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
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If a prescription has not been filled for the targeted brand-name drug in the last six months (180 days) or the clinical program criteria is not met, the prescribing physician must be contacted to see if the drug prescribed can be changed to a drug listed in the Preferred Drug column. Note: Program criteria must be followed as listed, for the targeted brand-name drug to be covered. Categ