Maintenance Drug List

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1 Maintenance Drug List December 2017 Maintenance drugs are medications prescribed for chronic, long term conditions and are taken on a regular, recurring basis. Examples of chronic conditions that may require maintenance drugs are: high blood pressure, high cholesterol, and diabetes. HAP has developed a list of drugs classified as "maintenance drugs" based on the most prevalent chronic health conditions in our member population. Drugs placed on the Maintenance Drug List are well established medications that have proven safety and efficacy and are considered first line therapy options for the treatment of common chronic conditions. The list refers to the most common dosage forms and strengths of a product. Less common forms or strengths of a listed product may not be covered under the maintainance drug list. The majority of these drugs are now available as generic drugs. How are Drugs Approved to be on the Maintenance Drug List? Many of the medications that you may be taking on a regular basis will not be classified as a maintenance drug on our Maintenance Drug List. HAP uses a committee of physicians, nurses, and pharmacists to determine which drugs are to be placed on our Maintenance Drug List. All requests for adding drugs to this list are thoroughly reviewed by the committee and a determination is made to add a drug to the Maintenance Drug List. How are Maintenance Drugs Dispensed? Up to a 90 day supply is covered for drugs listed on the HAP Maintenance Drug List if filled at an eligible 90 Day HAP retail pharmacy or by using the Pharmacy Advantage Home Delivery Service. Most major chains and many independent pharmacies are in the HAP 90 Day network. Typically the charge for a 90 day supply is two retail copays but individual plans may vary. Drugs that are not listed on the maintenance drug list will be limited to 30 day supply at retail pharmacies. In order to fill a 90 day prescription, the physician must write the prescription for a 90 day supply. Eligibility for 90-day fills may be excluded where the remaining duration of subscriber coverage is less than 90 days. PRODUCT ROUTE PRODUCT ROUTE acebutolol amiodarone acetazolamide amitriptyline adapalene External amlodipine ADVAIR amlodipine benazepril ADVICOR AGGRENOX albuterol alendronate alfuzosin allopurinol alprazolam amantadine amiloride amiloride hydrochlorothiazide amlodipine besylate olmesartan medoxomil amlodipine besylate valsartan amlodipine valsartanhydrochlorothiazide amphetamine dextroamphetamine anastrozole aripiprazole aspirin atenolol atenolol chlorthalidone Page 1 of 7

2 atorvastatin carteolol azathioprine carvedilol azelastine Nasal celecoxib baclofen cetirizine balsalazide disodium chlorothiazide beclomethasone dipropionate chlorpropamide benazepril chlorthalidone benazepril hydrochlorothiazide cholestyramine benztropine cholestyramine light betamethasone External citalopram betaxolol clonazepam betaxolol clonidine bethanechol clonidine bisoprolol fumarate clonidine (adhd) bisoprolol hydrochlorothiazide clopidogrel brimonidine tartrate (0.15% SOLUTION) CLORPRES bromocriptine colchicine budesonide colchicine w/ probenecid budesonide (inhalation) colestipol bumetanide COMBIGAN bupropion COMBIVENT RESPIMAT bupropion ER contraceptives (generic, max 3 cycles) bupropion SR cyclobenzaprine bupropion XL cyclosporine buspirone cyclosporine (NEORAL) BYSTOLIC cyclosporine modified cabergoline desloratadine calcitriol desmopressin acetate candesartan cilexetil diazepam captopril diclofenac captopril hydrochlorothiazide diclofenac carbamazepine dicyclomine carbamazepine ER digoxin carbidopa/levodopa diltiazem Page 2 of 7

3 diltiazem ER fenofibric acid dipyridamole finasteride disopyramide phosphate flecainide acetate disulfiram fludrocortisone acetate divalproex fluoxetine dofetilide fluphenazine donepezil flurbiprofen dorzolamide timolol maleate flurbiprofen doxazosin fluvastatin doxepin fluvoxamine maleate duloxetine folic acid duoneb fosinopril dutasteride fosinopril hydrochlorothiazide EFFIENT furosemide ELIQUIS gabapentin enalapril maleate gemfibrozil enalapril hydrochlorothiazide glimepiride ENTRESTO glipizide eplerenone glipizide ER estradiol glipizide XL estradiol glipizide metformin estradiol/noreth AC glyburide estradiol norethindrone acetate glyburide micronized estrogen & methyltestosterone glyburide metformin estrogens,conjugated glycopyrrolate estrogens,esterified guanfacine estropipate guanfacine (adhd) etodolac hydralazine ezetimibe hydralazine/hydrochlorothiazide famotidine hydrochlorothiazide felodipine ER hydroxyzine fenofibrate ibandronate fenofibrate nanocrystallized ibuprofen fenofibrate,micronized imipramine Page 3 of 7

4 indapamide lithium carbonate insulin needles and syringes loperamide ipratropium bromide (nasal) Nasal loratadine irbesartan losartan irbesartan hydrochlorothiazide losartan hydrochlorothiazide isoniazid lovastatin isosorbide dinitrate LUMIGAN (max 7.5ml) isosorbide dinitrate Sublingual LYRICA isosorbide mononitrate meclizine isradipine medroxyprogesterone JANUMET meloxicam JANUMET XR memantine JANUVIA mercaptopurine labetalol mesalamine lactic acid (ammonium lactate) External mesalamine Retal lactulose metaproterenol lamotrigine metformin lansoprazole metformin ER LANTUS methazolamide LANTUS SOLOSTAR methenamine latanoprost (XALATAN max 7.5ml) methimazole leflunomide methocarbamol letrozole methotrexate leucovorin calcium methyclothiazide levalbuterol methyldopa levetiracetam methyldopa hydrochlorothiazide levobunolol methylphenidate levocetirizine dihydrochloride metipranolol levonorgestrel ethinyl estradiol (91 day) metoclopramide levothyroxine metolazone liothyronine metoprolol succinate (TOPROL XL) liotrix metoprolol tartrate lisinopril metoprolol hydrochlorothiazide lisinopril hydrochlorothiazide mexiletine Page 4 of 7

5 midodrine minoxidil mirtazapine moexipril moexipril hydrochlorothiazide montelukast MULTAQ multivitamins (generic Rx only) mycophenolate nabumetone nadolol nadolol bendroflumethiazide naltrexone naproxen nefazodone niacin niacin er nicardipine nicotine nifedipine nifedipine ER nisoldipine nitroglycerin nitroglycerin Sublingual nitroglycerin nitroglycerin patch nizatidine norelgestromin ethinyl estradiol norethindrone acetate ethinyl estradiol norgestimate ethinyl estradiol (triphasic) nortriptyline NOVOLIN N NOVOLIN R NOVOLOG FLEXPEN NOVOLOG MIX 70/30 PREFILLED FLEXPEN NOVOLOG PENFILL olmesartan medoxomil olopatadine omega 3 acid ethyl esters omeprazole (Rx only) orphenadrine citrate OSCIMIN oxandrolone oxcarbazepine oxybutynin oxybutynin chloride oxybutynin chloride ER pantoprazole paroxetine PENTASA pentoxifylline perindopril erbumine phenobarbital phenytoin phenytoin extended pilocarpine pilocarpine pindolol pioglitazone pioglitazone metformin potassium chloride potassium gluconate PRADAXA pramipexole dihydrochloride pravastatin prazosin prednisolone Page 5 of 7

6 prednisone sertraline prednisone intensol sildenafil citrate 20 mg PREMARIN Vaginal simvastatin PREMPHASE (max 3 cycles) sodium citrate PREMPRO (max 3 cycles) sodium fluoride prenatal vitamins (generic Rx only) sotalol primidone SPIRIVA HANDIHALER probenecid SPIRIVA RESPIMAT progesterone spironolact/hydrochlorothiazid promethazine & phenylephrine spironolactone propafenone STIOLTO RESPIMAT propranolol sucralfate propranolol hydrochlorothiazide sulfasalazine propylthiouracil sulfasalazine DR quetiapine fumarate sulindac quinapril hydrochlorothiazide sumatriptan quinidine SYMBICORT rabeprazole tacrolimus raloxifene tamoxifen citrate ramipril tamsulosin RANEXA TEKTURNA ranitidine telmisartan rasagiline temazepam repaglinide terazosin reserpine terbutaline rifampin theophylline risedronate theophylline anhydrous risperidone thyroid ropinirole timolol rosuvastatin tolazamide salsalate tolbutamide SAVELLA tolterodine tartrate selegiline topiramate SEREVENT DISKUS torsemide Page 6 of 7

7 TOUJEO SOLOSTAR tramadol trandolapril trandolapril verapamil travoprost (TRAVATAN Z 7.5ml) trazodone triamterene triamterene hydrochlorothiazide trifluoperazine trihexyphenidyl ursodiol valproic acid valsartan hct (DIOVAN HCT) venlafaxine venlafaxine ER (capsules) verapamil verapamil ER VESICARE VIMPAT VYTORIN VYVANSE warfarin WELCHOL XARELTO zafirlukast zaleplon ziprasidone zolpidem tartrate zonisamide Page 7 of 7

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