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Prmtehdanp-13.anp.120813

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)

Source: http://www.hrsolutions.cooperstandard.com/2013_ExpressScripts_Maintenance_Medications.pdf

Nd1.lc_bd_9

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