYANOCOBALAMIN (VITAMIN DICYCLOMINE HCL CARVEDILOL PHOSPHATE B-12) DIGOXIN CELEBREX CYCLOSET DILANTIN CELECOXIB CYCLOSPORINE DILANTIN-125 CELONTIN CYCLOSPORINE, MODIFIED DILATRATE-SR CEPHALEXIN CYSTAGON DILTIAZEM HCL CEVIMELINE HCL DALIRESP DIPENTUM CHLOROTHIAZIDE DANTROLENE SODIUM DIPYRIDAMOLE CHLORPROMAZINE HCL DAPSONE DISOPYRAMIDE CHLORPROPAMIDE DARIFENACIN PHOSPHATE CHLORTHALIDONE HYDROBROMIDE DISULFIRAM CHOLESTYRAMINE (WITH DAYTRANA DIVALPROEX SODIUM SUGAR) DELZICOL DIVIGEL CHOLESTYRAMINE/ASPART DEPO-PROVERA DOFETILIDE AME DEPO-SUBQ PROVERA 104 DONEPEZIL HCL CIALIS DEPO-TESTOSTERONE DORZOLAMIDE HCL CILOSTAZOL DESIPRAMINE HCL DORZOLAMIDE CIMETIDINE DESLORATADINE HCL/TIMOLOL MALEATE CIMETIDINE HCL DESMOPRESSIN ACETATE DOXAZOSIN MESYLATE CITALOPRAM DESMOPRESSIN ACETATE DOXEPIN HCL HYDROBROMIDE (NON-REFRIGERATED) DOXERCALCIFEROL CLIMARA PRO DESOGESTREL-ETHINYL DOXYCYCLINE CLOBAZAM ESTRADIOL MONOHYDRATE CLOMIPRAMINE HCL DESOGESTREL-ETHINYL DROSPIRENONE/ETHINYL CLONAZEPAM ESTRADIOL/ETHINYL ESTRADIOL/LEVOMEFOLAT CLONIDINE ESTRADIOL E CALCIUM CLONIDINE HCL DESVENLAFAXINE DROXIA CLOZAPINE DESVENLAFAXINE DUAVEE COLCHICINE FUMARATE DULERA COLESEVELAM HCL DESVENLAFAXINE DULOXETINE HCL COLESTIPOL HCL SUCCINATE DUTASTERIDE COMBIGAN DEXAMETHASONE DYANAVEL XR COMBIPATCH DEXILANT DYRENIUM COMBIVENT RESPIMAT DEXMETHYLPHENIDATE HCL EDARBI COREG CR EDECRIN EFFIENT EZETIMIBE/SIMVASTATIN FUROSEMIDE ELESTRIN FAMCICLOVIR FYCOMPA ELIQUIS FAMOTIDINE GABAPENTIN ELIXOPHYLLIN FANAPT GABITRIL EMSAM FARESTON GALANTAMINE HBR ENALAPRIL MALEATE FARXIGA GELNIQUE ENALAPRIL FELBAMATE GEMFIBROZIL MALEATE/HYDROCHLOROT FELODIPINE GLIMEPIRIDE HIAZIDE FEMRING GLIPIZIDE ENTACAPONE FENOFIBRATE GLIPIZIDE/METFORMIN HCL ENTRESTO FENOFIBRATE GLYBURIDE EPANED NANOCRYSTALLIZED GLYBURIDE,MICRONIZED EPLERENONE FENOFIBRATE,MICRONIZED GLYBURIDE/METFORMIN EPROSARTAN MESYLATE FENOFIBRIC ACID (CHOLINE) HCL EQUETRO FENOFIBRIC ACID GLYCOPYRROLATE ERGOCALCIFEROL (VITAMIN FETZIMA GLYXAMBI D2) FINASTERIDE GRASTEK ERGOLOID MESYLATES FLAVOXATE HCL GUANFACINE HCL ESCITALOPRAM OXALATE FLECAINIDE ACETATE HALOPERIDOL ESOMEPRAZOLE FLOVENT DISKUS HALOPERIDOL LACTATE MAGNESIUM FLOVENT HFA HOMATROPINE HBR ESTRACE FLUDROCORTISONE HUMALOG ESTRADIOL ACETATE HUMALOG JUNIOR KWIKPEN ESTRADIOL/NORETHINDRON FLUNISOLIDE HUMALOG KWIKPEN U-100 E ACETATE FLUORIDE (SODIUM) HUMALOG KWIKPEN U-200 ESTRING FLUOXETINE HCL HUMALOG MIX 50-50 ESTROGEL FLUOXYMESTERONE HUMALOG MIX 50-50 ESTROGENS,ESTERIFIED/M FLUPHENAZINE HCL KWIKPEN ETHYLTESTOSTERONE FLUTAMIDE HUMALOG MIX 75-25 ESTROPIPATE FLUTICASONE HUMALOG MIX 75-25 ETHACRYNIC ACID PROPIONATE/SALMETEROL KWIKPEN ETHINYL XINAFOATE HUMULIN R U-500 ESTRADIOL/DROSPIRENONE FLUVASTATIN SODIUM HUMULIN R U-500 KWIKPEN ETHOSUXIMIDE FLUVOXAMINE MALEATE HYDRALAZINE HCL ETHYNODIOL DIACETATE- FOLIC ACID HYDROCHLOROTHIAZIDE ETHINYL ESTRADIOL FOSAMAX PLUS D HYDROCORTISONE ETIDRONATE DISODIUM FOSINOPRIL SODIUM HYDROXYCHLOROQUINE ETODOLAC FOSINOPRIL SULFATE EUTHYROX SODIUM/HYDROCHLOROTHI HYDROXYUREA EXEMESTANE AZIDE HYDROXYZINE HCL EZETIMIBE FOSRENOL HYDROXYZINE PAMOATE HYOSCYAMINE SULFATE LATUDA LOXAPINE SUCCINATE IBANDRONATE SODIUM LEFLUNOMIDE LUMIGAN IBUPROFEN LETROZOLE LYRICA IMIPRAMINE HCL LEUPROLIDE ACETATE LYSODREN INCRUSE ELLIPTA LEVALBUTEROL HCL MAPROTILINE HCL INDAPAMIDE LEVALBUTEROL TARTRATE MARPLAN INVOKAMET LEVATOL MEDROXYPROGESTERONE INVOKAMET XR LEVEMIR ACETATE INVOKANA LEVEMIR FLEXTOUCH MEGESTROL ACETATE IPRATROPIUM BROMIDE LEVETIRACETAM MELOXICAM IPRATROPIUM LEVITRA MEMANTINE HCL BROMIDE/ALBUTEROL LEVOBUNOLOL HCL MENEST SULFATE LEVOCARNITINE (WITH MENOSTAR IRBESARTAN SUGAR) MERCAPTOPURINE IRBESARTAN/HYDROCHLOR LEVOCARNITINE MESALAMINE OTHIAZIDE LEVOCETIRIZINE MESTINON ISORDIL DIHYDROCHLORIDE METAPROTERENOL ISOSORBIDE DINITRATE LEVONORGESTREL-ETHINYL SULFATE ISOSORBIDE MONONITRATE ESTRADIOL METFORMIN HCL ISOXSUPRINE HCL LEVONORGESTREL/ETHINYL METFORMIN HCL ER 500 ISRADIPINE ESTRADIOL AND ETHINYL (GENERIC FOR JANUMET ESTRADIOL GLUCOPHAGE XR) JANUMET XR LEVOTHYROXINE SODIUM METHAMPHETAMINE HCL JANUVIA LEVOXYL METHAZOLAMIDE JARDIANCE LIALDA METHIMAZOLE JENTADUETO LINZESS METHOTREXATE SODIUM JENTADUETO XR LIOTHYRONINE SODIUM METHYCLOTHIAZIDE K-TAB ER LISINOPRIL METHYLDOPA KLOR-CON 10 LISINOPRIL/HYDROCHLORO METHYLPHENIDATE HCL KLOR-CON 8 THIAZIDE METHYLPREDNISOLONE KLOR-CON M15 LITHIUM CARBONATE METIPRANOLOL KOMBIGLYZE XR LITHIUM CITRATE METOLAZONE LABETALOL HCL LIVALO METOPROLOL SUCCINATE LACTULOSE LO LOESTRIN FE METOPROLOL TARTRATE LAMOTRIGINE LODOSYN METOPROLOL LANOXIN LOPERAMIDE HCL TARTRATE/HYDROCHLORO LANSOPRAZOLE LOSARTAN POTASSIUM THIAZIDE LANTHANUM CARBONATE LOSARTAN MEXILETINE HCL LANTUS POTASSIUM/HYDROCHLORO MIGLITOL LANTUS SOLOSTAR THIAZIDE MINASTRIN 24 FE LATANOPROST LOVASTATIN MINOCYCLINE HCL MINOXIDIL NORETHINDRONE ACETATE- PALIPERIDONE MIRTAZAPINE ETHINYL PANTOPRAZOLE SODIUM MISOPROSTOL ESTRADIOL/FERROUS PARICALCITOL MODAFINIL FUMARATE PAROXETINE HCL MOEXIPRIL HCL NORETHINDRONE-ETHINYL PAXIL MOEXIPRIL ESTRADIOL PEGANONE HCL/HYDROCHLOROTHIAZID NORETHINDRONE-ETHINYL PENICILLIN V POTASSIUM E ESTRADIOL/FERROUS PENTASA MOLINDONE HCL FUMARATE PENTOXIFYLLINE MONTELUKAST SODIUM NORETHINDRONE- PERINDOPRIL ERBUMINE MULTAQ MESTRANOL PERPHENAZINE MYCOPHENOLATE MOFETIL NORGESTIMATE-ETHINYL PERPHENAZINE/AMITRIPTYL MYRBETRIQ ESTRADIOL INE HCL NADOLOL NORGESTREL-ETHINYL PHENELZINE SULFATE NAMENDA ESTRADIOL PHENOBARBITAL NAPROXEN NORPACE CR PHENYTOIN NAPROXEN SODIUM NORTRIPTYLINE HCL PHENYTOIN SODIUM NASCOBAL NOVOLOG EXTENDED NATAZIA NOVOLOG FLEXPEN PHOSLYRA NATEGLINIDE NOVOLOG MIX 70-30 PHOSPHOLINE IODIDE NATURE-THROID NOVOLOG MIX 70-30 PILOCARPINE HCL NEBUPENT FLEXPEN PIMOZIDE NEFAZODONE HCL NUVARING PINDOLOL NESINA OLANZAPINE PIOGLITAZONE HCL NEUPRO OLMESARTAN MEDOXOMIL PIOGLITAZONE NIACIN OLMESARTAN HCL/METFORMIN HCL NICARDIPINE HCL MEDOXOMIL/HYDROCHLOR POTASSIUM NIFEDIPINE OTHIAZIDE BICARBONATE/CITRIC ACID NISOLDIPINE OMEGA-3 ACID ETHYL POTASSIUM CHLORIDE NITRO-BID ESTERS POTASSIUM CITRATE NITRO-DUR OMEPRAZOLE POTIGA NITROGLYCERIN ONFI PRADAXA NIZATIDINE ONGLYZA PRAMIPEXOLE DI-HCL NORELGESTROMIN/ETHINYL ORALAIR PRANDIN ESTRADIOL ORAP PRASUGREL HCL NORETHINDRONE OSPHENA PRAVASTATIN SODIUM NORETHINDRONE ACETATE OXANDROLONE PRAZOSIN HCL NORETHINDRONE ACETATE- OXCARBAZEPINE PREDNISOLONE ETHINYL ESTRADIOL OXYBUTYNIN CHLORIDE PREDNISOLONE SOD OXYTROL PHOSPHATE PACERONE PREDNISONE PREFEST QUINIDINE SULFATE SILODOSIN PREMARIN QVAR SIMBRINZA PREMPHASE RABEPRAZOLE SODIUM SIMVASTATIN PREMPRO RAGWITEK SODIUM PHENYLBUTYRATE PRENATAL VITS WITH RALOXIFENE HCL SOLIQUA 100-33 CALCIUM NO.72/FERROUS RAMIPRIL SOTALOL HCL FUMARATE/FOLIC ACID RANEXA SPIRIVA PREVACID RANITIDINE HCL SPIRIVA RESPIMAT PREVIDENT 5000 RAPAFLO SPIRONOLACTONE PREVIDENT RASAGILINE MESYLATE SPIRONOLACTONE/HYDROC PREVIDENT 5000 ENAMEL RENAGEL HLOROTHIAZIDE PROTECT RENVELA STIMATE PREVIDENT 5000 PLUS REPAGLINIDE STIOLTO RESPIMAT PREVIDENT 5000 SENSITIVE RESCULA STRATTERA PRIMIDONE RESERPINE STRIVERDI RESPIMAT PRISTIQ RESTASIS SUBOXONE PROAIR HFA RESTASIS MULTIDOSE SUCRALFATE PROAIR RESPICLICK REXULTI SULFASALAZINE PROBENECID RIDAURA SYMBICORT PROBENECID/COLCHICINE RILUTEK SYMLINPEN 120 PROGESTERONE, RILUZOLE SYMLINPEN 60 MICRONIZED RIOMET SYNJARDY PROGLYCEM RISEDRONATE SODIUM SYNJARDY XR PROPAFENONE HCL RISPERIDONE SYNTHROID PROPRANOLOL HCL RITALIN LA TADALAFIL PROPYLTHIOURACIL RIVASTIGMINE TADALAFIL 20 MG TABLET PROTRIPTYLINE HCL RIVASTIGMINE TARTRATE (GENERIC FOR CIALIS) PULMICORT FLEXHALER ROPINIROLE HCL TAMOXIFEN CITRATE PURIXAN ROSUVASTATIN CALCIUM TAMSULOSIN HCL PYRIDOSTIGMINE BROMIDE RYTARY TANZEUM QNASL SAFYRAL
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