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Prmtpdla-14.130805

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: Brand-name drugs may move to nonformulary status if a generic version
2014 Express Scripts
becomes available during the year. Not all the drugs listed are covered by all
prescription-drug benefit programs; check your benefit materials for the specific drugs

Preferred Drug List
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
J
D
K
L
G
C
N
H
E
O
M
I
B
F
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2014 Express Scripts Holding Company
PRMTPDLA-14
All Rights Reserved
Excluded Medications With Covered Preferred Alternatives
The following is a list of excluded brand-name medications with covered preferred alternatives that are on the formulary. Column 1 lists excluded medications. Column 2 lists covered preferred alternatives that can be prescribed.
Excluded Medications
Covered Preferred Alternative(s)
U
morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, S
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl P
V
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, 80 MG, 105 MG, 115 MG venlafaxine ext-release morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, T
W
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl X
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl TEKTURNA, TEKTURNA HCT Z
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Q
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl latanoprost, travoprost, Lumigan, Travatan Z The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
R
For the member: Generic medications contain the same active ingredients as their corresponding
brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2014 Express Scripts Holding Company
PRMTPDLA-14
All Rights Reserved

Source: http://concordia-plan.com/graphics/assets/documents/2014-ESI-Preferred-Drug-List.pdf

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