Maintenance Medication List:Rochester Regional Health Apothecaries

8-MOPABILIFYABILIFY DISCMELTACAMPROSATE CALCIUMACARBOSEACCOLATEACCUPRILACCURETICACEBUTOLOL HCLACEONACETAZOLAMIDEACTIGALLACTIVELLAACTONELACTOPLUS METACTOPLUS MET XRACTOSADALAT CCADASUVEADVAIR DISKUSADVAIR HFAAEROSPANAFEDITAB CRAIRDUO RESPICLICKALDACTAZIDEALDACTONEALENDRONATE SODIUMALFUZOSIN HCLALLOPURINOLALOGLIPTIN BENZOATEALOGLIPTIN BENZOATE/METFORMIN HCLALOGLIPTIN BENZOATE/PIOGLITAZONEHCLALORAALPHAGAN PALTACEALTAVERA

ALTOPREVALVESCOALYACENAMABELZAMANTADINE HCLAMARYLAMETHIAAMETHIA LOAMETHYSTAMILORIDE HCLAMILORIDEHCL/HYDROCHLOROTHIAZIDEAMIODARONE HCLAMITRIPTYLINE HCLAMITRIPTYLINE HCL/CHLORDIAZEPOXIDEAMLODIPINE BESYLATEAMLODIPINE BESYLATE/BENAZEPRIL HCLAMLODIPINE BESYLATE/OLMESARTANMEDOXOMILAMLODIPINE BESYLATE/VALSARTANAMLODIPINEBESYLATE/VALSARTAN/HYDROCHLOROTHIAZIDEAMOXAPINEANAFRANILANGELIQANORO ELLIPTAANTABUSEANTARAAPLENZINAPOKYNAPRACLONIDINE HCLAPRIAPRISOARANELLEARCAPTA NEOHALERARICEPT

PAGE 1 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

ARIPIPRAZOLEARMOUR THYROIDARNUITY ELLIPTAASACOL HDASHLYNAASMANEXASMANEX HFAASPIRIN/DIPYRIDAMOLEATACANDATACAND HCTATELVIAATENOLOLATENOLOL/CHLORTHALIDONEATORVASTATIN CALCIUMATROPINE SULFATEATROVENTATROVENT HFAAUBRAAVALIDEAVAPROAVIANEAVODARTAYGESTINAZASANAZATHIOPRINEAZILECTAZOPTAZORAZULFIDINEAZURETTEBACLOFENBALCOLTRABALSALAZIDE DISODIUMBALZIVABANZELBECONASE AQBEKYREE

BENAZEPRIL HCLBENAZEPRILHCL/HYDROCHLOROTHIAZIDEBENICARBENICAR HCTBENZTROPINE MESYLATEBETAGANBETAPACEBETAPACE AFBETAXOLOL HCLBETIMOLBETOPTIC SBEVESPI AEROSPHEREBEYAZBIDILBINOSTOBISOPROLOL FUMARATEBISOPROLOLFUMARATE/HYDROCHLOROTHIAZIDEBLISOVI 24 FEBLISOVI FEBONIVABREO ELLIPTABREVICONBRIELLYNBRILINTABRIMONIDINE TARTRATEBROMOCRIPTINE MESYLATEBUDESONIDEBUMETANIDEBUPROPION HCLBUSPIRONE HCLBYSTOLICBYVALSONCABERGOLINECADUETCALAN

PAGE 2 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

CALAN SRCALCIPOTRIENECALCIPOTRIENE/BETAMETHASONEDIPROPIONATECALCITONIN,SALMON,SYNTHETICCALCITRENECALCITRIOLCALCITRIOL 3 MCG/G OINTMENTCALCIUM ACETATECAMILACAMRESECAMRESE LOCANASACANDESARTAN CILEXETILCANDESARTANCILEXETIL/HYDROCHLOROTHIAZIDECAPTOPRILCAPTOPRIL/HYDROCHLOROTHIAZIDECARBAMAZEPINECARBATROLCARBIDOPACARBIDOPA/LEVODOPACARBIDOPA/LEVODOPA/ENTACAPONECARDIZEMCARDIZEM CDCARDIZEM LACARDURACARDURA XLCARTEOLOL HCLCARTIA XTCARVEDILOLCARVEDILOL PHOSPHATECATAPRESCATAPRES-TTSCAZIANTCELEXACELLCEPT

CELONTINCHATEALCHLOROQUINE PHOSPHATECHLOROTHIAZIDECHLORPROMAZINE HCLCHLORPROPAMIDECHLORTHALIDONECHOLESTYRAMINE/ASPARTAMECILOSTAZOLCITALOPRAM HYDROBROMIDECLIMARACLIMARA PROCLOBETASOL PROPIONATECLOBETASOL PROPIONATE/EMOLLIENTBASECLOBEXCLOMIPRAMINE HCLCLONIDINECLONIDINE HCLCLOPIDOGREL BISULFATECLORPRESCOLAZALCOLCHICINECOLCRYSCOLESTIDCOLESTIPOL HCLCOMBIGANCOMBIPATCHCOMBIVENT RESPIMATCOMTANCORDARONECOREGCOREG CRCORGARDCORMAXCORZIDECOSOPT

PAGE 3 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

COSOPT PFCOZAARCRESTORCRYSELLECYCLAFEMCYCLESSACYCLOPENTOLATE HCLCYCLOSETCYCLOSPORINECYCLOSPORINE, MODIFIEDCYMBALTACYREDCYSTAGONCYTOMELCYTRA-KDALIRESPDAPSONEDASETTADAYSEEDDAVPDEBLITANEDELESTROGENDELYLADELZICOLDEMADEXDEMSERDEPAKENEDEPAKOTEDEPAKOTE ERDEPAKOTE SPRINKLEDEPO-ESTRADIOLDESIPRAMINE HCLDESMOPRESSIN ACETATEDESOGENDESOGESTREL-ETHINYL ESTRADIOLDESOGESTREL-ETHINYLESTRADIOL/ETHINYL ESTRADIOL

DESVENLAFAXINE ERDESVENLAFAXINE FUMARATEDIABETADIAMOX SEQUELSDIBENZYLINEDIGITEKDIGOXDIGOXINDILANTINDILANTIN-125DILT-XRDILTIAZEM HCLDIOVANDIOVAN HCTDIPENTUMDIPYRIDAMOLEDISOPYRAMIDE PHOSPHATEDISULFIRAMDIURILDIVALPROEX SODIUMDIVIGELDOFETILIDEDONEPEZIL HCLDORZOLAMIDE HCLDORZOLAMIDE HCL/TIMOLOL MALEATEDORZOLAMIDE HCL/TIMOLOLMALEATE/PFDOVONEXDOXAZOSIN MESYLATEDOXEPIN HCLDRITHOCREME HPDROSPIRENONE/ETHINYLESTRADIOL/LEVOMEFOLATE CALCIUMDROXIADUETACTDULERADULOXETINE HCL

PAGE 4 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

DUTASTERIDEDUTOPROLDYAZIDEDYRENIUMEDARBIEDARBYCLOREDECRINEFFER-KEFFEXOR XREFFIENTELDEPRYLELESTRINELINESTELIPHOSELIQUISELIXOPHYLLINEMOQUETTEEMSAMENALAPRIL MALEATEENALAPRILMALEATE/HYDROCHLOROTHIAZIDEENJUVIAENPRESSEENSKYCEENSTILARENTACAPONEENTRESTOEPANDED SOLUTIONEPITOLEPROSARTAN MESYLATEEQUETROERGOCALCIFEROL (VITAMIN D2)ERGOLOID MESYLATESERRINESCITALOPRAM OXALATEESTARYLLAESTRACE

ESTRADIOLESTRADIOL VALERATEESTRADIOL/NORETHINDRONE ACETATEESTRINGESTROGELESTROPIPATEESTROSTEP FEETHACRYNIC ACIDETHINYL ESTRADIOL/DROSPIRENONEETHOSUXIMIDEETIDRONATE DISODIUMEVAMISTEXELONEXFORGEEXFORGE HCTEZETIMIBEEZETIMIBE/SIMVASTATINFALMINAFANAPTFARXIGAFAYOSIMFELBAMATEFELBATOLFELODIPINEFEMCON FEFEMHRTFEMRINGFEMYNORFENOFIBRATE,MICRONIZEDFENOFIBRIC ACIDFETZIMAFIBRICORFINASTERIDEFLECAINIDE ACETATEFLOMAXFLOVENT DISKUSFLOVENT HFA

PAGE 5 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

FLUNISOLIDEFLUOXETINE HCLFLUPHENAZINE HCLFLUTICASONEPROPIONATE/SALMETEROL XINAFOATEFLUVASTATIN SODIUMFLUVOXAMINE MALEATEFOLIC ACIDFORADILFORFIVO XLFORTAMETFORTICALFOSAMAXFOSINOPRIL SODIUMFOSINOPRILSODIUM/HYDROCHLOROTHIAZIDEFUROSEMIDEFYAVOLVGABAPENTINGABITRILGALANTAMINE HBRGASTROCROMGEMFIBROZILGENERESS FEGENGRAFGEODONGIANVIGIAZOGILDAGIAGILDESSGILDESS 24 FEGILDESS FEGLIMEPIRIDEGLIPIZIDEGLIPIZIDE/METFORMIN HCLGLUCOPHAGEGLUCOPHAGE XR

GLUCOTROLGLUCOTROL XLGLUCOVANCEGLUMETZAGLYBURIDEGLYBURIDE,MICRONIZEDGLYBURIDE/METFORMIN HCLGLYNASEGLYSETGLYXAMBIGRALISEGUANFACINE HCLGUANIDINE HCL HALOPERIDOLHEATHERHIPREXHYDRALAZINE HCLHYDREAHYDROCHLOROTHIAZIDEHYDROXYCHLOROQUINE SULFATEHYDROXYUREAHYZAARIBANDRONATE SODIUMIMIPRAMINE HCLIMIPRAMINE PAMOATEIMURANIMVEXXYINCRUSE ELLIPTAINDAPAMIDEINDERAL LAINDERAL XLINNOPRAN XLINSPRAINTROVALEINVEGAINVOKAMETINVOKAMET XR

PAGE 6 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

INVOKANAIOPIDINEIPRATROPIUM BROMIDEIPRATROPIUM BROMIDE/ALBUTEROLSULFATEIPRIVASKIRBESARTANIRBESARTAN/HYDROCHLOROTHIAZIDEIRENKAISOPTO CARPINEISOSORBIDE MONONITRATEISOXSUPRINE HCLISRADIPINEISTALOLJANUMETJANUMET XRJANUVIAJARDIANCEJENCYCLAJENTADUETOJENTADUETO XRJEVANTIQUE LOJINTELIJOLESSAJOLIVETTEJULEBERJUNELJUNEL FEJUNEL FE 24K EFFERVESCENTK-PHOS NO.2K-PHOS ORIGINALK-SOLK-TAB ERKAITLIB FEKARIVAKAZANO

KELNOR 1-35 KEPPRAKEPPRA XR KHEDEZLA KIMIDESSKLOR-CONKLOR-CON 10 KLOR-CON 8KLOR-CON M10 KLOR-CON M15 KLOR-CON M20 KLOR-CON SPRINKLE KLOR-CON-EF KOMBIGLYZE XR KURVELO LABETALOL HCL LAMICTAL LAMICTAL ODT LAMICTAL XR LAMOTRIGINE LANOXINLARINLARIN 24 FELARIN FELARISSIALASIXLATUDALAYOLIS FELEENALESCOLLESCOL XL LESSINALEVATOL LEVETIRACETAM

PAGE 7 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

LEVO-TLEVOBUNOLOL HCLLEVONESTLEVONORGESTREL-ETHINYL ESTRADIOLLEVORA-28LEVOTHYROXINE SODIUMLEVOXYLLEXAPROLIALDALIOTHYRONINE SODIUMLIPITORLISINOPRILLISINOPRIL/HYDROCHLOROTHIAZIDELITHIUM CARBONATELITHOBIDLIVALOLO LOESTRIN FELODOSYNLOESTRINLOESTRIN FELOFIBRALOMEDIA 24 FELONHALA MAGNAIR REFILLLONHALA MAGNAIR STARTERLOPIDLOPREEZALOPRESSORLOPRESSOR HCTLORYNALOSARTAN POTASSIUMLOSARTANPOTASSIUM/HYDROCHLOROTHIAZIDELOSEASONIQUELOTENSINLOTENSIN HCTLOTRELLOVASTATIN

LOW-OGESTRELLOXAPINE SUCCINATELUTERALYZAMAPROTILINE HCLMARLISSAMARPLANMATZIM LAMAVIKMAXZIDEMAXZIDE-25 MGMEDROXYPROGESTERONE ACETATEMEGACEMEGACE ESMEGESTROL ACETATEMEMANTINE HCLMENESTMENOSTARMERCAPTOPURINEMESALAMINEMESALAMINE 800 MG TABLET DRMESALAMINE WITH CLEANSING WIPESMESTINONMETFORMIN ER 500MG & 1000MG TAB(GENERIC VERSION OF GLUMETZA)METFORMIN HCLMETHAZOLAMIDEMETHIMAZOLEMETHOXSALENMETHYCLOTHIAZIDEMETHYLDOPAMETIPRANOLOLMETOLAZONEMETOPROLOL SUCCINATEMETOPROLOLSUCCINATE/HYDROCHLOROTHIAZIDEMETOPROLOL TARTRATE

PAGE 8 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

METOPROLOLTARTRATE/HYDROCHLOROTHIAZIDEMEXILETINE HCLMIACALCINMIBELAS 24 FEMICARDISMICARDIS HCTMICROGESTINMICROGESTIN 24 FEMICROGESTIN FEMICROZIDEMIDODRINE HCLMIGLITOLMIMVEYMIMVEY LOMINASTRIN 24 FEMINIPRESSMINITRANMINIVELLEMINOXIDILMIRAPEXMIRAPEX ERMIRCETTEMIRTAZAPINEMITIGAREMODICONMOEXIPRIL HCLMOEXIPRILHCL/HYDROCHLOROTHIAZIDEMOLINDONE HCLMONO-LINYAHMONONESSAMONTELUKAST SODIUMMYCOPHENOLATE MOFETILMYSOLINEMYZILRANADOLOL

NADOLOL/BENDROFLUMETHIAZIDENAMENDANAMENDA XRNAMZARICNARDILNASONEXNATAZIANATEGLINIDENATURE-THROIDNECONNEFAZODONE HCLNEORALNEPTAZANENESINANEUPRONEURONTINNIACINNIACORNIASPANNICARDIPINE HCLNIFEDICAL XLNIFEDIPINENIKKINIMODIPINENISOLDIPINENITRO-DURNITRO-TIMENITROGLYCERINNOR-Q-DNORA-BENORETHINDRONENORETHINDRONE ACETATENORETHINDRONE ACETATE-ETHINYLESTRADIOLNORETHINDRONE ACETATE-ETHINYLESTRADIOL/FERROUS FUMARATE

PAGE 9 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

NORETHINDRONE-ETHINYLESTRADIOL/FERROUS FUMARATENORGESTIMATE-ETHINYL ESTRADIOLNORINYL 1-35NORLYROCNORPACENORPACE CRNORPRAMINNORTRELNORTRIPTYLINE HCLNORVASCNP THYROIDNUPLAZIDNUVARINGNYMALIZEOCELLAOGESTRELOLANZAPINEOLANZAPINE/FLUOXETINE HCLOLEPTRO EROLMESARTAN MEDOXOMILOLMESARTAN MEDOXOMIL/AMLODIPINEBESYLATE/HYDROCHLOROTHIAZIDEOLMESARTANMEDOXOMIL/HYDROCHLOROTHIAZIDEOLUXOLUX-EOMNARISONGLYZAORACITORSYTHIAORTHO MICRONORORTHO TRI-CYCLENORTHO TRI-CYCLEN LOORTHO-CYCLENORTHO-NOVUMOSENI

OSMOLEX EROVCON-35OXCARBAZEPINEOXSORALEN-ULTRAOXTELLAR XRPACERONEPALIPERIDONEPAMELORPAREMYDPARLODELPARNATEPAROXETINE HCLPAROXETINE MESYLATEPAXILPAXIL CRPEGANONEPENTASAPENTOXIFYLLINEPERFOROMISTPERINDOPRIL ERBUMINEPERPHENAZINEPERPHENAZINE/AMITRIPTYLINE HCLPERSANTINEPEXEVAPHENELZINE SULFATEPHENOXYBENZAMINE HCLPHENYTEKPHENYTOINPHENYTOIN SODIUM EXTENDEDPHILITHPHOSLOPHOSLYRAPHOSPHOLINE IODIDEPIMTREAPINDOLOLPIOGLITAZONE HCLPIOGLITAZONE HCL/GLIMEPIRIDE

PAGE 10 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

PIOGLITAZONE HCL/METFORMIN HCLPIRMELLAPLAQUENILPLAVIXPLETALPORTIAPOTASSIUM BICARBONATE/CITRIC ACIDPOTASSIUM CHLORIDEPOTASSIUM CHLORIDE/POTASSIUMBICARBONATE/CITRIC ACIDPOTASSIUM CITRATEPOTASSIUM CITRATE/CITRIC ACIDPRADAXAPRAMIPEXOLE DI-HCLPRANDINPRAVACHOLPRAVASTATIN SODIUMPRAZOSIN HCLPRECOSEPREFESTPREMARINPREMPHASEPREMPROPRESTALIAPREVALITEPREVIFEMPRIMIDONEPRINIVILPRISTIQPROBENECIDPROBENECID/COLCHICINEPROCARDIAPROCARDIA XLPROCYSBIPROGESTERONEPROGESTERONE, MICRONIZEDPROMETRIUM

PROPAFENONE HCLPROPRANOLOL HCLPROPRANOLOLHCL/HYDROCHLOROTHIAZIDEPROPYLTHIOURACILPROSCARPROTRIPTYLINE HCLPROVERAPROZACPROZAC WEEKLYPULMICORTPULMICORT FLEXHALERPURIXANPYRIDOSTIGMINE BROMIDEQBRELISQNASLQNASL CHILDRENQTERNQUARTETTEQUASENSEQUDEXY XRQUESTRAN LIGHTQUETIAPINE FUMARATEQUINAPRIL HCLQUINAPRIL HCL/HYDROCHLOROTHIAZIDEQUINIDINE GLUCONATEQUINIDINE SULFATEQVARRAJANIRAMIPRILRANEXARAPAFLORASAGILINE MESYLATERAZADYNERAZADYNE ERRECLIPSENREMERON

PAGE 11 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

REPAGLINIDEREPAGLINIDE/METFORMINREQUIPREQUIP XLRESTASISRESTASIS MULTIDOSEREXULTIRHINOCORT AQUARHOPRESSARILUTEKRILUZOLERIOMETRISEDRONATE SODIUMRISPERDALRISPERDAL M-TABRISPERIDONERIVASTIGMINERIVASTIGMINE TARTRATERIVELSAROCALTROLROPINIROLE HCLROSUVASTATIN CALCIUMROWASAROWEEPRAROZEREMRYTARYRYTHMOLRYTHMOL SRSABRILSAFYRALSANDIMMUNESAPHRISSARAFEMSAVAYSASAVELLASEASONIQUESECTRAL

SEEBRI NEOHALERSELEGILINE HCLSEREVENT DISKUSSEROQUELSEROQUEL XRSERTRALINE HCLSETLAKINSFROWASASHAROBELSIKLOSSIMBRINZASIMVASTATINSINEMET 10-100SINEMET 25-100SINEMET 25-250SINEMET CRSINGULAIRSORILUXSORINESOTALOL HCLSOTYLIZESPIRIVASPIRIVA RESPIMATSPIRONOLACTONESPIRONOLACTONE/HYDROCHLOROTHIAZIDESPRINTECSPRITAMSRONYXSTALEVOSTARLIXSTEGLATROSTEGLUJANSTIMATESTIOLTO RESPIMATSULARSULFASALAZINE

PAGE 12 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

SURMONTILSYEDASYMBICORTSYMBYAXSYNJARDYSYNJARDY XRSYNTHROIDTABLOIDTACLONEXTAMSULOSIN HCLTAPAZOLETARINA FETARKATASMARTAYTULLATAZORACTAZTIA XTTEGRETOLTEGRETOL XRTEKTURNATEKTURNA HCTTELMISARTANTELMISARTAN/AMLODIPINE BESYLATETELMISARTAN/HYDROCHLOROTHIAZIDETEMOVATETENEXTENORETIC 100TENORETIC 50TENORMINTERAZOSIN HCLTHEO-24THEOCHRONTHEOPHYLLINE ANHYDROUSTHIOLATHIORIDAZINE HCLTHIOTHIXENETHYROLAR-1

THYROLAR-1/2THYROLAR-1/4THYROLAR-2THYROLAR-3TIAGABINE HCLTIAZACTICLOPIDINE HCLTIKOSYNTILIA FETIMOLOL MALEATETIMOPTICTIMOPTIC OCUDOSETIMOPTIC-XETIROSINTTL G-FOL OSTOBI PODHALERTOFRANILTOFRANIL-PMTOLAZAMIDETOLBUTAMIDETOLCAPONETOPAMAXTOPIRAMATETOPIRAMATE ER CAPSTOPROL XLTORSEMIDETRADJENTATRANDOLAPRILTRANDOLAPRIL/VERAPAMIL HCLTRANYLCYPROMINE SULFATETRAZODONE HCLTRELEGY ELLIPTATRI-ESTARYLLATRI-LEGEST FETRI-LINYAHTRI-LO-ESTARYLLATRI-LO-MARZIA

PAGE 13 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

TRI-LO-SPRINTECTRI-NORINYLTRI-PREVIFEMTRI-SPRINTECTRIAMTERENE/HYDROCHLOROTHIAZIDETRIBENZORTRIFLUOPERAZINE HCLTRIHEXYPHENIDYL HCLTRILEPTALTRIMIPRAMINE MALEATETRINESSATRINESSA LOTRIVORA-28TROKENDI XRTROPICAMIDETRUSOPTTUDORZA PRESSAIRTWYNSTATYDEMYULORICUNITHROIDUROCIT-KUROQID-ACID NO.2UROXATRALURSOURSO FORTEURSODIOLUTIBRON NEOHALERVAGIFEMVALCYTEVALGANCICLOVIR HCLVALPROIC ACID (AS SODIUM SALT)(VALPROATE SODIUM)VALPROIC ACIDVALSARTANVALSARTAN/HYDROCHLOROTHIAZIDEVASERETIC

VASOTECVECTICALVELIVETVENLAFAXINE ER TAB VENLAFAXINE HCLVERAMYSTVERAPAMIL HCLVERELANVERELAN PMVESTURAVIENVAVIIBRYDVIMPATVIORELEVIVELLE-DOTVRAYLARVYFEMLAWELLBUTRINWELLBUTRIN SRWELLBUTRIN XLWERAWESTHROIDWP THYROIDWYMZYA FEXARELTOXHANCEXIGDUO XRXULANEYASMIN 28YAZYUVAFEMZAFIRLUKASTZARAHZARONTINZEBETA

PAGE 14 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

ZELAPARZENCHENTZENCHENT FEZESTORETICZESTRILZETONNAZIACZILEUTONZIPRASIDONE HCLZITHRANOL-RRZOCORZOLOFTZONEGRANZONISAMIDEZONTIVITYZOVIA 1-35EZOVIA 1-50EZURAMPICZYFLOZYFLO CRZYLOPRIMZYPREXAZYPREXA ZYDIS

PAGE 15 LAST UPDATED 09/2018

Maintenance medications are typically prescribed for long-term use. This list provides examples of commonly prescribed maintenance medications required for purchase through the mail order program. It is not comprehensive. Coverage requirements and co-payments are based upon the specific rider chosen by the employer group. If you have any questions regarding this service, please call the Customer Care number on the back of your Member Card.

TRADE NAME

Purchase Required through The General Apothecary, Park Ridge Apothecary, Rochester Regional Health Perinton Pharmacy, Rochester Regional Health Wilson Pharmacy, Unity St. Mary’s Apothecary or Excellus Mail Order Vendors, Express Scripts Home Delivery Pharmacy or Wegmans Home Delivery

List of Mandatory Mail Drugs