Selected Maintenance Medications Blue Shield of California BRAND NAME of GENERIC NAME of selected Treatment Category selected maintenance maintenance medication medication Alzheimer's Disease Aricept donepezil hcl Alzheimer's Disease Exelon rivastigmine Alzheimer's Disease Mestinon pyridostigmine bromide Namenda Alzheimer's Disease memantine hcl Namenda XR Alzheimer's Disease Namzaric memantine hcl/donepezil hcl Alzheimer's Disease Razadyne galantamine hydrobromide Arthritis or Gout Duzallo lesinurad/allopurinol Arthritis or Gout Gloperba colchicine Arthritis or Gout Leflunomide leflunomide Arthritis or Gout Mitigare colchicine Arthritis or Gout Plaquenil hydroxychloroquine sulfate Arthritis or Gout Probenecid probenecid Arthritis or Gout Ridaura auranofin Arthritis or Gout Uloric febuxostat
Arthritis or Gout Zurampic lesinurad Arthritis or Gout Zyloprim allopurinol Asthma or COPD Accolate zafirlukast Asthma or COPD Advair fluticasone/salmeterol Aerobid Asthma or COPD flunisolide Aerobid-M Asthma or COPD Aerospan flunisolide Asthma or COPD Airduo Respiclick fluticasone/salmeterol Asthma or COPD Alvesco ciclesonide Asthma or COPD Aminophylline aminophylline Asthma or COPD Anoro Ellipta umeclidinium/vilanterol Asthma or COPD Arcapta Neohaler indacaterol maleate Asthma or COPD Armonair Respiclick fluticasone propionate Asthma or COPD Arnuity Ellipta fluticasone furoate Asthma or COPD Asmanex mometasone furoate Asthma or COPD Atrovent HFA ipratropium bromide Asthma or COPD Azmacort triamcinolone acetonide Asthma or COPD Bevespi Aerosphere glycopyrrolate/formoterol Asthma or COPD Breo Ellipta fluticasone/vilanterol Asthma or COPD Brovana arformoterol tartrate Page 1 of 19
Effective: 05/2020
Combivent Asthma or COPD ipratropium/albuterol sulfate Combivent Respimat Asthma or COPD Daliresp roflumilast Asthma or COPD Duaklir Pressair alcidinium brom/formoterol Asthma or COPD Dulera mometasone/formoterol Elixophyllin Asthma or COPD Uniphyl theophylline anhydrous Theo-24 Asthma or COPD Flovent fluticasone propionate Foradil, Asthma or COPD formoterol fumarate Perforomist Asthma or COPD Incruse Ellipta umeclidinium bromide Asthma or COPD Intal cromolyn sodium Asthma or COPD Lonhala Magnair glycopyrrolate Asthma or COPD Pulmicort budesonide Asthma or COPD Qvar beclomethasone dipropionate Asthma or COPD Qvar Redihaler beclomethasone dipropionate Asthma or COPD Seebri Neohaler glycopyrrolate Asthma or COPD Serevent Diskus salmeterol xinafoate Asthma or COPD Singulair montelukast sodium Spiriva Asthma or COPD tiotropium bromide Spiriva Respimat Asthma or COPD Stiolto Respimat tiotropium bromide/olodaterol hcl Asthma or COPD Striverdi Respimat olodaterol hcl Asthma or COPD Symbicort budesonide/formoterol fumarate Asthma or COPD Trelegy Ellipta Fluticasone/umeclidin/vilanter Asthma or COPD Tudorza Pressair aclidinium bromide Asthma or COPD Utibron indacaterol/glycopyrrolate Asthma or COPD Vospire ER albuterol sulfate Asthma or COPD Zyflo CR zileuton Bladder Gelnique oxybutynin chloride Contraceptives (Birth control) Altavera levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Alyacen norethindrone/ethinyl estradiol Contraceptives (Birth control) Amethyst levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Apri desogestrel/ethinyl estradiol Contraceptives (Birth control) Aranelle norethindrone/ethinyl estradiol Contraceptives (Birth control) Aviane levonorgestrel/ethinyl estradiol desogestrel/ethinyl estradiol, ethinyl Contraceptives (Birth control) Azurette estradiol
Contraceptives (Birth control) Balcoltra levonorgestrel/ethinyl estradiol/iron
Contraceptives (Birth control) Balziva norethindrone/ethinyl estradiol drospirenone/ethinyl Contraceptives (Birth control) Beyaz estradiol/levomefolate
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Effective: 05/2020
norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Blisovi fe fumarate Contraceptives (Birth control) Brevicon norethindrone/ethinyl estradiol Contraceptives (Birth control) Briellyn norethindrone/ethinyl estradiol Contraceptives (Birth control) Camila norethindrone Contraceptives (Birth control) Caziant desogestrel/ethinyl estradiol Contraceptives (Birth control) Cesia desogestrel/ethinyl estradiol Contraceptives (Birth control) Chateal levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Cryselle norgestrel/ethinyl estradiol Contraceptives (Birth control) Cyclafem norethindrone/ethinyl estradiol Contraceptives (Birth control) Cyclessa desogestrel/ethinyl estradiol Contraceptives (Birth control) Cyred desogestrel/ethinyl estradiol Contraceptives (Birth control) Dasetta norethindrone/ethinyl estradiol Contraceptives (Birth control) Delyla levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Desogen desogestrel/ethinyl estradiol Contraceptives (Birth control) Elinest norgestrel/ethinyl estradiol drospiren-e.estrad- Contraceptives (Birth control) drospiren-e.estrad-l.mefol l.mefol Contraceptives (Birth control) Emoquette desogestrel/ethinyl estradiol Contraceptives (Birth control) Enpresse levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Enskyce desogestrel/ethinyl estradiol Contraceptives (Birth control) Errin norethindrone Contraceptives (Birth control) Estarylla norgestimate/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Estrostep Fe fumarate Contraceptives (Birth control) Falmina levonorgestrel/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Femcon Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Generess Fe fumarate Contraceptives (Birth control) Gianvi drospirenone/ethinyl estradiol Contraceptives (Birth control) Gildagia norethindrone/ethinyl estradiol Contraceptives (Birth control) Gildess norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Gildess Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Gildess 24 Fe fumarate
Contraceptives (Birth control) Hailey norethindrone ac-eth estradiol
Contraceptives (Birth control) Heather norethindrone Contraceptives (Birth control) Isibloom desogestrel/ethinyl estradiol Contraceptives (Birth control) Jencycla norethindrone Contraceptives (Birth control) Jolivette norethindrone Contraceptives (Birth control) Juleber desogestrel/ethinyl estradiol Contraceptives (Birth control) Junel norethindrone/ethinyl estradiol Page 3 of 19
Effective: 05/2020
norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Junel Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Junel 24 Fe fumarate
Contraceptives (Birth control) Kaliga norethindrone/ethinyl estradiol
desogestrel/ethinyl estradiol, ethinyl Contraceptives (Birth control) Kariva estradiol Contraceptives (Birth control) Kelnor 1-35 ethynodiol/ethinyl estradiol Contraceptives (Birth control) Kelnor 1-50 ethynodiol/ethinyl estradiol desogestrel/ethinyl estradiol, ethinyl Contraceptives (Birth control) Kimidess estradiol Contraceptives (Birth control) Kurvelo levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Larin norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Larin Fe fumarate Contraceptives (Birth control) Leena norethindrone/ethinyl estradiol Contraceptives (Birth control) Lessina levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Levlen 28 levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Levonest levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Levora-28 levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Lillow levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Loestrin norethindrone/ethinyl estradiol Loestrin 24 Fe norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Lomedia 24 Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Loestrin Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Lo Loestrin FE fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Lo Minastrin Fe fumarate Contraceptives (Birth control) Lo-Ovral-28 norgestrel/ethinyl estradiol Contraceptives (Birth control) Loryna drospirenone/ethinyl estradiol Contraceptives (Birth control) Low-Ogestrel norgestrel/ethinyl estradiol Contraceptives (Birth control) Lutera levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Lybrel levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Marlissa levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Microgestin norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Microgestin Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Microgestin 24 Fe fumarate Contraceptives (Birth control) Micronor norethindrone
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Effective: 05/2020
Contraceptives (Birth control) Mili norgestimate/ethinyl estradiol
norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Minastrin 24 Fe fumarate desogestrel/ethinyl estradiol, ethinyl Contraceptives (Birth control) Mircette estradiol Contraceptives (Birth control) Modicon norethindrone/ethinyl estradiol Contraceptives (Birth control) Mono-linyah norgestimate/ethinyl estradiol Contraceptives (Birth control) Mononessa norgestimate/ethinyl estradiol Contraceptives (Birth control) Myzilra levonorgestrel/ethinyl estradiol estradiol valerate, dienogest/estradiol Contraceptives (Birth control) Natazia valerate, estradiol valerate Necon 0.5-35, 1-35, 10- Contraceptives (Birth control) norethindrone/ethinyl estradiol 11, 777 Contraceptives (Birth control) Necon 1-50 norethindrone/mestranol Contraceptives (Birth control) Nikki drospirenone/ethinyl estradiol Contraceptives (Birth control) Nora-Be norethindrone Contraceptives (Birth control) Nordette-28 levonorgestrel/ethinyl estradiol Contraceptives (Birth control) norethindrone 0.35mg norethindrone Contraceptives (Birth control) Norinyl 1+35 norethindrone/ethinyl estradiol Contraceptives (Birth control) Norinyl 1+50 norethindrone/mestranol Contraceptives (Birth control) Norlyda norethindrone Contraceptives (Birth control) Norlyroc norethindrone Contraceptives (Birth control) Nor-Q-D norethindrone Contraceptives (Birth control) Nortrel norethindrone/ethinyl estradiol Contraceptives (Birth control) Nuvaring etonogestrel/ethinyl estradiol Contraceptives (Birth control) Ocella drospirenone/ethinyl estradiol Contraceptives (Birth control) Ogestrel norgestrel/ethinyl estradiol Contraceptives (Birth control) Orsythia levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Ortho Cyclen norgestimate/ethinyl estradiol Contraceptives (Birth control) Ortho Evra norelgestromin/ethinyl estradiol Contraceptives (Birth control) Ortho Tri-Cyclen norgestimate/ethinyl estradiol Contraceptives (Birth control) Ortho Tri-Cyclen Lo norgestimate/ethinyl estradiol Contraceptives (Birth control) Ortho-Cept desogestrel/ethinyl estradiol Contraceptives (Birth control) Ortho-Micronor norethindrone Contraceptives (Birth control) Ortho-Novum norethindrone/ethinyl estradiol Contraceptives (Birth control) Ovcon-35 norethindrone/ethinyl estradiol Contraceptives (Birth control) Ovcon-50 norethindrone/ethinyl estradiol Contraceptives (Birth control) Philith norethindrone/ethinyl estradiol desogestrel/ethinyl estradiol, ethinyl Contraceptives (Birth control) Pimtrea estradiol Contraceptives (Birth control) Pirmella norethindrone/ethinyl estradiol Contraceptives (Birth control) Portia levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Previfem norgestimate/ethinyl estradiol
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Effective: 05/2020
Contraceptives (Birth control) Reclipsen desogestrel/ethinyl estradiol drospirenone/ethinyl Contraceptives (Birth control) Safyral estradiol/levomefolate Contraceptives (Birth control) Sharobel norethindrone Contraceptives (Birth control) Solia desogestrel/ethinyl estradiol Contraceptives (Birth control) Slynd drospirenone Contraceptives (Birth control) Sprintec norgestimate/ethinyl estradiol Contraceptives (Birth control) Sronyx levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Syeda drospirenone/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Tarina Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Taytulla fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Tilia Fe fumarate Contraceptives (Birth control) Tri-estarylla norgestimate/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Tri-Legest Fe fumarate Contraceptives (Birth control) Tri-linyah norgestimate/ethinyl estradiol Contraceptives (Birth control) Tri-Lo-Marzia norgestimate/ethinyl estradiol Contraceptives (Birth control) Tri-Lo-Sprintec norgestimate/ethinyl estradiol Contraceptives (Birth control) Trinessa norgestimate/ethinyl estradiol Contraceptives (Birth control) Trinessa Lo norgestimate/ethinyl estradiol Contraceptives (Birth control) Tri-Norinyl norethindrone/ethinyl estradiol Contraceptives (Birth control) Tri-Previfem norgestimate/ethinyl estradiol Contraceptives (Birth control) Tri-Sprintec norgestimate/ethinyl estradiol Contraceptives (Birth control) Trivora-28 levonorgestrel/ethinyl estradiol Contraceptives (Birth control) Tri-Vylibra norgestimate/ethinyl estradiol Contraceptives (Birth control) Velivet desogestrel/ethinyl estradiol Contraceptives (Birth control) Vestura drospirenone/ethinyl estradiol desogestrel/ethinyl estradiol, ethinyl Contraceptives (Birth control) Viorele estradiol
Contraceptives (Birth control) Vylibra norgestimate/ethinyl estradiol
Contraceptives (Birth control) Wera norethindrone/ethinyl estradiol Contraceptives (Birth control) Wymzya Fe norethindrone/ethinyl estradiol/iron Contraceptives (Birth control) Yasmin 28 drospirenone/ethinyl estradiol Contraceptives (Birth control) Yaz drospirenone/ethinyl estradiol Contraceptives (Birth control) Zarah drospirenone/ethinyl estradiol Contraceptives (Birth control) Zenchent norethindrone/ethinyl estradiol norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Zenchent Fe fumarate norethindrone/ethinyl estradiol/ferrous Contraceptives (Birth control) Zeosa fumarate
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Effective: 05/2020
Contraceptives (Birth control) Zovia 1-35E ethynodiol/ethinyl estradiol Contraceptives (Birth control) Zovia 1-50E ethynodiol/ethinyl estradiol Actoplus MET Diabetes pioglitazone/metformin Actoplus MET XR Diabetes Actos pioglitazone Diabetes Adlyxin lixisenatide Diabetes Amaryl glimepiride Diabetes Bydureon pen exenatide microspheres Bydureon BCise auto Diabetes exenatide microspheres injectorr Diabetes Chlorpropamide chlorpropamide Diabetes Cycloset bromocriptine mesylate Diabetes Diabeta glyburide Diabetes Duetact pioglitazone/glimepiride Diabetes Farxiga dapagliflozin propanediol Fortamet Glucophage Diabetes metformin Glumetza Riomet Diabetes Glucotrol glipizide Diabetes Glucovance glyburide/metformin Diabetes Glyset miglitol Diabetes Glyxambi empagliflozin/linagliptin Invokamet Diabetes canagliflozin/metformin hcl Invokamet XR Diabetes Invokana canagliflozin Janumet Diabetes sitagliptin/metformin hcl Janumet XR Diabetes Januvia sitagliptin phosphate Diabetes Jardiance empagliflozin Jentadueto Diabetes linagliptin/metformin Jentadueto XR Diabetes Juvisync sitagliptin/simvastatin Diabetes Kazano alogliptin benzoate/metformin Diabetes Kombiglyze XR saxagliptin hcl/metformin hcl Diabetes Metaglip glipizide/metformin Diabetes Nesina alogliptin benzoate Diabetes Onglyza saxagliptin hcl Diabetes Oseni alogliptin benzoate/pioglitazone Diabetes Ozempic semaglutide Diabetes Prandin repaglinide Diabetes Precose acarbose Diabetes Qtern dapagliflozin/saxagliptin Diabetes Rybelsus semaglutide Diabetes Segluromet ertugliflozin/metformin Page 7 of 19
Effective: 05/2020
Diabetes Soliqua insulin glargine/lixisenatide Diabetes Starlix nateglinide
Diabetes Steglatro ertugliflozin
Diabetes Steglujan ertugliflozin/sitagliptin
Synjardy, Diabetes empagliflozin/metformin hcl Synjardy XR Diabetes Tanzeum albiglutide Diabetes Tolazamide tolazamide Diabetes Tolbutamide tolbutamide Diabetes Tradjenta linagliptin Diabetes Trijardy XR empagliflozin/linaglip/metformin Diabetes Trulicity dulaglutide Diabetes Xigduo XR dapagliflozin/metformin hcl Diabetes Xultophy insulin degludec/liraglutide Enlarged Prostate (BPH) Avodart dutasteride Enlarged Prostate (BPH) Flomax tamsulosin hcl Enlarged Prostate (BPH) Jalyn dutasteride/tamsulosin hcl Enlarged Prostate (BPH) Proscar finasteride Enlarged Prostate (BPH) Rapaflo silodosin Enlarged Prostate (BPH) Uroxatral alfuzosin HCL Eye Conditions or Glaucoma Alphagan-P brimonidine tartrate Eye Conditions or Glaucoma Atropine Sulfate atropine sulfate Eye Conditions or Glaucoma Azopt brinzolamide Eye Conditions or Glaucoma Betagan levobunolol hcl Eye Conditions or Glaucoma Betimol timolol Eye Conditions or Glaucoma Betoptic-S betaxolol hcl Eye Conditions or Glaucoma Carteolol HCL carteolol hcl Eye Conditions or Glaucoma Cequa cyclosporine Eye Conditions or Glaucoma Combigan brimonidine tartrate/timolol Eye Conditions or Glaucoma Cosopt dorzolamide hcl/timolol Eye Conditions or Glaucoma Cosopt PF dorzolamide hcl/timolol/pf Eye Conditions or Glaucoma Cyclogyl cyclopentolate hcl Eye Conditions or Glaucoma Cyclomydril cyclopentolate/phenylephrine Eye Conditions or Glaucoma Dipivefrin HCL dipivefrin hcl Homatropaire Eye Conditions or Glaucoma homatropine hbr Isopto Homatropine Eye Conditions or Glaucoma Isopto Carbachol carbachol Eye Conditions or Glaucoma Isopto Hyoscine scopolamine hydrobromide Istalol Eye Conditions or Glaucoma timolol maleate Timoptic Eye Conditions or Glaucoma Lumigan bimatoprost Eye Conditions or Glaucoma Metipranolol metipranolol
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Effective: 05/2020
Eye Conditions or Glaucoma Phospholine Iodide echothiophate iodide Eye Conditions or Glaucoma Pilopine HS pilocarpine hcl Eye Conditions or Glaucoma Restasis cyclosporine Eye Conditions or Glaucoma Rocklatan netarsudil mesylate/latanoprost Eye Conditions or Glaucoma Simbrinza brinzolamide/brimonidine tartrate Eye Conditions or Glaucoma Rhopressa netarsudil mesylate Eye Conditions or Glaucoma Travatan travoprost (benzalkonium) Eye Conditions or Glaucoma Tropicamide tropicamide Eye Conditions or Glaucoma Trusopt dorzolamide hcl Eye Conditions or Glaucoma Vyzulta latanoprostene bunod Eye Conditions or Glaucoma Xalatan latanoprost Eye Conditions or Glaucoma Xelpros latanoprost Eye Conditions or Glaucoma Xiidra lifitegrast Eye Conditions or Glaucoma Zioptan tafluprost
Apriso Asacol, Asacol HD Canasa Gastrointestinal Conditions mesalamine Delzicol Lialda Pentasa
Gastrointestinal Conditions Azulfidine sulfasalazine Gastrointestinal Conditions Dipentum olsalazine sodium Creon Pancreaze Gastrointestinal Conditions Pertzye lipase/amylase/protease Viokace Zenpep Gastrointestinal Conditions Motegrity prucalopride succinate Heart Conditions Accupril quinapril hcl Heart Conditions Accuretic quinapril/hydrochlorothiazide Heart Conditions Acebutolol HCL acebutolol hcl Heart Conditions Aceon perindopril erbumine Adalat CC Afeditab CR Heart Conditions Nifediac CC nifedipine Nifedical XL Procardia XL Heart Conditions Aggrenox aspirin/dipyridamole Heart Conditions Agrylin anagrelide hcl Heart Conditions Aldactazide spironolactone/hydrochlorothiazide Heart Conditions Aldactone spironolactone Heart Conditions Altace ramipril Heart Conditions Amiloride HCL-HCTZ amiloride/hydrochlorothiazide Heart Conditions Amturnide aliskiren/amlodipine/hctz
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Effective: 05/2020
Heart Conditions Atacand candesartan cilexetil Heart Conditions Atacand HCT candesartan/hydrochlorothiazide Atenolol- Heart Conditions atenolol/chlorthalidone Chlorthalidone Heart Conditions Avalide irbesartan/hydrochlorothiazide Heart Conditions Avapro irbesartan Heart Conditions Azor amlodipine/olmesartan Heart Conditions Benicar olmesartan medoxomil Heart Conditions Benicar HCT olmesartan/hydrochlorothiazide Betapace Heart Conditions sotalol hcl Sorine Heart Conditions Bidil isosorbide dinitrate/hydralazine hcl Heart Conditions Brilinta tacagrelor Heart Conditions Bumetanide bumetanide Heart Conditions Bystolic nebivolol hcl Heart Conditions Caduet amlodipine/atorvastatin calcium Calan SR Heart Conditions verapamil hcl Verelan Heart Conditions Captopril captopril Heart Conditions Captopril-HCTZ captopril/hydrochlorothiazide Heart Conditions Cardene SR nicardipine hcl Cardizem Heart Conditions diltiazem hcl Cartia XT Heart Conditions Cardura doxazosin mesylate Heart Conditions Carospir spironolactone Catapres Heart Conditions clonidine Nexiclon XR Heart Conditions Chlorthalidone chlorthalidone Cordarone Heart Conditions amiodarone hcl Pacerone Heart Conditions Carvediol phosphate carvediol Heart Conditions Coreg carvedilol Heart Conditions Corlanor ivabradine hcl Heart Conditions Cozaar losartan potassium Heart Conditions Diamox Sequels acetazolamide Dilacor XR Dilt-CD Heart Conditions diltiazem hcl Dilt-XR Diltzac ER Heart Conditions Diovan valsartan Heart Conditions Diovan HCT valsartan/hydrochlorothiazide Heart Conditions Dipyridamole dipyridamole Heart Conditions Diuril chlorothiazide Heart Conditions Durlaza aspirin Heart Conditions Dutoprol metoprolol succinate/hctz Page 10 of 19
Effective: 05/2020
Dyazide Heart Conditions triamterene/hydrochlorothiazide Maxzide Heart Conditions Dynacirc CR isradipine Heart Conditions Dyrenium triamterene Heart Conditions Edarbi azilsartan medoxomil Heart Conditions Edarbyclor azilsartan medoxomil/chlorthalidone Heart Conditions Edecrin ethacrynic acid Heart Conditions Effient prasugrel hydrochloride Heart Conditions Entresto sacubitril/valsartan Heart Conditions Epaned enalapril maleate Heart Conditions Exforge amlodipine/valsartan Heart Conditions Exforge HCT amlodipine/valsartan/hctz Heart Conditions Felodipine ER felodipine Heart Conditions Fosinopril-HCTZ fosinopril/hydrochlorothiazide Heart Conditions Guanfacine guanfacine hcl Heart Conditions Hydralazine HCL hydralazine hcl Heart Conditions Hydro Diuril hydrochlorothiazide Heart Conditions Hytrin terazosin hcl Heart Conditions Hyzaar losartan/hydrochlorothiazide Heart Conditions Imdur isosorbide mononitrate Heart Conditions Indapamide indapamide Inderal LA Heart Conditions propranolol hcl Innopran XL Heart Conditions Inspra eplerenone Heart Conditions Isordil isosorbide dinitrate Heart Conditions Kapspargo metoprolol succinate Heart Conditions Katerzia amlodipine benzoate Heart Conditions Labetalol HCL labetalol hcl Heart Conditions Lanoxin digoxin Heart Conditions Lasix furosemide Heart Conditions Levatol penbutolol sulfate Heart Conditions Livalo pitavastatin Heart Conditions Lopressor metoprolol tartrate Heart Conditions Lotensin benazepril hcl Heart Conditions Lotensin HCT benazepril/hydrochlorothiazide Heart Conditions Lotrel amlodipine /benazepril Heart Conditions Mavik trandolapril Heart Conditions Methazolamide methazolamide Heart Conditions Methyclothiazide methyclothiazide Heart Conditions Methyldopa methyldopa Heart Conditions Metolazone metolazone Heart Conditions Metoprolol metoprolol Heart Conditions Metoprolol-HCTZ metoprolol/hydrochlorothiazide Heart Conditions Mexiletine HCL mexiletine hcl
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Effective: 05/2020
Heart Conditions Micardis telmisartan Heart Conditions Micardis HCT telmisartan/hydrochlorothiazide Heart Conditions Midamor amiloride hcl Minitran Heart Conditions Nitro-BID nitroglycerin Nitro-DUR Heart Conditions Minoxidil minoxidil Heart Conditions Monopril fosinopril sodium Heart Conditions Multaq dronedarone Heart Conditions Nadolol nadolol Heart Conditions Nexiclon XR clonidine hcl Heart Conditions Nicardipine HCL nicardipine hcl Heart Conditions Norpace CR disopyramide phosphate Heart Conditions Norvasc amlodipine Heart Conditions Pindolol pindolol Heart Conditions Plavix clopidogrel bisulfate Heart Conditions Pletal cilostazol Heart Conditions Prazosin HCL prazosin hcl Heart Conditions Prestalia perindopril/amlodipine Prinivil Heart Conditions lisinopril Zestril Heart Conditions Propranolol-HCTZ propranolol/hydrochlorothiazide Heart Conditions Quinidine Gluconate quinidine gluconate Heart Conditions Quinidine Sulfate quinidine sulfate Heart Conditions Ranexa ranolazine Heart Conditions Reserpine reserpine Heart Conditions Rythmol SR propafenone hcl Heart Conditions Sotylize sotalol hcl Heart Conditions Sular nisoldipine Heart Conditions Tambocor flecainide acetate Heart Conditions Tarka trandolapril/verapamil hcl Taztia XT Heart Conditions diltiazem hcl Tiazac Heart Conditions Tekamlo aliskiren/amlodipine Heart Conditions Tekturna aliskiren hemifumarate Heart Conditions Tekturna HCT aliskiren/hydrochlorothiazide Heart Conditions Tenormin atenolol Heart Conditions Teveten eprosartan mesylate Heart Conditions Teveten HCT eprosartan/hydrochlorothiazide Heart Conditions Ticlopidine HCL ticlopidine hcl Heart Conditions Tikosyn dofetilide Heart Conditions Toprol XL metoprolol succinate Heart Conditions Torsemide torsemide Heart Conditions Tribenzor olmesartan/amlodipine/hctz
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Effective: 05/2020
Heart Conditions Twynsta telmisartan/amlodopine Heart Conditions Uniretic moexipril/hydrochlorothiazide Heart Conditions Univasc moexipril hcl Heart Conditions Vaseretic enalapril/hydrochlorothiazide Heart Conditions Vasotec enalapril maleate Heart Conditions Yosprala aspirin/omeprazole Heart Conditions Zebeta bisoprolol fumarate Heart Conditions Zestoretic lisinopril/hydrochlorothiazide Heart Conditions Ziac bisoprolol fumarate/hctz Heart Conditions Zontivity vorapaxar sulfate High Cholesterol Advicor niacin/lovastatin High Cholesterol Altoprev lovastatin High Cholesterol Antara fenofibrate, micronized Cholestyramine Light High Cholesterol cholestyramine/aspartame Prevalite High Cholesterol Colestid colestipol hcl High Cholesterol Crestor rosuvastatin calcium High Cholesterol Ezallor Sprinkle rosuvastatin calcium Fenoglide Lipofen High Cholesterol fenofibrate Lofibra Triglide High Cholesterol Flolipid simvastatin High Cholesterol Gemfibrozil gemfibrozil High Cholesterol Lescol fluvastatin sodium High Cholesterol Lipitor atorvastatin calcium High Cholesterol Liptruzet ezetimibe/atrovastatin calcium High Cholesterol Livalo pitavastatin calcium High Cholesterol Lovaza omega-3 acid ethyl esters Niacor High Cholesterol niacin Niaspan High Cholesterol Pravachol pravastatin sodium High Cholesterol Nexletol bempedoic acid High Cholesterol Questran cholestyramine/sucrose High Cholesterol Simcor niacin/simvastatin High Cholesterol Tricor fenofibrate nanocrystallized High Cholesterol Trilipix fenofibric acid (choline) High Cholesterol Vascepa icosapent ethyl High Cholesterol Vytorin ezetimibe/simvastatin High Cholesterol Welchol colesevelam hcl High Cholesterol Zetia ezetimibe High Cholesterol Zocor simvastatin High Cholesterol Zypitamag pivastatin magnesium HIV or Hepatitis Aptivus tipranavir
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Effective: 05/2020
HIV or Hepatitis Atripla efavirenz/emtricitab/tenofovir HIV or Hepatitis Baraclude entecavir HIV or Hepatitis Biktarvy bictegravir HIV or Hepatitis Cimduo lamivudine/tenofovir/disop fum HIV or Hepatitis Combivir lamivudine/zidovudine HIV or Hepatitis Complera emtricitabine/rilpivirine/tenofovir HIV or Hepatitis Crixivan indinavir sulfate HIV or Hepatitis Descovy emtricitabine/tenofovir/alafenamide HIV or Hepatitis Delstrigo doravirine/lamivudine/tenofovir HIV or Hepatitis Dovato dolutegravir sodium/lamivudine HIV or Hepatitis Edurant rilpivirine hydrochloride Epivir HIV or Hepatitis lamivudine Epivir HBV HIV or Hepatitis Epzicom abacavir sulfate/lamivudine HIV or Hepatitis Evotaz atazanavir sulfate/cobicistat elvitegravir/cobicistat/emtricitabine/ HIV or Hepatitis Genvoya tenofovir alafenamide HIV or Hepatitis Intelence etravirine HIV or Hepatitis Invirase saquinavir mesylate Isentress, HIV or Hepatitis raltegravir potassium Isentress HD HIV or Hepatitis Kaletra lopinavir/ritonavir HIV or Hepatitis Lexiva fosamprenavir calcium HIV or Hepatitis Norvir ritonavir emtricitabine/rilpivirine/tenofovir HIV or Hepatitis Odefsey alafenamide
HIV or Hepatitis Pifeltro doravirine
HIV or Hepatitis Prezcobix darunavir/cobicistat HIV or Hepatitis Prezista darunavir ethanolate HIV or Hepatitis Retrovir zidovudine HIV or Hepatitis Reyataz atazanavir sulfate HIV or Hepatitis Selzentry maraviroc elvitegravir/cobicistat/emtricitabine/ HIV or Hepatitis Stribild tenofovir disoproxil HIV or Hepatitis Sustiva efavirenz efavirenz/lamivudine/tenofovir HIV or Hepatitis Symfi disoproxil efavirenz/lamivudine/tenofovir HIV or Hepatitis Symfilo disoproxil HIV or Hepatitis Symtuza darunavir/cob/emtri/tenof alaf HIV or Hepatitis Tivicay dolutegravir sodium HIV or Hepatitis Triumeq abacavir/dolutegravir/lamivudine HIV or Hepatitis Trizivir abacavir/lamivudine/zidovudine HIV or Hepatitis Truvada emtricitabine/tenofovir Page 14 of 19
Effective: 05/2020
HIV or Hepatitis Tybost cobicistat HIV or Hepatitis Tyzeka telbivudine HIV or Hepatitis Videx EC didanosine HIV or Hepatitis Viracept nelfinavir mesylate HIV or Hepatitis Viramune nevirapine HIV or Hepatitis Viramune XR nevirapine HIV or Hepatitis Viread tenofovir disoproxil fumarate HIV or Hepatitis Vitekta elvitegravir HIV or Hepatitis Zerit stavudine HIV or Hepatitis Ziagen abacavir sulfate Activella Hormone Therapy (Estrogen) Mimvey estradiol/norethindrone Mimvey Lo Hormone Therapy (Estrogen) Alora estradiol Hormone Therapy (Estrogen) Angeliq estradiol/drospirenone Hormone Therapy (Estrogen) Cenestin conjugated estrogens, synthetic A Hormone Therapy (Estrogen) Climara estradiol Hormone Therapy (Estrogen) Climara Pro estradiol/levonorgestrel Hormone Therapy (Estrogen) Combipatch estradiol/norethindrone Hormone Therapy (Estrogen) Divigel estradiol Hormone Therapy (Estrogen) Duavee estrogens, conjugated/bazedoxifene Hormone Therapy (Estrogen) Elestrin estradiol Hormone Therapy (Estrogen) Enjuvia conjugated estrogens, synthetic B Hormone Therapy (Estrogen) Estrace estradiol Hormone Therapy (Estrogen) Estraderm estradiol Hormone Therapy (Estrogen) Estrasorb estradiol Hormone Therapy (Estrogen) Estrogel estradiol Femhrt Hormone Therapy (Estrogen) estradiol/norethindrone Jinteli Hormone Therapy (Estrogen) Femtrace estradiol acetate Hormone Therapy (Estrogen) Menest esterified estrogens Hormone Therapy (Estrogen) Menostar estradiol Hormone Therapy (Estrogen) Minivelle estradiol Hormone Therapy (Estrogen) Ogen estropipate Hormone Therapy (Estrogen) Prefest estradiol/norgestimate Hormone Therapy (Estrogen) Premarin conjugated estrogens conjugated estrogens/ Hormone Therapy (Estrogen) Premphase medroxyprogesterone conjugated estrogens/ Hormone Therapy (Estrogen) Prempro medroxyprogesterone Hormone Therapy (Estrogen) Vagifem estradiol Hormone Therapy (Estrogen) Vivelle-Dot estradiol Hormone Therapy (Progesterone) Aygestin norethindrone Hormone Therapy (Progesterone) Prometrium micronized progesterone Page 15 of 19
Effective: 05/2020
Hormone Therapy (Progesterone) Provera medroxyprogesterone Women's Health (non-hormone) Brisdelle paroxetine mesylate Kidney Disease Ferric citrate ferric citrate Kidney Disease Fosrenol lanthanum carbonate Kidney Disease Phos-Lo calcium acetate Kidney Disease Rayaldee calcifediol Kidney Disease Renagel sevelamer hcl Kidney Disease Renvela sevelamer carbonate Kidney Disease Sensipar cinacalcet hcl Kidney Disease Velphoro sucroferric oxyhydroxide Kidney Disease Zemplar paricalcitol Mental Health Aplenzin bupropion hbr Mental Health Brintellix vortioxetine hydrobromide Budeprion Mental Health Forfivo XL bupropion hcl Wellbutrin Mental Health Celexa citalopram hydrobromide Mental Health Cymbalta duloxetine hcl Mental Health Desvenlafaxine ER desvenlafaxine Desyrel Mental Health trazodone hcl Oleptro ER Mental Health Drizalma duloxetine Mental Health Effexor venlafaxine hcl Mental Health Fetzima levomilnacipran hydrochloride Mental Health Irenka duloxetine hcl Mental Health Kapvay clonidine hcl Mental Health Khedezla desvenlafaxine Mental Health Lexapro escitalopram oxalate Mental Health Lithium Citrate lithium citrate Mental Health Lithobid lithium carbonate Mental Health Luvox CR fluvoxamine maleate Mental Health Marplan isocarboxazid Mental Health Nardil phenelzine sulfate Mental Health Nefazodone HCL nefazodone hcl Mental Health Paxil paroxetine hcl Mental Health Pexeva paroxetine mesylate Mental Health Pristiq desvenlafaxine succinate Prozac Prozac Weekly Mental Health fluoxetine hcl Sarafem Selfemra Mental Health Remeron mirtazapine Mental Health Strattera atomoxetine hcl Mental Health Symbyax olanzapine/fluoxetine hcl
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Effective: 05/2020
Tranylcypromine Mental Health tranylcypromine sulfate Sulfate Mental Health Viibryd vilazodone hydrochloride Mental Health Zoloft sertraline hcl Menstrual Condition Lysteda tranexamic acid Nerve Conditions Gralise gabapentin Nerve Conditions Horizant gabapentin enacarbil Nerve Conditions Ozobax baclofen Osteoporosis Actonel risedronate sodium Osteoporosis Actonel w/Calcium risedronate/calcium carbonate Osteoporosis Atelvia risedronate sodium Osteoporosis Binosto alendronate sodium Osteoporosis Boniva ibandronate sodium Osteoporosis Evista raloxifene hcl Fortical Osteoporosis calcitonin, salmon, synthetic Miacalcin Osteoporosis Fosamax alendronate sodium Osteoporosis Fosamax Plus D alendronate sodium/vitamin D Parkinson's Disease Azilect rasagiline mesylate Parkinson's Disease Comtan entacapone Parkinson's Disease Gocovri amantadine hcl Mirapex Parkinson's Disease pramipexole di-hcl Mirapex ER Parkinson's Disease Neupro rotigotine Parkinson's Disease Osmolex ER amantadine hcl Parkinson's Disease Parlodel bromocriptine mesylate Parkinson's Disease Requip ropinirole hcl Parkinson's Disease Rytary carbidopa/levodopa Parkinson's Disease Sinemet carbidopa/levodopa Parkinson's Disease Stalevo carbidopa/levodopa/entacapone Parkinson's Disease Tasmar tolcapone Parkinson's Disease Xadago safinamide mesylate Parkinson's Disease Zelapar selegiline hcl Seizure Aptiom eslicarbazepine acetate Seizure Banzel rufinamide Seizure Briviact brivaracetam Carbatrol Epitol Seizure carbamazepine Equetro Tegretol Seizure Celontin methsuximide Seizure Depakene valproate sodium Seizure Depakote divalproex sodium Seizure Dilantin phenytoin
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Effective: 05/2020
Seizure Ethosuximide ethosuximide Seizure Felbatol felbamate Seizure Fycompa perampanel Seizure Gabitril tiagabine hcl Seizure Klonopin clonazepam Seizure Mephobarbital mephobarbital Seizure Mysoline primidone Seizure Onfi clobazam Seizure Phenobarbital phenobarbital Seizure Phenytek phenytoin sodium extended Seizure Stavzor valproic acid Seizure Sympazan clobazam Seizure Trileptal oxcarbazepine Seizure Trokendi XR topiramate Seizure Vimpat lacosamide Seizure Xcopri cenobamate Seizure Zarontin ethosuximide Seizure Zonegran zonisamide Thyroid Conditions Cytomel liothyronine sodium Levothroid Levoxyl Synthroid Thyroid Conditions levothyroxine sodium Tirosint Unithroid Euthyrox Armour Thyroid Nature-Throid Thyroid Conditions thyroid, pork NP Thyroid Westhroid Thyroid Conditions Propylthiouracil propylthiouracil Thyroid Conditions Tapazole methimazole Thyroid Conditions Thyrolar liotrix Tuberculosis (TB) Ethambutol HCL ethambutol hcl Tuberculosis (TB) Isoniazid isoniazid Tuberculosis (TB) Pyrazinamide pyrazinamide Vitamins, Nutrients & Electrolytes Carnitor levocarnitine Vitamins, Nutrients & Electrolytes Etidronate Disodium etidronate disodium Vitamins, Nutrients & Electrolytes Folic Acid folic acid Vitamins, Nutrients & Electrolytes Hectorol doxercalciferol Vitamins, Nutrients & Electrolytes K Effervescent potassium bicarbonate Klor-Con Vitamins, Nutrients & Electrolytes potassium chloride Micro-K Vitamins, Nutrients & Electrolytes Nascobal cyanocobalamin potassium chloride/potassium Vitamins, Nutrients & Electrolytes Potassium Chloride bicarbonate/citric acid
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Effective: 05/2020
Vitamins, Nutrients & Electrolytes Rocaltrol calcitriol Vitamins, Nutrients & Electrolytes Urocit-K potassium citrate
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Effective: 05/2020