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 Page 2 of 19 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 Page 4 of 19 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.