Preferred Drug List 2013 Standard Formulary (3 ... - Express Scripts

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES CARDURA XL X alfuzosn er,tamsulosn,RAPAFLO 4.5.2 CENTRALLY ACTING ANTIHYPERTENSIVES clonidine X clonidine hcl X guanfacine hcl X methyldopa X 4.5.4.1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS benazepril hcl X captopril X enalapril maleate X fosinopril sodium X lisinopril X moexipril hcl X quinapril hcl X ramipril X trandolapril X 4.5.4.2 ANGIOTENSIN II RECEPTOR ANTAGONISTS eprosartan mesylate X irbesartan X losartan potassium X ATACAND ST X losartan, BENICAR, DIOVAN ATACAND HCT ST X candesartan/hydrochlorothiazde AVALIDE ST X irbesartan/hydrochlorothiazide AVAPRO ST X irbesartan BENICAR ST X BENICAR HCT ST X COZAAR ST X losartan potassium DIOVAN ST X DIOVAN HCT ST X valsartan/hydrochlorthiazide EDARBI X losartan, BENICAR, DIOVAN HYZAAR ST X losartan‐hctz MICARDIS ST X losartan, BENICAR, DIOVAN MICARDIS HCT ST X losar‐ht,valsar‐ht,BENICAR HCT TEVETEN ST X eprosartan TEVETEN HCT ST X losar‐ht,valsar‐ht,BENICAR HCT 4.5.6 OTHER ANTIHYPERTENSIVES amlodipine besylate‐benazepril X atenolol‐chlorthalidone X benazepril‐hydrochlorothiazide X bisoprolol‐hydrochlorothiazide X captopril‐hydrochlorothiazide X enalapril‐hydrochlorothiazide X fosinopril‐hydrochlorothiazide X irbesartan‐hydrochlorothiazide X TIER
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES lisinopril‐hydrochlorothiazide X losartan‐hydrochlorothiazide X metoprolol‐hydrochlorothiazide X moexipril‐hydrochlorothiazide X quinapril‐hydrochlorothiazide X AMTURNIDE X AZOR ST X EDARBYCLOR X losar‐ht,valsar‐ht,BENICAR HCT EXFORGE ST X EXFORGE HCT ST X LOTREL X amlodipine‐benazepril TARKA X TEKAMLO X TEKTURNA X TEKTURNA HCT X TRIBENZOR ST X TWYNSTA ST X AZOR, EXFORGE/HCT, TRIBENZOR 4.6.1 NITRATES isosorbide X isosorbide dinitrate X nitroglycerin X nitroglycerin patch X NITROSTAT X 4.6.2 OTHER VASODILATING DRUGS ADCIRCA X BIDIL X isosorbide dn + hydralazine REVATIO X sildenafil 4.6.3 ENDOTHELIN RECEPTOR ANTAGONIST LETAIRIS X TRACLEER X 4.7.1.3 CLASS 1C flecainide acetate X propafenone hcl X RYTHMOL SR X propafenone er 4.7.3 AMIODARONES amiodarone hcl X 4.7.5 OTHER ANTIARRHYTHMICS sotalol X MULTAQ X amiodarone TIKOSYN X 4.8.1 HYPOLIPOPROTEINEMICS cholestyramine X colestipol hcl X fenofibrate X TIER
Page 1 and 2: Preferred Drug List 2013 Standard F
Page 3 and 4: Prior Authorization Process If a pa
Page 5 and 6: DRUG NAME 2.1.5 PENICILLINS amox tr
Page 7 and 8: DRUG NAME 1 2 3 SUGGESTED PREFFERED
Page 9: DRUG NAME 1 2 3 SUGGESTED PREFFERED
Page 15 and 16: TIER DRUG NAME 1 2 3 primidone X SU
Page 23 and 24: TIER DRUG NAME 1 2 3 ACTONEL ST X A
Page 25 and 26: TIER DRUG NAME 1 2 3 SUGGESTED PREF
Page 35 and 36: DRUG NAME 16.1.3 URINARY ANESTHETIC
Page 39 and 40: AVALIDE 4.5.4.2 AVANDAMET 8.1.3 AVA
Page 41 and 42: donepezil hcl 5.9.3 DORYX 2.1.7 dor
Page 43 and 44: KAPVAY 5.9.6 kariva 13.7 kelnor 1
Page 45 and 46: ONGLYZA 8.1.5.2 ONSOLIS 5.1.1.1 OPA
Page 47 and 48: SUPREP 9.6 SURESTEP 18.1 SURE‐T 1

Preferred Drug List 2013 Standard Formulary (3 ... - Express Scripts

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