Prmt22037-13.np.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.

ANTIINFECTIVES
Angiotensin II Receptor
Drugs to Treat Multiple
Antagonists + HCT Combos
Sclerosis
H. Pylori Drugs
Antivirals
Drugs Affecting The Nose
Proton Pump Inhibitors
Anti-Arrhythmic Drugs
Non-Narcotic Analgesics
Beta-Adrenergic Antagonists
Other GI Drugs
ENDOCRINE MEDICATIONS
Sedative/Hypnotics
Cephalosporins
Antidementia Drugs
Amylin Analogues
Selective Serotonin
Androgen Drugs
Macrolides
Reuptake Inhibitors
Antidepressants
Oral Antifungals
Dipeptidyl Peptidase-IV
Inhibitors & Combos
Calcium Antagonists
Tertiary Amines
Penicillins
Antiparkinson Drugs
Diuretics
Other Autonomic/CNS Drugs
IMMUNOLOGICALS
Glucocorticoids
Quinolones
Other Drugs For ADHD
Antipsychotic Drugs
Erythroid Stimulants
Endothelin Receptor
DERMATOLOGICAL
Antagonists
Tetracyclines
MEDICATIONS
Interferons
Antiacne Drugs
Glucose Elevating Drugs
HMG-CoA Reductase
Inhibitors
Topical Antibacterials
Growth Hormones
MUSCULOSKELETAL
MEDICATIONS
Antivertigo & Antiemetics
Topical Antifungals
CNS Muscle Relaxants
HMG-CoA Combinations
Anxiolytics
Incretin Mimetics
Hypolipoproteinemics
Urinary Antiinfectives
Drugs to Prevent & Treat
Gout
Other Antiinfective Drugs
Insulins
Class II Narcotics
Antipsoriasis & Antieczema
Drugs
Injectable Drugs For Arthritis
Non-Steroidal Anti-
ANTINEOPLASTIC/IMMUNO-
Insulin Sensitizers
Nitrates
Inflammatory Agents
SUPPRESSANT DRUGS
Corticosteroid Drugs
Oral Hypoglycemics
Other Antihypertensives
considered formulary, unless AMTURNIDE Class III Narcotics
Miscellaneous
hydrocodone/acetaminophen Dermatologicals
NUTRITION & BLOOD
Thyroid Supplements
MODIFIERS
CNS Stimulants
Antiplatelet Drugs
Other Cardiovascular Drugs
Other Endocrine Drugs
CARDIOVASCULAR
MEDICATIONS
Topical Anti-Inflammatory
Drugs
ACE Inhibitors + HCT Combos
Blood Detoxicants
Drugs to Prevent & Treat
AUTONOMIC & CNS
Headaches
MEDICATIONS
GASTROINTESTINAL
EAR-NOSE MEDICATIONS
MEDICATIONS
Oral and Inj. Anticoagulants
Anticonvulsants
Drugs Affecting The Ear
Antispasmodics/Drugs
Affecting GI Motility
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2013 THROUGH DECEMBER 31, 2013. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2013 Express Scripts Holding Company
#393 NP-T
All Rights Reserved
PRMT22037-13 (08/13/12)
Therapeutic Vitamins &
Examples of Nonformulary Medications With Selected Formulary Alternatives
Minerals
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary.
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
RESPIRATORY MEDICATIONS
Thrombin Inhibitors
Antihistamines
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
OBSTETRICAL &
GYNECOLOGICAL
MEDICATIONS
Antihistamine/Antitussives
Contraceptives
Antitussive & Expectorants
fenofibrate/micronized, Tricor*, Trilipix Beta-2 Adrenergics
fenofibrate/micronized, Tricor*, Trilipix Leukotriene Modifiers
Estrogen Drugs
Other Drugs For Asthma
ciprofloxacin/er, levofloxacin, ofloxacin, Estrogen/Progestin
Combinations
ORTHO EVRA, ORTHO generic oral contraceptives, Beyaz, Ovulatory Stimulants
UROLOGICAL MEDICATIONS
Anticholinergic
Antispasmodics
ciprofloxacin/er, levofloxacin, ofloxacin, Prenatal Vitamins
generic prenatal vitamins are oxybutynin, er Progestin Drugs
Drugs Used For BPH
Specialized OB/GYN Drugs
oxybutynin er, Detrol LA, Enablex, Toviaz, Erectile Dysfunction Agents
OPHTHALMIC MEDICATIONS
ciprofloxacin/er, levofloxacin, ofloxacin, Antibacterial Drugs
DIABETIC SUPPLIES
Meters & Strips
fenofibrate/micronized, Tricor*, Trilipix fenofibrate/micronized, Tricor*, Trilipix FLOVENT DISKUS, HFA Asmanex, Pulmicort Flexhaler, Qvar Antiglaucoma Drugs
fenofibrate/micronized, Tricor*, Trilipix Corticosteroid Drugs
Miscellaneous Supplies
Other Ophthalmic Drugs
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, 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 medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
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.
You can get more information and updates to this document at our website at www.express-scripts.com.
2013 Express Scripts Holding Company
#393 NP-T
All Rights Reserved
PRMT22037-13 (08/13/12)

Source: https://www.maricopa.edu/employees/divisions/hr/files/benefits/ESIPreferredTClass2013.pdf

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