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

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES venlafaxine hcl er X VENLAFAXINE HCL ER ST X venlafax er(NOT UCB NDCS‐65580 CYMBALTA PA X EFFEXOR XR ST X venlafax er(NOT UCB NDCS‐65580 PRISTIQ ER ST X SAVELLA PA X WELLBUTRIN XL X bupropion xl 5.5.2 MAO INHIBITORS tranylcypromine sulfate X 5.6 ANTIVERTIGO AND ANTIEMETIC DRUGS dronabinol X granisetron hcl X meclizine hcl X ondansetron hcl X ondansetron odt X prochlorperazine maleate X promethazine hcl X promethegan X EMEND X SANCUSO X TRANSDERM‐SCOP X meclizine ZUPLENZ X ondansetron odt 5.7.1 ANTIPARKINSON ANTICHOLINERGIC DRUGS benztropine mesylate X trihexyphenidyl hcl X 5.7.2 OTHER ANTIPARKINSON DRUGS bromocriptine mesylate X carbidopa‐levodopa X carbidopa‐levodopa‐entacapone X pramipexole dihydrochloride X ropinirole hcl X AZILECT X COMTAN X entacapone MIRAPEX X pramipexole MIRAPEX ER X NEUPRO X pramipex,ropinir/er,MIRAPEX ER REQUIP XL X ropinirole er STALEVO 100 X carbidopa/levodopa/entacapone 5.8 ANTIPSYCHOTIC DRUGS clozapine X fluphenazine hcl X haloperidol X olanzapine X olanzapine odt X TIER
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES perphenazine X quetiapine fumarate X risperidone X thioridazine hcl X thiothixene X trifluoperazine hcl X ziprasidone hcl X ABILIFY X ABILIFY DISCMELT X generic, ABILIFY/DISC, LATUDA, SEROQUEL FANAPT X XR GEODON X ziprasidone generic, ABILIFY/DISC, LATUDA, SEROQUEL INVEGA X XR LATUDA X RISPERDAL CONSTA X generic, ABILIFY/DISC, LATUDA, SEROQUEL SAPHRIS X XR SEROQUEL X quetiapine fumarate SEROQUEL XR X ZYPREXA X olanzapine ZYPREXA ZYDIS X olanzapine odt 5.8.1 ALIPHATIC PHENOTHIAZINES chlorpromazine hcl X 5.8.1.1 PSYCHOTHERAPEUTIC COMBINATIONS olanzapine‐fluoxetine hcl X SYMBYAX X SYMBYAX X olanzapine/fluoxetine hcl 5.9.1 CNS STIMULANT DRUGS amphetamine salt combo X dexmethylphenidate hcl X dextroamphetamine sulfate X dextroamphetamine‐amphetamine X methylphenidate er X methylphenidate hcl X methylphenidate sr X modafinil PA X ADDERALL XR ST X dextroamphetamne‐amphetamne er CONCERTA ST X methylphenidate er DAYTRANA ST X methylphenidate cd, er,VYVANSE FOCALIN XR ST X methylphenidate cd, er,VYVANSE METADATE CD ST X methylphenidate cd NUVIGIL PA X modafinil PROVIGIL PA X modafinil RITALIN LA ST X methylphenidate cd, er,VYVANSE 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 15: 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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