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

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES VECTICAL X calcitriol 6.9.2 TOPICAL DERMATOLOGICAL DRUGS fluorouracil X imiquimod X tretinoin X CARAC X ELIDEL X EPICERAM X emulsion sb, tl‐cermide FLUOROPLEX X fluorouracil, imiquimod, ZYCLARA PICATO X fluorouracil, imiquimod, ZYCLARA PROMISEB X selenium sulfide, sod sulfacet PROTOPIC X SANTYL X SOLARAZE X VEREGEN X imiquimod, podofilox ZYCLARA X 6.9.3 SCABICIDES permethrin X EURAX X ULESFIA X permethrin 6.9.5 TOPICAL ANTI‐INFLAMMATORY DRUGS FLECTOR X PENNSAID X FLECTOR, VOLTAREN GEL VOLTAREN X CHAPTER 7: EAR‐NOSE‐THROAT MEDICATIONS 7.1 DRUGS AFFECTING THE EAR antipyrine‐benzocaine X neomycin‐polymyxin‐hc X neomycin‐polymyxin‐hydrocort X ofloxacin X CETRAXAL X ciprofloxacin 0.2% otic CIPRO HC X CIPRODEX CIPRODEX X 7.2 DRUGS AFFECTING THE NOSE azelastine hcl X flunisolide X fluticasone propionate X ipratropium bromide X triamcinolone acetonide X ASTELIN X azelastine ASTEPRO X BECONASE AQ ST X flunisoli, flutic, NASONEX,QNASL DYMISTA ST X azelastine + fluticasone NASACORT AQ ST X triamcinolone acetonide TIER
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES NASONEX ST X OMNARIS ST X flunisoli, flutic, NASONEX,QNASL PATANASE X azelastine, ASTEPRO QNASL ST X RHINOCORT AQUA ST X flunisoli, flutic, NASONEX, QNASL VERAMYST ST X flunisoli, flutic, NASONEX, QNASL ZETONNA ST X flunisoli, flutic, NASONEX, QNASL 7.3 DRUGS AFFECTING THE THROAT AND MOUTH doxycycline hyclate X pilocarpine hcl X triamcinolone acetonide X CHAPTER 8: ENDOCRINE MEDICATIONS 8.1.1 INSULIN APIDRA/SOLOSTAR X HUMALOG, NOVOLOG HUMALOG products X HUMULIN products X LANTUS/SOLOSTAR X LEVEMIR/FLEXPEN X NOVOLIN products X HUMULIN NOVOLOG products X 8.1.2 ORAL HYPOGLYCEMIC DRUGS acarbose X glimepiride X glipizide/er X glipizide‐metformin X glyburide X glyburide micronized X glyburide‐metformin hcl X metformin hcl X metformin hcl er X nateglinide X FORTAMET X metformin hcl er PRANDIMET X PRANDIN X RIOMET X 8.1.3 INSULIN SENSITIZERS ACTOPLUS MET X pioglitazone/metformin ACTOPLUS MET XR X ACTOS X pioglitazone AVANDAMET X pioglit+metfor, ACTOPLUS MET XR AVANDARYL X pioglitzone/glimepiride AVANDIA X pioglitazone DUETACT X pioglitazone/glimepiride 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 19: 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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