Maintenance Medications ListPrecision Formulary

Quality Driven and Cost-Conscious MedicationsAs the pharmacy benefit manager for your benefit plan, Magellan Rx Management strives to offer you access to a broad choice of medications at a reasonable price.

The Maintenance Medication List is a subset of products included within your plan’s preferred, or formulary, medication list, that are used to treat chronic conditions requiring ongoing treatment with medication.

Mandatory 90-Day supply at retail or mail A 90-day supply is mandatory upon the third fill of a Tier 1 or Tier 2 maintenance medication. You’ll be allowed two 30 day fills within 90 days before being required to obtain 90 days through mail order or at a participating pharmacy location. Mandatory 90 requirement does not apply to medications on Tier 3, Tier 4 or Tier 5.

How to get a 90-day supply Call 352-265-0405 to get a 90 day through Shands Pharmacy (In person or by mail!)

Call 877-276-9360 to get a 90 day through Walgreens Mail Order

To locate a retail pharmacy, visit magellanrx.com or contact customer service at the toll-free member phone number on your benefit plan ID card.

To check the cost of a medication, refer to your benefit handbook or contact customer service at the toll-free member phone number on your benefit plan ID card.

Money Saving GenericsIf you have questions or would like additional information on the GatorCare Maintenance Medication List, please contact customer service at the toll-free member phone number on your ID card or visit gatorcare.org.

A list of covered maintenance medications begins on the next page. Medications are listed both alphabetically and by therapeutic category. They are indicated by:

Generics: Lower case italic. For example, acarbose

Brands: Capitalized and not italics. For example, Abilify

*This maintenance medication list is subject to change and does not guarantee coverage. For a current listing of covered medications, visit the Formulary Lookup Tool.

magellanrx.com

2020 Maintenance Medication List Alphabetical Listings

Aacamprosate calcium

acarbose

acebutolol hcl

acetazolamide

Actoplus Met Xr

acyclovir

albuterol sulfate

alendronate sodium

alfuzosin hcl

amantadine hcl

amiloride hcl

amiloride hcl/hydrochlorothiazide

amiodarone hcl

amitriptyline hcl

amlodipine besylate

amlodipine besylate/atorvastatin calcium

amlodipine besylate/benazepril hcl

amlodipine besylate/olmesartan medoxomil

amlodipine besylate/valsartan

amlodipine besylate/valsartan/hydrochlorothiazide

amoxapine

anagrelide hcl

anastrozole

Apriso

aripiprazole

aspirin/dipyridamole

atenolol

atenolol/chlorthalidone

atorvastatin calcium

Avandia

azathioprine

B

benazepril hcl

benazepril hcl/hydrochlorothiazide

benztropine mesylate

betaxolol hcl

bicalutamide

bisoprolol fumarate

bisoprolol fumarate/hydrochlorothiazide

Brilinta

bromocriptine mesylate

bumetanide

bupropion hcl

buspirone hcl

Bystolic

Ccabergoline

calcitonin,salmon,synthetic

calcitriol

calcium acetate

candesartan cilexetil

candesartan cilexetil/hydrochlorothiazide

captopril

captopril/hydrochlorothiazide

Carafate

carbamazepine

carbidopa

carbidopa/levodopa

carbidopa/levodopa/entacapone

carvedilol

cevimeline hcl

chlorothiazide

chlorpromazine hcl

chlorpropamide

chlorthalidone

cholestyramine (with sugar)

cholestyramine/aspartame

cilostazol

cimetidine

citalopram hydrobromide

Climara Pro

clomipramine hcl

clonidine

clonidine hcl

clopidogrel bisulfate

colestipol hcl

Creon

cyanocobalamin (vitamin b-12)

D

darifenacin hydrobromide

Depakote Er

Depakote Sprinkle

desipramine hcl

desmopressin acetate

desogestrel-ethinyl estradiol

desogestrel-ethinyl estradiol/ethinyl estradiol

desvenlafaxine

desvenlafaxine fumarate

desvenlafaxine succinate

dicyclomine hcl

digoxin

Dilantin

Dilantin-125

diltiazem hcl

dipyridamole

disopyramide phosphate

disulfiram

divalproex sodium

Divigel

donepezil hcl

doxazosin mesylate

doxepin hcl

drospirenone/ethinyl estradiol/levomefolate calcium

Duavee

duloxetine hcl

dutasteride

dutasteride/tamsulosin hcl

E

enalapril maleate

enalapril maleate/hydrochlorothiazide

entacapone

eplerenone

eprosartan mesylate

ergocalciferol (vitamin d2)

ergoloid mesylates

escitalopram oxalate

esomeprazole magnesium

esomeprazole strontium

estradiol

estradiol/norethindrone acetate

Estring

estropipate

ethinyl estradiol/drospirenone

ethosuximide

ethynodiol diacetate-ethinyl estradiol

etidronate disodium

exemestane

ezetimibe

ezetimibe/simvastatin

F

famciclovir

famotidine

felbamate

felodipine

fenofibrate nanocrystallized

fenofibric acid (choline)

finasteride

flavoxate hcl

flecainide acetate

fludrocortisone acetate

fluoxetine hcl

fluphenazine hcl

flutamide

fluvastatin sodium

fluvoxamine maleate

folic acid

fosinopril sodium

fosinopril sodium/hydrochlorothiazide

furosemide

G

gabapentin

galantamine hbr

gemfibrozil

glimepiride

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glipizide

glipizide/metformin hcl

glyburide

glyburide,micronized

glyburide/metformin hcl

glycopyrrolate

guanfacine hcl

H

haloperidol

haloperidol lactate

hydralazine hcl

hydrochlorothiazide

hydrocortisone

hydroxyurea

I

ibandronate sodium

imipramine hcl

imipramine pamoate

indapamide

Invokamet

Invokamet Xr

Invokana

irbesartan

irbesartan/hydrochlorothiazide

isosorbide dinitrate

isosorbide mononitrate

isoxsuprine hcl

isradipine

J

Janumet

Janumet Xr

Januvia

Jardiance

Jentadueto

Jentadueto Xr

L

labetalol hcl

lactulose

lamotrigine

Lanoxin

lansoprazole

letrozole

levetiracetam

levocarnitine (with sugar)

levonorgestrel/ethinyl estradiol and ethinyl estradiol

levonorgestrel-ethinyl estradiol

levothyroxine sodium

Linzess

liothyronine sodium

lipase/protease/amylase

lisinopril

lisinopril/hydrochlorothiazide

lithium carbonate

lithium citrate

losartan potassium

losartan potassium/hydrochlorothiazide

lovastatin

loxapine succinate

M

maprotiline hcl

medroxyprogesterone acetate

megestrol acetate

memantine hcl

Menest

mesalamine

metaproterenol sulfate

metformin hcl

methazolamide

methimazole

methotrexate sodium

methyclothiazide

methyldopa

methyldopa/hydrochlorothiazide

metolazone

metoprolol succinate

metoprolol tartrate

metoprolol tartrate/hydrochlorothiazide

mexiletine hcl

miglitol

minoxidil

mirtazapine

moexipril hcl

moexipril hcl/hydrochlorothiazide

molindone hcl

montelukast sodium

N

nadolol

nadolol/bendroflumethiazide

Natazia

nateglinide

nefazodone hcl

niacin

nicardipine hcl

nifedipine

nisoldipine

Nitro-Bid

nitroglycerin

nizatidine

norelgestromin/ethinyl estradiol

norethindrone

norethindrone acetate

norethindrone acetate-ethinyl estradiol

norethindrone acetate-ethinyl estradiol/ferrous fumarate

norethindrone-ethinyl estradiol

norethindrone-ethinyl estradiol/ferrous fumarate

norgestimate-ethinyl estradiol

norgestrel-ethinyl estradiol

Norpace Cr

nortriptyline hcl

O

olanzapine

olanzapine/fluoxetine hcl

olmesartan medoxomil

olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide

olmesartan medoxomil/hydrochlorothiazide

omega-3 acid ethyl esters

omeprazole

omeprazole/sodium bicarbonate

oxcarbazepine

oxybutynin chloride

P

paliperidone

pantoprazole sodium

paroxetine hcl

pentoxifylline

perindopril erbumine

perphenazine

perphenazine/amitriptyline hcl

phenelzine sulfate

Phenytek

phenytoin

phenytoin sodium extended

pilocarpine hcl

pimozide

pindolol

pioglitazone hcl

pioglitazone hcl/glimepiride

pioglitazone hcl/metformin hcl

potassium bicarbonate/citric acid

potassium chloride

potassium citrate

pramipexole di-hcl

pravastatin sodium

prazosin hcl

Premarin

Premphase

Prempro

prenatal vit no.80/iron carb,bisgl/methylfolate gluc/dss/dha

prenatal vits no.12/iron,carb/folic acid/docusate/omega-3

primidone

progesterone, micronized

propafenone hcl

propranolol hcl

propranolol hcl/hydrochlorothiazide

propylthiouracil

protriptyline hcl

pyridostigmine bromide

Q

quetiapine fumarate

quinapril hcl

quinapril hcl/hydrochlorothiazide

quinidine gluconate

quinidine sulfate

R

rabeprazole sodium

raloxifene hcl

ramipril

ranitidine hcl

rasagiline mesylate

repaglinide

repaglinide/metformin hcl

riluzole

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risedronate sodium

risperidone

rivastigmine tartrate

ropinirole hcl

rosuvastatin calcium

S

selegiline hcl

sertraline hcl

simvastatin

sodium fluoride

sotalol hcl

spironolactone

spironolactone/hydrochlorothiazide

sucralfate

sulfasalazine

Synjardy

Synjardy Xr

Synthroid

T

tamoxifen citrate

tamsulosin hcl

telmisartan

telmisartan/amlodipine besylate

telmisartan/hydrochlorothiazide

terazosin hcl

terbutaline sulfate

theophylline anhydrous

thioridazine hcl

thiothixene

thyroid,pork

tiagabine hcl

ticlopidine hcl

timolol maleate

tolazamide

tolbutamide

tolcapone

tolterodine tartrate

Topamax

topiramate

torsemide

Tradjenta

trandolapril

trandolapril/verapamil hcl

tranylcypromine sulfate

trazodone hcl

Trexall

triamterene/hydrochlorothiazide

trifluoperazine hcl

trihexyphenidyl hcl

trimipramine maleate

trospium chloride

U

ursodiol

V

valacyclovir hcl

valganciclovir hcl

valproic acid (as sodium salt) (valproate sodium)

valsartan

valsartan/hydrochlorothiazide

venlafaxine hcl

verapamil hcl

vitamin b complex no.3/folic acid/ascorbic acid(vitc)/biotin

Z

zafirlukast

Zarontin

Zenpep

zileuton

ziprasidone hcl

Zonegran

zonisamide

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Therapeutic Category

ALZHEIMER'S THERAPYmemantine hcl

AMYOTROPHIC LATERAL SCLEROSIS AGENTSriluzole

ANTICONVULSANTS

carbamazepine

Carbatrol

Depakote Er

Depakote Sprinkle

Dilantin

Dilantin-125

divalproex sodium

ethosuximide

felbamate

gabapentin

Gabitril

lamotrigine

levetiracetam

oxcarbazepine

Phenytek

phenytoin

phenytoin sodium extended

primidone

Tegretol Xr

tiagabine hcl

Topamax

topiramate

valproic acid (as sodium salt) (valproate sodium)

Zarontin

Zonegran zonisamide

ANTIPARKINSON DRUGSamantadine hcl

benztropine mesylate

bromocriptine mesylate

carbidopa

carbidopa/levodopa

carbidopa/levodopa

carbidopa/levodopa/entacapone

entacapone

pramipexole di-hcl

pramipexole di-hcl

rasagiline mesylate

ropinirole hcl

ropinirole hcl

selegiline hcl

tolcapone

trihexyphenidyl hcl

ANTIPLATELET DRUGSanagrelide hcl

aspirin/dipyridamole

Brilinta

cilostazol

clopidogrel bisulfate

dipyridamole

Effient

prasugrel hcl

ticlopidine hcl

ANTIVIRALSacyclovir

famciclovir

valacyclovir hcl

valganciclovir hcl

ASTHMAalbuterol sulfate

metaproterenol sulfate

montelukast sodium

terbutaline sulfate

theophylline anhydrous

theophylline anhydrous

theophylline anhydrous

zafirlukast

zileuton

AUTONOMIC DRUGScevimeline hcl

donepezil hcl

galantamine hbr Mestinon

pilocarpine hcl

pyridostigmine bromide

rivastigmine tartrate

BLOOD DISORDERpentoxifylline

BHPalfuzosin hcl

dutasteride

dutasteride/tamsulosin hcl

finasteride

Rapaflo

silodosin

tamsulosin hcl

CANCERanastrozole

bicalutamide

exemestane

Fareston

flutamide

hydroxyurea

letrozole

methotrexate sodium

tamoxifen citrate

toremifene citrate

Trexall

CARDIAC DRUGSamiodarone hcl

Cordarone

Corlanor

digoxin

Dilatrate-sr

disopyramide phosphate

flecainide acetate

Isordil

isosorbide dinitrate

isosorbide mononitrate

Lanoxin

mexiletine hcl

Nitro-bid

Nitro-dur

nitroglycerin

Norpace cr

propafenone hcl

quinidine gluconate

quinidine sulfate

Ranexa

ranolazine er

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CARDIOVASCULARergoloid mesylates

isoxsuprine hcl

CONTRACEPTIVESdesogestrel-ethinyl estradiol

desogestrel-ethinyl estradiol/ethinyl estradiol

drospirenone/ethinyl estradiol/levomefolate calcium

ethinyl estradiol/drospirenone

ethynodiol diacetate-ethinyl estradiol

levonorgestrel/ethinyl estradiol and ethinyl estradiol

levonorgestrel-ethinyl estradiol

Natazia

norelgestromin/ethinyl estradiol

norethindrone

norethindrone acetate-ethinyl estradiol

norethindrone acetate-ethinyl estradiol/ferrous fumarate

norethindrone-ethinyl estradiol

norethindrone-ethinyl estradiol/ferrous fumarate

norgestimate-ethinyl estradiol

norgestrel-ethinyl estradiol

Nuvaring

DIABETESacarbose

Actoplus Met Xr

Avandamet

Avandaryl

Avandia

chlorpropamide

glimepiride

glipizide

glipizide/metformin hcl

glyburide

glyburide,micronized

glyburide/metformin hcl

Invokamet

Invokamet Xr

Invokana

Janumet

Janumet Xr

Januvia

Jardiance

Jentadueto

Jentadueto Xr

metformin hcl

miglitol

nateglinide

pioglitazone hcl

pioglitazone hcl/glimepiride

pioglitazone hcl/metformin hcl

repaglinide

repaglinide/metformin hcl

Synjardy

Synjardy Xr

tolazamide

tolbutamide

Tradjenta

DIABETIC SUPPLIESLancets

Needles

Pen Needles

Syringes

Test Strips

DIURETICSacetazolamide

amiloride hcl

amiloride hcl/hydrochlorothiazide

bumetanide

chlorothiazide

chlorthalidone

eplerenone

furosemide

hydrochlorothiazide

indapamide

lanthanum carbonate

methazolamide

methyclothiazide

metolazone

sevelamer carbonate

spironolactone

spironolactone/hydrochlorothiazide

torsemide

triamterene/hydrochlorothiazide

DIURETICScalcium acetate

Fosrenol

potassium bicarbonate/citric acid

potassium chloride

potassium citrate

Renvela

sodium fluoride

GASTROINTESTINALAmitiza

Apriso

Canasa

Carafate

cimetidine

Creon

dicyclomine hcl

esomeprazole magnesium

esomeprazole strontium

famotidine

glycopyrrolate

lactulose

lansoprazole

Lialda

Linzess

lipase/protease/amylase

mesalamine

nizatidine

omega-3 acid ethyl esters

omeprazole

omeprazole/sodium bicarbonate

pantoprazole sodium

rabeprazole sodium

ranitidine hcl

sucralfate

sulfasalazine

ursodiol

Zenpep

HIGH BLOOD PRESSUREacebutolol hcl

amlodipine besylate

amlodipine besylate/benazepril hcl

amlodipine besylate/olmesartan medoxomil

amlodipine besylate/valsartan

amlodipine besylate/valsartan/hydrochlorothiazide

atenolol

atenolol/chlorthalidone

benazepril hcl

benazepril hcl/hydrochlorothiazide

betaxolol hcl

bisoprolol fumarate

bisoprolol fumarate/

hydrochlorothiazide

Bystolic

candesartan cilexetil

candesartan cilexetil/hydrochlorothiazide

captopril

captopril/hydrochlorothiazide

carvedilol

clonidine

clonidine hcl

diltiazem hcl

doxazosin mesylate

enalapril maleate

enalapril maleate/hydrochlorothiazide

eprosartan mesylate

felodipine

fosinopril sodium

fosinopril sodium/hydrochlorothiazide

guanfacine hcl

hydralazine hcl

irbesartan

irbesartan/hydrochlorothiazide

isradipine

labetalol hcl

lisinopril

lisinopril/hydrochlorothiazide

losartan potassium

losartan potassium/hydrochlorothiazide

methyldopa

methyldopa/hydrochlorothiazide

metoprolol succinate

metoprolol tartrate

metoprolol tartrate/hydrochlorothiazide

minoxidil

moexipril hcl

moexipril hcl/hydrochlorothiazide

nadolol

nadolol/bendroflumethiazide

nicardipine hcl

nifedipine

nisoldipine

olmesartan medoxomil

olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide

olmesartan medoxomil/hydrochlorothiazide

perindopril erbumine

pindolol

prazosin hcl

propranolol hcl

propranolol hcl/hydrochlorothiazide

quinapril hcl

quinapril hcl/hydrochlorothiazide

ramipril

reserpine

sotalol hcl

telmisartan

telmisartan/amlodipine besylate

telmisartan/hydrochlorothiazide

terazosin hcl

timolol maleate

trandolapril

trandolapril/verapamil hcl

valsartan

valsartan/hydrochlorothiazide

verapamil hcl

HIGH BLOOD PRESSURE/CHOLESTEROLamlodipine besylate/atorvastatin calcium

HIGH CHOLESTEROLatorvastatin calcium

cholestyramine (with sugar)

cholestyramine/aspartame

colestipol hcl

ezetimibe

ezetimibe/simvastatin

fenofibrate nanocrystallized

fenofibric acid (choline)

fluvastatin sodium

gemfibrozil

lovastatin

niacin

pravastatin sodium

rosuvastatin calcium

simvastatin

Welchol

HORMONEScabergoline

calcitonin,salmon,synthetic

Climara Pro

desmopressin acetate

Divigel

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Duavee

Enjuvia

Estrace

estradiol

estradiol/norethindrone acetate

Estring

estropipate

fludrocortisone acetate

hydrocortisone

medroxyprogesterone acetate

Menest

norethindrone acetate

norethindrone acetate-ethinyl estradiol

Premarin

Premphase

Prempro

progesterone, micronized

IMMUNOSUPPRESSANTSazathioprine

MISCELLANEOUSacamprosate calcium

disulfiram

levocarnitine (with sugar)

megestrol acetate

OSTEOPOROSISalendronate sodium

darifenacin hydrobromide

etidronate disodium

ibandronate sodium

raloxifene hcl

risedronate sodium

PRE-NATAL VITAMINSprenatal vit no.80/iron carb,bisgl/methylfolate gluc/dss/dha

prenatal vits no.12/iron,carb/folic acid/docusate/omega-3

PSYCHOTHERAPEUTIC DRUGSamitriptyline hcl

amoxapine

aripiprazole

bupropion hcl

buspirone hcl

chlorpromazine hcl

citalopram hydrobromide

clomipramine hcl

desipramine hcl

desvenlafaxine

desvenlafaxine fumarate

desvenlafaxine succinate

doxepin hcl

duloxetine hcl

escitalopram oxalate

fluoxetine hcl

fluphenazine hcl

fluvoxamine maleate

haloperidol

haloperidol lactate

imipramine hcl

imipramine pamoate

lithium carbonate

lithium citrate

loxapine succinate

maprotiline hcl

mirtazapine

molindone hcl

nefazodone hcl

nortriptyline hcl

olanzapine

olanzapine/fluoxetine hcl

paliperidone

paroxetine hcl

perphenazine

perphenazine/amitriptyline hcl

phenelzine sulfate

pimozide

protriptyline hcl

quetiapine fumarate

risperidone

Seroquel Xr

sertraline hcl

thioridazine hcl

thiothixene

tranylcypromine sulfate

trazodone hcl

trifluoperazine hcl

trimipramine maleate

venlafaxine hcl

ziprasidone hcl

PSYCHOTHERAPEUTIC DRUGSlevothyroxine sodium

liothyronine sodium

methimazole

propylthiouracil

Synthroid

thyroid,pork

URINARYflavoxate hcl

Gelnique

oxybutynin chloride

solifenacin succinate

tolterodine tartrate

trospium chloride

Vesicare

VITAMINScalcitriol

cyanocobalamin (vitamin b-12)

ergocalciferol (vitamin d2)

folic acid

vitamin b complex no.3/folic acid/ascorbic acid(vitc)/biotin

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