The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: The symbol * next to a drug signifies that it is subject to nonformulary status 2013 Express Scripts when a generic is available throughout the year. Not all the drugs listed are covered by all prescription-drug benefit programs; check your benefit materials for the specific drugs National Preferred Formulary covered and the copayments for your prescription-drug benefit program. For specific questions about your coverage, please call the phone number printed on your ID card. A cryselle lansoprazole, odt NATAZIA AZOPT* fosinopril, /hctz LANTUS, SOLOSTAR [INJ] nateglinide AZOR latanoprost CYMBALTA* furosemide B D G LEVEMIR, FLEXPEN [INJ] baclofen levetiracetam NEXIUM NIASPAN*
PLUS, NANO SMARTVIEW benazepril, /hctz GELNIQUE nifedipine er BENICAR, HCT DETROL LA gemfibrozil levothyroxine sodium LIALDA gianvi NOVOFINE diclofenac tablets glimepiride liothyronine tablets NOVOLOG [INJ] glipizide, er lisinopril, /hctz BEYAZ glyburide, micronized LOESTRIN 24 FE, bisoprolol, /hctz digoxin glyburide/metformin LO LOESTRIN FE BRILINTA diltiazem, 12 hr, 24 hr NUVARING ACTONEL (excluding brimonidine tartrate losartan, /hctz 30 mg) donepezil, odt ACTOPLUS MET XR budesonide neb susp dorzolamide, /timolol H lovastatin O bupropion, 12 hr, 24 hr doxazosin LOVAZA buspirone LUMIGAN ocella HUMALOG [INJ] ADVAIR DISKUS, HFA DULERA ADVICOR* BYDUREON [INJ] omeprazole AGGRENOX BYETTA [INJ] albuterol syrup, tablets BYSTOLIC E hydralazine M hydrochlorothiazide alendronate sodium C EFFIENT alfuzosin er allopurinol ENABLEX medroxyprogesterone ALPHAGAN P 0.1% CANASA* enalapril, /hctz hydrocortisone tablets tablets carbidopa/levodopa, er meloxicam ONGLYZA amiodarone carvedilol ENJUVIA hydroxychloroquine metformin, er I amlodipine, /benazepril CELEBREX oxcarbazepine CENESTIN* ibandronate oxybutynin, er ibuprofen chlorthalidone estradiol patches, tablets OXYTROL estradiol/norethindrone metoprolol succinate er acetate metoprolol tartrate, /hctz P AMTURNIDE etodolac isosorbide mononitrate, er METROGEL pantoprazole MICARDIS, HCT paroxetine citalopram J EXELON PATCHES MIRAPEX ER apri CLIMARA PRO EXFORGE, HCT JANUMET, XR JANUVIA F JENTADUETO ARICEPT 23 MG* junel fe montelukast ASACOL, HD JUVISYNC PENTASA ASMANEX famotidine PERFOROMIST clonidine felodipine er K ATELVIA fenofibrate, micronized atenolol, /chlorthalidone kariva atorvastatin potassium chloride, er KOMBIGLYZE XR N finasteride PRADAXA aviane COMBIGAN L nabumetone pramipexole COMBIPATCH nadolol PRANDIMET labetalol hcl NAMENDA PRANDIN* COREG CR* fluoxetine, dr naproxen, pravastatin naproxen sodium CRESTOR folic acid NASCOBAL AZILECT THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2013 THROUGH DECEMBER 31, 2013. THIS LIST IS SUBJECT TO CHANGE. www.express-scripts.com 2013 Express Scripts Holding Company #393 NP-A W MM All Rights Reserved PRMTEHDANP-13 (08/13/12) TEKTURNA, HCT Examples of Nonformulary Medications With Selected Formulary Alternatives terazosin
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary. PREMARIN TABLETS timolol maleate PREMPHASE tizanidine
Column 1 lists examples of nonformulary medications. PREMPRO
Column 2 lists some alternatives that can be prescribed. PRISTIQ topiramate Nonformulary Formulary Alternative Nonformulary Formulary Alternative PRODIGY INSULIN SYR, TOVIAZ ACIPHEX lansoprazole, omeprazole, Nexium PEN NEEDLES TRADJENTA LESCOL XL atorvastatin, lovastatin, simvastatin, propranolol, /hctz TRAVATAN Z* ALORA generic estradiol patches, Crestor Vivelle-Dot* PULMICORT FLEXHALER ALTOPREV atorvastatin, lovastatin, simvastatin, LIPITOR atorvastatin PULMICORT RESPULES Crestor LIPOFEN fenofibrate/micronized, Tricor*, 1 MG/2 ML* ALVESCO Asmanex, Pulmicort Flexhaler, Qvar Trilipix triamterene/hctz ANTARA fenofibrate/micronized, Tricor*, LIVALO atorvastatin, lovastatin, simvastatin, TRIBENZOR Trilipix Crestor Q TRICOR* APIDRA Humalog, Novolog TRILIPIX APRISO
balsalazide, Asacol/HD, Lialda, Pentasa trinessa ATACAND losartan, Benicar, Micardis MENEST estradiol, Cenestin*, Enjuvia, tri-sprintec ATACAND HCT losartan/hctz, Benicar HCT, Premarin tabs quinapril, /hctz Micardis HCT MENOSTAR generic estradiol patches, QVAR Vivelle-Dot* U R ULORIC
ciprofloxacin/er, levofloxacin, ofloxacin,
ramipril V NOVOLIN RANEXA ranitidine VAGIFEM BONIVA TABS ibandronate RAPAFLO BROVANA Perforomist ORTHO EVRA, ORTHO generic oral contraceptives, Beyaz, CARDURA XL alfuzosin er, doxazosin, tamsulosin, TRI-CYCLEN LO Loestrin 24 Fe/Lo Loestrin Fe, Natazia, venlafaxine, er Rapaflo Nuvaring, Safyral RESTASIS verapamil, er PENNSAID
Flector, Voltaren Gel* RIOMET VESICARE DEXILANT lansoprazole, omeprazole, Nexium ropinirole, er DIVIGEL generic estradiol patches, Evamist VICTOZA [INJ] EDARBI losartan, Benicar, Micardis
ciprofloxacin/er, levofloxacin, ofloxacin,
S EDARBYCLOR losartan/hctz, Benicar HCT, Micardis HCT SAFYRAL VIIBRYD VIMOVO ELESTRIN generic estradiol patches, Evamist SAVELLA SEREVENT DISKUS VIVELLE-DOT* VOLTAREN GEL* ESTRASORB generic estradiol patches, Evamist sertraline ESTROGEL generic estradiol patches, Evamist SANCTURA XR oxybutynin er, Detrol LA, Enablex, SIMCOR
ciprofloxacin/er, levofloxacin, ofloxacin,
Toviaz, Vesicare simvastatin W
80 MG, 105 MG, 115 MG WELCHOL FEMTRACE estradiol, Cenestin*, Enjuvia, Premarin tabs SINGULAIR montelukast sotalol X FENOGLIDE fenofibrate/micronized, Tricor*, SPIRIVA Trilipix SYNTHROID levothyroxine sodium spironolactone FIBRICOR fenofibrate/micronized, Tricor*, sprintec Trilipix TEVETEN losartan, Benicar, Micardis FLOVENT DISKUS, Asmanex, Pulmicort Flexhaler, Qvar TEVETEN HCT losartan/hctz, Benicar HCT, HFA Micardis HCT Z sucralfate TRIGLIDE fenofibrate/micronized, Tricor*, ZETIA Trilipix generic oral contraceptives, Beyaz, TWYNSTA Azor, Exforge/HCT, Tribenzor Loestrin 24 Fe/Lo Loestrin Fe, Natazia, Nuvaring, Safyral VYTORIN simvastatin or Crestor + Zetia SYMBICORT SYMLIN, SYMLINPEN [INJ] T KEY The color red, bold and italics indicates agents that are used for long term therapy and may be required by some plan sponsors to be filled by Express Scripts’ pharmacy. List is subject to change.
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only. For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, tamsulosin
although they may look different in color or shape. They have been FDA-approved under strict standards. TARKA For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters. TEKAMLO
Generic drugs are listed in lower case letters. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2013 THROUGH DECEMBER 31, 2013. THIS LIST IS SUBJECT TO CHANGE. www.express-scripts.com 2013 Express Scripts Holding Company #393 NP-A W MM All Rights Reserved PRMTEHDANP-13 (08/13/12)
FIRST SCHEDULE ( EXEMPTED GOODS ) Agricultural implements manually operated or animal driven Axes, bill hooks, and similar hewing tools 8201.40.00 Secateurs and similar one-handed pruners 8201.50.00 Hedge shears, two-handed pruning shears 8201.60.00 and similar two-handed shears Other hand tools of a kind used in 8201.90.00 Agricultural sprayers operated by hand and its parts
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