-
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