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

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DRUG NAME 5.2.1 ANXIOLYTICS alprazolam/er/xr X buspirone hcl X chlordiazepoxide hcl X clorazepate dipotassium X diazepam X lorazepam X oxazepam X TIER 1 2 3 SUGGESTED PREFFERED ALTERNATIVES 5.2.2 SEDATIVE/HYPNOTIC DRUGS estazolam X flurazepam hcl X temazepam X triazolam X zaleplon X zolpidem tartrate/er X AMBIEN ST X zolpidem AMBIEN CR ST X zolpidem er EDLUAR ST X zolpidem immed‐rel/er, LUNESTA INTERMEZZO ST X zolpidem immed‐rel/er, LUNESTA LUNESTA ST X ROZEREM ST X SILENOR ST X zolpidem immed‐rel/er, LUNESTA ZOLPIMIST ST X zolpidem tablet 5.3 ANTIMANIA DRUGS lithium carbonate X 5.4.1 CARBAMAZEPINES carbamazepine/er/xr X oxcarbazepine X CARBATROL X carbamazepine er TEGRETOL XR X TEGRETOL XR X carbamazepine xr 5.4.2 ANTICONVULSANT BENZODIAZEPINES clonazepam X diazepam X 5.4.3 HYDANTOINS phenytoin sodium extended X DILANTIN X PHENYTEK X phenytoin sodium extended 5.4.4 VALPROIC ACID AND DERIVATIVES divalproex sodium/er X VALPROIC ACID X DEPAKOTE ER X divalproex sodium er 5.4.6 ANTICONVULSANT BARBITURATES phenobarbital X
TIER DRUG NAME 1 2 3 primidone X SUGGESTED PREFFERED ALTERNATIVES 5.4.7 OTHER ANTICONVULSANTS gabapentin X lamotrigine X levetiracetam X topiramate X zonisamide X GRALISE ST X gabapentin HORIZANT ST X gabapentin KEPPRA X levetiracetam KEPPRA XR X levetiracetam er LAMICTAL X lamotrigine LAMICTAL ODT X LAMICTAL XR X LYRICA ST X POTIGA X TOPAMAX X topiramate sprinkle caps VIMPAT PA X 5.5.1.1 TERTIARY AMINES amitriptyline hcl X clomipramine hcl X doxepin hcl X imipramine hcl X 5.5.1.2 SECONDARY AMINES desipramine hcl X nortriptyline hcl X 5.5.1.3 SELECTIVE SEROTONIN REUPTAKE INHIBITORS citalopram X citalopram hbr X escitalopram oxalate X fluoxetine hcl X fluvoxamine maleate X paroxetine hcl X sertraline hcl X LEXAPRO X escitalopram LUVOX CR X generic SSRIs, VIIBRYD VIIBRYD ST X 5.5.1.4 OTHER ANTIDEPRESSANTS bupropion hcl X bupropion hcl sr X bupropion xl X mirtazapine X trazodone hcl X venlafaxine hcl X
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 13: DRUG NAME 1 2 3 SUGGESTED PREFFERED
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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