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

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TIER DRUG NAME 1 2 3 VYVANSE ST X 5.9.2 OTHER CNS/AUTONOMIC DRUGS atropine sulfate X naltrexone hcl X pyridostigmine bromide X NUEDEXTA X 5.9.3 ANTIDEMENTIA DRUGS donepezil hcl X galantamine hbr X rivastigmine X ARICEPT X donepezil ARICEPT ODT X donepezil odt EXELON X rivastigmine NAMENDA X 5.9.4 DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA X 5.9.5 SMOKING CESSATION PRODUCTS bupropion hcl sr X CHANTIX X SUGGESTED PREFFERED ALTERNATIVES 5.9.6 OTHER DRUGS FOR ADHD INTUNIV X methylphenidate er KAPVAY X generic clonidine(imm release) STRATTERA X CHAPTER 6: DERMATOLOGICAL MEDICATIONS 6.1 TOPICAL CORTICOSTEROID DRUGS alclometasone dipropionate X betamethasone dipropionate X betamethasone valerate X clobetasol emollient X clobetasol propionate X desonide X desoximetasone X fluocinolone acetonide X fluocinonide X fluticasone propionate X halobetasol propionate X hydrocortisone X hydrocortisone butyrate X hydrocortisone valerate X mometasone furoate X triamcinolone acetonide X CLOBEX X clobetasol solution HALOG X betmeth val, triamcin 0.1% crm KENALOG X triamcinolone acetonide
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES LOCOID X hydrocortisone butyrate LOCOID LIPOCREAM X hydrocortisone butyrate OLUX X clobetasol propion 0.05% foam OLUX‐E X clobetasol propionate crm,oint PRAMOSONE X hydrocort 2.5/pramoxine 1% crm PRAMOSONE E X hydrocort 2.5/pramoxine 1% crm ULTRAVATE PAC X halobetasol propionate oint 6.2 ANTIPRURITIC DRUGS hydroxyzine X 6.3 ANTIACNE DRUGS adapalene X benzoyl peroxide X clindamycin phosphate X clindamycin‐benzoyl peroxide X erythromycin X erythromycin‐benzoyl peroxide X metronidazole X sodium sulfacetamide‐sulfur X tretinoin X ACANYA X ATRALIN X BENZACLIN X DIFFERIN X adapalene DUAC X clindamycin phos/benzoyl perox EPIDUO X FINACEA X METROGEL X RETIN‐A MICRO X generics, ATRALIN, DIFFERIN LOTN, EPIDUO RETIN‐A MICRO PUMP X generics, ATRALIN, DIFFERIN LOTN, EPIDUO VELTIN X ZIANA X generics, ACANYA, BENZACLIN, VELTIN 6.3.1 ACCUTANES isotretinoin X 6.7 KERATOLYTIC DRUGS CONDYLOX X podofilox 6.8 ANTIPSORIASIS AND ANTIECZEMA DRUGS calcipotriene X calcitrene X selenium sulfide X sulfacetamide sodium X DOVONEX X calcipotriene SORILUX X calcipotriene,TACLONEX TACLONEX X TAZORAC 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 15 and 16: TIER DRUG NAME 1 2 3 primidone X SU
Page 17: 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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