Commonly Prescribed Maintenance Medications

1 Commonly Prescribed Maintenance Medications Maintenance Medications are those drugs you may take on a regular basis to treat conditions such as high cholesterol, high blood pressure or diabetes. Depending on your benefit plan, you may have coverage to obtain up to a 90-day supply of covered Maintenance medication delivered to you through PrimeMail '.*. Using PrimeMail to obtain covered Maintenance Medications may save you time and money: Your Medications will be delivered directly to you, to the address of your choice. To receive coverage, your pharmacy options for obtaining Maintenance Medications may vary depending on your particular benefit plan. For example, some plans require that Maintenance Medications be obtained through PrimeMail in order to receive coverage.

2 With many plans, a higher out-of-pocket payment amount applies when prescription Medications are obtained at an out-of-network pharmacy. See your benefit booklet for information about your particular plan. Commonly used Maintenance Medications are listed below. This list is not all-inclusive and may change from time to time. Generic drugs are available for many of the brand drugs listed. Generic equivalents may not be available in all strengths for every product noted as having a generic. Please note that oral contraceptives are Maintenance Medications and are part of this list. However, this list does not include the trade names of all available oral contraceptives because there are a large number of products.

3 Coverage is always subject to the exclusions and limitations noted in Generic drugs = bold, lower-case type your benefit plan booklet. For details about your plan, check your benefit Brand drugs** = CAPITAL LETTERS. booklet or call the Pharmacy Program number on the back of your = generic available member ID card. ABILIFY AEROBID-M amlodipine ABILIFY ORAL SOLN Afeditab CR amlodipine/benazepril ABILIFY DISCMELT AGGRENOX AMOXAPINE. acarbose ALDACTAZIDE /HYDROCHLOROTHIAZIDE ANAFRANIL. ACCOLATE 25/25 ANAPROX. ACCUPRIL ALDACTAZIDE / ANASPAZ. HYDROCHLOROTHIAZIDE 50/50. ACCURETIC ANTARA. ALDACTONE. acebutolol APLENZIN. alendronate ACEON APRISO. allopurinol acetazolamide ARICEPT.

4 ALORA. acetazolamide ER ARICEPT ODT. ALPHAGAN P OPHTH. ACIPHEX ARIMIDEX. ALPHAGAN P OPHTH. ACTIGALL AROMASIN. ALTACE CAPS. ACTIVELLA MG ARTHROTEC. ALTACE TABS. ACTIVELLA 1 MG ASACOL. ALTOPREV. ACTONEL ASMANEX. ALVESCO. ACTONEL WITH CALCIUM ATACAND. amantadine ACTOPLUS MET ATACAND HCT. AMARYL. ACTOS atenolol amiloride ADALAT CC atenolol/chlorthalidone amiloride/hydrochlorothiazide ADVAIR DISKUS ATROVENT NASAL SOLN. amiodarone ADVAIR HFA ATROVENT HFA. amitriptyline ADVICOR AVALIDE. amitriptyline/chlordiazepoxide AEROBID AVANDAMET. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 1 of 6.

5 AVANDARYL CALOMIST Generic drugs = bold, lower-case type AVANDIA captopril Brand drugs** = CAPITAL LETTERS. AVAPRO captopril/hydrochlorothiazide = generic available AVODART CARAFATE. AXID CAPS CARAFATE SUSP COMBIGAN. AXID ORAL SOLN carbidopa-levodopa COMBIPATCH. AYGESTIN carbidopa-levodopa ER COMBIVENT. AZILECT CARDENE CD COMTAN. AZMACORT CARDENE SR CORDARONE. AZOPT CARDIZEM COREG. AZOR CARDIZEM LA COREG CR. AZULFIDINE CARDURA CORGARD. AZULFIDINE EN-TABS CARDURA XL CORZIDE. baclofen CARNITOR COSOPT. benazepril carteolol ophth COVERA-HS. benazepril/hydrochlorothiazide carvedilol COZAAR. BENICAR CATAFLAM CREON 6,000, 12,000, 24,000 U. BENICAR HCT CATAPRES CRESTOR. benztropine CATAPRES-TTS cromolyn sodium for inhal BETAGAN CELEBREX CYMBALTA.

6 BETAPACE CELEXA CYTOMEL. BETAPACE AF CENESTIN CYTOTEC. betaxolol chlorothiazide DAYPRO. BETAXOLOL OPHTH chlorpromazine DEMADEX. BETIMOL chlorpropamide desipramine BETOPTIC-S chlorthalidone DETROL. BIDIL cholestyramine DETROL LA. bisoprolol cholestyramine light DIAMOX SEQUELS. bisoprolol/hydrochlorothiazide CIALIS , 5 MG diclofenac potassium BONIVA cilostazol diclofenac sodium DR. brimonidine cimetidine diclofenac sodium SR 24 hr bromocriptine citalopram digoxin BROVANA FOR INHAL CLIMARA DIGOXIN ORAL SOLN. bumetanide CLIMARA PRO DILACOR XR. bupropion CLINORIL DILATRATE SR. bupropion SR 12 hr clomipramine diltiazem bupropion XL 24 hr clonazepam diltiazem ER 12 hr BYSTOLIC clonazepam ODT diltiazem ER 24 hr CADUET clonidine DIOVAN.

7 CALAN clonidine patches DIOVAN HCT. CALAN SR CLORPRES DIPENTUM. calcitonin salmon nasal soln COGNEX dipyridamole calcitriol COLESTID disopyramide calcium acetate colestipol DITROPAN XL. page 2 of 6. DIVIGEL FELDENE Generic drugs = bold, lower-case type dorzolamide ophth felodipine ER Brand drugs** = CAPITAL LETTERS. dorzolamide-timolol ophth FEMARA = generic available doxazosin FEMHRT 1/5. doxepin FEMHRT LOW DOSE GLUCOTROL. DUETACT FEMRING GLUCOTROL XL. DUONEB FEMTRACE GLUCOVANCE. DYAZIDE fenofibrate GLUMETZA. DYNACIRC CR FENOGLIDE GLYBURIDE, DISTRIBUTOR OF DIABETA. DYRENIUM FIBRICOR glyburide, generics of Micronase EASPRIN finasteride glyburide micronized EC-NAPROSYN flavoxate glyburide-metformin EFFEXOR flecainide GLYNASE.

8 EFFEXOR XR FLOMAX GLYSET. EFFIENT FLOVENT DISKUS GUANABENZ. ELDEPRYL FLOVENT HFA guanfacine ELESTRIN fludrocortisone haloperidol ELIPHOS fluoxetine HECTOROL. EMSAM FLUPHENAZINE ELIXIR, ORAL CONC HOMAPIN-10. ENABLEX fluphenazine tabs hydralazine enalapril fluvoxamine hydrochlorothiazide caps, tabs enalapril/hydrochlorothiazide folic acid 1 mg HYDROCHLOROTHIAZIDE TABS, MG. ENJUVIA FORADIL hyoscyamine sulfate eplerenone FORTAMET hyoscyamine sulfate ER. EQUETRO fortical HYZAAR. ESTRACE TABS FOSAMAX ibuprofen ESTRACE VAG CRM FOSAMAX PLUS D IMDUR. estradiol patches fosinopril imipramine HCl estradiol tabs fosinopril/hydrochlorothiazide IMIPRAMINE PAMOATE. estradiol/norethindrone FOSRENOL indapamide acetate 1 mg furosemide INDERAL LA.

9 ESTRASORB furosemide oral soln, 10 mg/mL INDOCIN SR. ESTRING FUROSEMIDE ORAL SOLN, 8 MG/ML indomethacin ESTROGEL galantamine indomethacin SR. estropipate galantamine ER INOPRAN XL. etodolac GELNIQUE INSPRA. etodolac ER gemfibrozil INTAL INHALER. EVAMIST GEODON INTUNIV. EVISTA glimepiride INVEGA. EVOXAC glipizide ipratropium for inhal EXELON glipizide ER ipratropium nasal soln EXFORGE glipizide-metformin ipratropium/albuterol for inhal EXFORGE HCT GLUCOPHAGE ISMO. famotidine GLUCOPHAGE XR ISONIAZIDE SYRUP. page 3 of 6. isoniazide tabs LOTREL Generic drugs = bold, lower-case type ISORDIL 40 MG LOTREL 5/40, 10/40 Brand drugs** = CAPITAL LETTERS. isosorbide dinitrate LOTRONEX = generic available isosorbide mononitrate lovastatin isosorbide mononitrate ER LOVAZA MIRAPEX.

10 Isradipine loxapine mirtazapine ISRADIPINE MG LOXITANE mirtazapine ODT. ISTALOL LUMIGAN misoprostol JANUMET LUVOX CR MOBAN. JANUVIA MAPROTILINE MOBIC. KAPIDEX MARPLAN MOBIC SUSP. KERLONE MAVIK moexipril KLONOPIN MAXZIDE moexipril/hydrochlorothiazide KLONOPIN WAFERS MAXZIDE-25 MONOKET. labetalol medroxyprogesterone acetate MONOPRIL. LANOXIN MEGACE ES SUSP MULTAQ. lansoprazole MELOXICAM SUSP nabumetone LASIX meloxicam tabs nadolol LESCOL MENEST nadolol/bendroflumethiazide LESCOL XL MENOSTAR NAMENDA. LEVATOL METAGLIP NAPRELAN. LEVBID metformin NAPROSYN. levobunolol ophth metformin ER NAPROSYN SUSP. levocarnitine methazolamide naproxen Levoxyl methimazole naproxen DR.