Commonly Prescribed Maintenance Medications Maintenance (or long-term) medications are those dosage form may be used to treat more than one drugs you may take on a regular basis to treat conditions medical condition. In these cases, each medication may such as high cholesterol, high blood pressure or diabetes. be classified according to its first U.S. Food and Drug Based on your benefit plan, you may get up to a 90-day Administration (FDA) approved use. Some strengths supply of covered maintenance medication delivered and/or formulations listed may not be covered. to you through a home delivery program or at select Please note that oral contraceptives are maintenance retail pharmacies. medications and are part of this list. However, this Some plans may require you to fill these prescriptions list does not include the trade names of all available through home delivery or at select retail pharmacies oral contraceptives because there are a large number in order to receive coverage. of products. Commonly used maintenance medications are listed in Coverage is always subject to the terms and limits of this guide. This list is not all-inclusive and may change your benefit plan. Please verify with your plan if there from time to time. are any additional requirements before a drug may be Most generic drugs listed are followed by a reference covered. For details about your plan, check your benefit brand drug in (parentheses). The brand name drug materials or call the number on your member ID card. in parentheses is listed for reference and may not be Third-party brand names are the property of their covered under your benefit. Some drugs in the same respective owners. ADHD/Stimulants Allergies GALANTAMINE HYDROBROMIDE - galantamine hydrobromide oral atomoxetine hcl cap 10 mg, 18 mg, ipratropium bromide nasal soln soln 4 mg/mL 25 mg, 40 mg, 60 mg, 80 mg, 0.03% (21 mcg/spray), 0.06% 100 mg (base equivalent) (42 mcg/spray) galantamine hydrobromide tab (Strattera) 4 mg (Razadyne) Alzheimer’s Disease clonidine hcl tab er 12hr 0.1 mg galantamine hydrobromide tab ARICEPT - donepezil hydrochloride (Kapvay) 8 mg, 12 mg tab 5 mg, 10 mg, 23 mg guanfacine hcl tab er 24hr 1 mg, memantine hcl cap er 24hr 7 mg, 2 mg, 3 mg, 4 mg donepezil hydrochloride orally 14 mg, 21 mg, 28 mg (base equivalent) (Intuniv) disintegrating tab 5 mg, 10 mg (Namenda xr) INTUNIV - guanfacine hcl tab er 24hr donepezil hydrochloride tab 5 mg, memantine hcl oral solution 1 mg, 2 mg, 3 mg, 4 mg 10 mg, 23 mg (Aricept) 2 mg/mL (base equivalent) EXELON - rivastigmine td patch 24hr memantine hcl tab 5 mg, 10 mg KAPVAY - clonidine hcl tab er 12hr 4.6 mg/24hr, 9.5 mg/24hr, (Namenda) 13.3 mg/24hr 0.1 mg NAMENDA - memantine hcl tab 5 mg, STRATTERA - atomoxetine hcl cap galantamine hydrobromide cap er 10 mg 24hr 8 mg, 16 mg, 24 mg 10 mg, 18 mg, 25 mg, 40 mg, NAMENDA XR - memantine hcl cap er (Razadyne er) 60 mg, 80 mg, 100 mg 24hr 7 mg, 14 mg, 21 mg, 28 mg (base equivalent) BRAND DRUGS generic drugs 1 Commonly Prescribed Maintenance Medications NAMZARIC - memantine hcl- nitroglycerin td patch 24hr propafenone hcl tab 150 mg, donepezil hcl cap er 24hr 7-10 mg, 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 225 mg, 300 mg 14-10 mg, 21-10 mg, 28-10 mg 0.6 mg/hr (Nitro-dur) propafenone hcl cap er 12hr 225 mg, RAZADYNE - galantamine PROCARDIA - nifedipine cap 10 mg 325 mg, 425 mg (Rythmol sr) hydrobromide tab 4 mg RANEXA - ranolazine tab er 12hr quinidine gluconate tab er 324 mg RAZADYNE ER - galantamine 500 mg, 1000 mg QUINIDINE SULFATE - quinidine hydrobromide cap er 24hr 8 mg, ranolazine tab er 12hr 500 mg, sulfate tab 200 mg, 300 mg 16 mg, 24 mg 1000 mg (Ranexa) RYTHMOL SR - propafenone hcl cap rivastigmine tartrate cap er 12hr 225 mg, 325 mg, 425 mg 1.5 mg, 3 mg, 4.5 mg, 6 mg Antiarrhythmics (base equivalent) amiodarone hcl tab 100 mg, sotalol hcl tab 80 mg, 120 mg, 160 mg (Betapace) rivastigmine td patch 24hr 200 mg, 400 mg 4.6 mg/24hr, 9.5 mg/24hr, BETAPACE - sotalol hcl tab 80 mg, sotalol hcl tab 240 mg 13.3 mg/24hr (Exelon) 120 mg, 160 mg sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg (Betapace af) Antiangina BETAPACE AF - sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg SOTYLIZE - sotalol hcl oral solution CARDIZEM - diltiazem hcl tab 30 mg, DIGOXIN - digoxin oral soln 5 mg/mL 60 mg, 120 mg 0.05 mg/mL TIKOSYN - dofetilide cap 125 mcg DILATRATE SR - isosorbide dinitrate (0.125 mg), 250 mcg (0.25 mg), cap er 40 mg digoxin oral soln 0.05 mg/mL (Digoxin) 500 mcg (0.5 mg) diltiazem hcl tab 30 mg, 60 mg, digoxin tab 125 mcg (0.125 mg), 120 mg (Cardizem) Anticoagulants/Antiplatelets 250 mcg (0.25 mg) (Lanoxin) AGGRENOX - aspirin-dipyridamole diltiazem hcl tab 90 mg disopyramide phosphate cap cap er 12hr 25-200 mg ISORDIL TITRADOSE - isosorbide 100 mg, 150 mg (Norpace) dinitrate tab 5 mg, 40 mg AGRYLIN - anagrelide hcl cap 0.5 mg dofetilide cap 125 mcg (0.125 mg), anagrelide hcl cap 0.5 mg (Agrylin) isosorbide dinitrate tab 5 mg, 250 mcg (0.25 mg), 500 mcg 40 mg (Isordil titradose) (0.5 mg) (Tikosyn) anagrelide hcl cap 1 mg isosorbide dinitrate tab 10 mg, flecainide acetate tab 50 mg, aspirin-dipyridamole cap er 12hr 20 mg, 30 mg 100 mg, 150 mg 25-200 mg (Aggrenox) isosorbide mononitrate tab 10 mg, LANOXIN - digoxin tab 62.5 mcg ASPIRIN/OMEPRAZOLE – aspirin- 20 mg (0.0625 mg), 125 mcg (0.125 mg), omeprazole tab delayed release 81-40 mg, 325-40 mg isosorbide mononitrate tab er 250 mcg (0.25 mg) 24hr 30 mg, 60 mg, 120 mg MEXILETINE HCL - mexiletine hcl cap BRILINTA - ticagrelor tab 60 mg, 90 mg nifedipine cap 10 mg (Procardia), 150 mg, 200 mg, 250 mg 20 mg MULTAQ - dronedarone hcl tab cilostazol tab 50 mg, 100 mg NITRO-BID - nitroglycerin oint 2% 400 mg (base equivalent) clopidogrel bisulfate tab 75 mg NITRO-DUR - nitroglycerin td patch NORPACE - disopyramide phosphate (base equivalent) (Plavix) 24hr 0.1 mg/hr, 0.2 mg/hr, 0.3 mg/hr, cap 100 mg, 150 mg dipyridamole tab 25 mg, 50 mg, 0.4 mg/hr, 0.6 mg/hr, 0.8 mg/hr NORPACE CR - disopyramide 75 mg NITRO-TIME – nitroglycerin cap er phosphate cap er 12hr 100 mg, DURLAZA - aspirin capsule er 24hr 2.5 mg, 6.5 mg, 9 mg 150 mg 162.5 mg BRAND DRUGS generic drugs 2 Commonly Prescribed Maintenance Medications EFFIENT - prasugrel hcl tab 5 mg, bupropion hcl tab er 24hr 150 mg, FETZIMA - levomilnacipran hcl cap er 10 mg (base equivalent) 300 mg (Wellbutrin xl) 24hr 20 mg, 40 mg, 80 mg, 120 mg ELIQUIS – apixaban tab 2.5 mg BUPROPION HYDROCHLORIDE ER - (base equivalent) PLAVIX - clopidogrel bisulfate tab bupropion hcl tab er 24hr 450 mg FLUOXETINE DR - fluoxetine hcl cap 75 mg (base equivalent) CAPLYTA – lumateperone tosylate delayed release 90 mg PRADAXA - dabigatran etexilate cap 42 mg FLUOXETINE HYDROCHLORIDE - mesylate cap 75 mg, 150 mg CELEXA - citalopram hydrobromide fluoxetine hcl tab 60 mg (etexilate base equivalent) tab 10 mg, 20 mg, 40 mg fluoxetine hcl (pmdd) tab 10 mg, prasugrel hcl tab 5 mg, 10 mg (base equivalent) 20 mg (Sarafem) (base equivalent) (Effient) citalopram hydrobromide oral fluoxetine hcl cap 10 mg, 20 mg, SAVAYSA - edoxaban tosylate tab soln 10 mg/5 mL 40 mg (Prozac) 15 mg, 30 mg, 60 mg citalopram hydrobromide tab fluoxetine hcl solution 20 mg/5 mL (base equivalent) 10 mg, 20 mg, 40 mg fluoxetine hcl tab 10 mg, 20 mg (base equivalent) (Celexa) XARELTO - rivaroxaban tab 2.5 mg, fluoxetine hcl tab 60 mg 15 mg, 20 mg CYMBALTA - duloxetine hcl enteric (Fluoxetine hcl) YOSPRALA - aspirin-omeprazole tab coated pellets cap 20 mg, 30 mg, 60 mg (base equivalent) fluvoxamine maleate tab 25 mg, delayed release 81-40 mg, 50 mg, 100 mg 325-40 mg DESVENLAFAXINE ER – desvenlafaxine tab er 24hr 50 mg, fluvoxamine maleate cap er 24hr ZONTIVITY - vorapaxar sulfate tab 100 mg, 150 mg 2.08 mg (base equivalent) 100 mg FORFIVO XL - bupropion hcl tab er desvenlafaxine succinate tab er 24hr 450 mg Arterial Disease 24hr 25 mg, 50 mg, 100 mg pentoxifylline tab er 400 mg (base equivalent) (Pristiq) GEODON - ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg Behavioral Health DRIZALMA SPRINKLE – duloxetine hcl cap delayed release sprinkle INVEGA - paliperidone tab er 24hr ABILIFY - aripiprazole tab 2 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg 1.5 mg, 3 mg, 6 mg, 9 mg 10 mg, 15 mg, 20 mg, 30 mg (base equivalent) LATUDA - lurasidone hcl tab 20 mg, ABILIFY MYCITE - aripiprazole tab duloxetine hcl enteric coated 40 mg, 60 mg, 80 mg, 120 mg 2 mg with sensor, 5 mg with sensor, pellets cap 20 mg, 30 mg, 60 mg 10 mg with sensor, 15 mg with LEXAPRO - escitalopram oxalate tab (base equivalent) (Cymbalta) sensor, 20 mg with sensor, 30 mg 5 mg, 10 mg, 20 mg with sensor duloxetine hcl enteric coated (base equivalent) pellets cap 40 mg APLENZIN - bupropion hbr tab er LITHIUM CARBONATE - lithium (base equivalent) 24hr 174 mg, 348 mg, 522 mg carbonate cap 150 mg, 600 mg EFFEXOR XR - venlafaxine hcl cap er aripiprazole oral solution 1 mg/mL lithium carbonate cap 150 mg, 24hr 37.5 mg, 75 mg, 150 mg 600 mg (Lithium carbonate) aripiprazole orally disintegrating (base equivalent) tab 10 mg, 15 mg lithium carbonate cap 300 mg EMSAM - selegiline td patch 24hr 6 lithium carbonate tab 300 mg aripiprazole tab 2 mg, 5 mg, 10 mg, mg/24hr, 9 mg/24hr, 12 mg/24hr 15 mg, 20 mg, 30 mg (Abilify) lithium carbonate tab er 300 mg escitalopram oxalate soln 5 mg/ (Lithobid) bupropion hcl tab 75 mg, 100 mg 5 mL (base equivalent) lithium carbonate tab er 450 mg bupropion hcl tab er 12hr 100 mg, escitalopram oxalate tab 5 mg, 150 mg, 200 mg (Wellbutrin sr) 10 mg, 20 mg (base equivalent) LITHIUM - lithium oral solution (Lexapro) 8 meq/5 mL BRAND DRUGS generic drugs 3 Commonly Prescribed Maintenance Medications LITHOBID