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. 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.
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
ALORA
acetazolamide ER ARICEPT ODT
ALPHAGAN P 0.1% OPHTH
ACIPHEX ARIMIDEX
ALPHAGAN P 0.15% OPHTH
ACTIGALL AROMASIN
ALTACE CAPS
ACTIVELLA 0.5 – 0.1 MG ARTHROTEC
ALTACE TABS
ACTIVELLA 1 – 0.5 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
71472.0810 page 1 of 6
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
BETAPACE CELEXA CYTOMEL
BETAPACE AF CENESTIN CYTOTEC
betaxolol chlorothiazide DAYPRO
BETAXOLOL 0.5% OPHTH chlorpromazine DEMADEX
BETIMOL chlorpropamide desipramine
BETOPTIC-S chlorthalidone DETROL
BIDIL cholestyramine DETROL LA
bisoprolol cholestyramine light DIAMOX SEQUELS
bisoprolol/hydrochlorothiazide CIALIS 2.5, 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
CALAN clonidine patches DIOVAN HCT
CALAN SR CLORPRES DIPENTUM
calcitonin salmon nasal soln COGNEX dipyridamole
calcitriol COLESTID disopyramide
calcium acetate colestipol DITROPAN XL
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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
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, 12.5 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 1/0.5 mg furosemide INDERAL LA
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
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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
isradipine loxapine mirtazapine
ISRADIPINE 2.5 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
LEVSIN methyldopa naproxen sodium
LEVSINEX METHYLDOPA/ NARDIL
LEXAPRO HYDROCHLOROTHIAZIDE NASCOBAL
LIMBITROL metipranolol ophth nateglinide
liothyronine metolazone NAVANE
LIPITOR metoprolol succinate ER NAVANE 20 MG
LIPOFEN metoprolol tartrate NEFAZODONE
lisinopril metoprolol/hydrochlorothiazide NEXIUM
lisinopril/hydrochlorothiazide METOPROLOL/ NIASPAN
HYDROCHLOROTHIAZIDE 100/50
lithium carbonate nicardipine
MEVACOR
lithium carbonate ER nifedipine
MEXILETINE
LITHOBID NIFEDIPINE 20 MG
MIACALCIN NASAL SPRAY
LODOSYN nifedipine ER
MICARDIS
LOFIBRA NISOLDIPINE ER
MICARDIS HCT
LOPID nizatidine
MICROZIDE
LOPRESSOR norethindrone acetate
MIDAMOR
LOPRESSOR HCT NORPACE
MINIPRESS
LOTENSIN NORPACE CR
minoxidil
LOTENSIN HCT NORPRAMIN
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nortriptyline PLETAL Generic drugs = bold, lower-case type
NORVASC PRANDIMET Brand drugs** = CAPITAL LETTERS
NOXAFIL PRANDIN = generic available
NULEV PRAVACHOL
NUVARING pravastatin QUESTRAN LIGHT
NUVIGIL prazosin quinapril
OGEN PRECOSE quinapril/hydrochlorothiazide
omeprazole DR PREFEST quinidine gluconate ER
ONGLYZA PREMARIN QUINIDINE SULFATE ER
OPTIPRANOLOL PREMARIN VAG CRM QVAR
ORAP PREMPHASE ramipril
ORTHO EVRA PREMPRO RANEXA
oxaprozin PREVACID ranitidine
oxybutynin PREVACID NAPRAPAC RAPAFLO
oxybutynin ER PREVACID SOLUTAB RAZADYNE
OXYTROL PRILOSEC REGLAN
PACERONE PRILOSEC POWDER PACKETS REMERON
PACERONE 100 MG primidone REMERON SOLTAB
Pacerone 200 mg PRINIVIL RENAGEL
PAMELOR PRINZIDE RENVELA
pantoprazole PRISTIQ REQUIP
PARCOPA probenecid REQUIP XL
PARLODEL probenecid/colchicine RESTASIS
PARNATE PROCARDIA XL RHEUMATREX
paroxetine PROMACTA RISPERDAL
paroxetine ER PROMETRIUM RISPERDAL M-TAB
PAXIL propafenone risperidone
PAXIL CR PROPRANOLOL SOLN RISPERIDONE ODT 0.25 MG
PAXIL CR 37.5 MG propranolol tabs risperidone ODT 0.5, 1, 2, 3, 4 mg
PENTASA propranolol SR ROCALTROL
pentoxifylline propranolol/hydrochlorothiazide 40/25 ropinirole
PEPCID PROPRANOLOL/ ROZEREM
PEPCID SUSP HYDROCHLOROTHIAZIDE 80/25 RYTHMOL
PERFOROMIST propylthiouracil RYTHMOL SR
perphenazine PROSCAR SALAGEN
PERPHENAZINE–AMITRIPTYLINE PROTONIX salsalate
PERSANTINE PROTONIX POWDER PACKETS SANCTURA
PEXEVA protriptyline SANCTURA XR
PHOSLO PROVERA SAPHRIS
pilocarpine ophth, tabs PROZAC SARAFEM TABS
PILOCARPINE 0.5, 3% OPHTH PROZAC WEEKLY SAVELLA
PINDOLOL PULMICORT FLEXHALER SECTRAL
piroxicam PULMICORT RESPULES selegiline caps
PLAVIX QUESTRAN SEREVENT DISKUS
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SEROQUEL ticlopidine Generic drugs = bold, lower-case type
SEROQUEL XR TIMOLOL TABS Brand drugs** = CAPITAL LETTERS
sertraline timolol maleate ophth = generic available
SIMCOR TIMOPTIC
simvastatin TIMOPTIC-XE verapamil
SINEMET tizanidine tabs verapamil ER
SINEMET CR TOFRANIL VERELAN
SINGULAIR TOFRANIL-PM VERELAN PM
sotalol TOPROL XL VESICARE
sotalol AF torsemide VIVACTIL
SPIRIVA TOVIAZ VIVELLE-DOT
spironolactone TRANDATE VOLTAREN-XR
spironolactone/hydrochlorothiazide trandolapril VYTORIN
STALEVO tranylcypromine WELCHOL
STARLIX TRAVATAN WELLBUTRIN
sucralfate TRAVATAN Z WELLBUTRIN SR
SUCRALFATE SUSP trazodone WELLBUTRIN XL
SULAR TRENTAL XALATAN
sulfasalazine triamterene/hydrochlorothiazide ZANAFLEX CAPS
sulfasalazine EC caps, tabs ZANAFLEX TABS
sulindac TRICOR ZANTAC
SURMONTIL trifluoperazine tabs ZANATAC EFFERVESCENT TABS
SYMBICORT TRIGLIDE ZAROXOLYN
SYMBYAX trihexyphenidyl ZEBETA
SYNTHROID TRILIPIX ZEGERID
TAMBOCOR TRUSOPT ZELAPAR
TAPAZOLE ULORIC ZEMPLAR
TARKA UNIRETIC ZESTRIL
TASMAR unithroid ZETIA
TEKTURNA UNIVASC ZIAC
TEKTURNA HCT UROXATRAL ZOCOR
TENEX URSO ZOLOFT
TENORETIC URSO FORTE ZORPRIN
TENORMIN ursodiol caps ZYFLO CR
terazosin VAGIFEM ZYLOPRIM
TEVETEN VALTURNA ZYPREXA
THALITONE 15 MG VASERETIC ZYPREXA ZYDIS
thiothixene VASOTEC
THYROLAR venlafaxine
TIAZAC VENLAFAXINE ER TABS

* PrimeMail is a mail order pharmacy owned and operated by Prime Therapeutics LLC, a pharmacy benefit management
company. Blue Cross and Blue Shield of Oklahoma contracts with Prime Therapeutics to provide pharmacy benefit
management and mail order pharmacy services. Blue Cross and Blue Shield of Oklahoma, as well as several other
independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

** Third-party brand names are the property of their respective owners. page 6 of 6