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

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DRUG NAME TIER 1 2 3 8.1.4 AMYLIN ANALOGUES SYMLINPEN X 8.1.5.1 INCRETIN MIMETICS BYDUREON X BYETTA X VICTOZA X 8.1.5.2 DIPEPTIDYL PEPTIDASE‐IV INHIBITORS JANUMET/XR X JANUVIA X JENTADUETO X JUVISYNC X KOMBIGLYZE XR X ONGLYZA X TRADJENTA X 8.2 GLUCOSE ELEVATING DRUGS GLUCAGEN X GLUCAGON EMERGENCY KIT X SUGGESTED PREFFERED ALTERNATIVES 8.3.1 GLUCOCORTICOID DRUGS dexamethasone X dexamethasone sodium phosphate X hydrocortisone X methylprednisolone X prednisolone X prednisolone sodium phosphate X prednisone X veripred 20 X RAYOS X immediate‐release prednisone 8.3.2 MINERALOCORTICOID DRUGS fludrocortisone acetate X 8.4.1 THYROID SUPPLEMENTS levothyroxine sodium X levoxyl X ARMOUR THYROID X CYTOMEL X liothyronine SYNTHROID X levothyroxine sodium 8.4.2 ANTITHYROID DRUGS methimazole X propylthiouracil X 8.6 OTHER ENDOCRINE DRUGS alendronate sodium X calcitonin nasal spray X desmopressin acetate X etidronate disodium X ibandronate sodium X
TIER DRUG NAME 1 2 3 ACTONEL ST X ATELVIA ST X BINOSTO ST X FORTEO PA X SUGGESTED PREFFERED ALTERNATIVES alendronate, ibandronate, ACTONEL, ATELVIA FOSAMAX PLUS D ST X alendronate, ibandronate, ACTONEL, ATELVIA SENSIPAR X CHAPTER 9: GASTROINTESTINAL MEDICATIONS 9.1.2 OTC H2 ANTAGONISTS famotidine X 9.2 ANTIDIARRHEAL DRUGS diphenoxylate‐atropine X loperamide X 9.3 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY chlordiazepoxide‐clidinium X dicyclomine hcl X hyoscyamine sulfate X metoclopramide hcl X 9.4 ANTIULCER DRUGS cimetidine X famotidine X nizatidine X ranitidine hcl X 9.4.1 OTHER ANTIULCER DRUGS misoprostol X sucralfate X CARAFATE X sucralfate 9.4.2 PROTON PUMP INHIBITORS lansoprazole X omeprazole X omeprazole‐sodium bicarbonate ST X pantoprazole sodium X ACIPHEX ST X generics, NEXIUM DEXILANT ST X generics, NEXIUM NEXIUM ST X PREVACID ST X lansoprazole PROTONIX ST X pantoprazole sodium ZEGERID ST X generics, NEXIUM 9.4.2.1 PROTON PUMP INHIBITORS ‐ OTC omeprazole X 9.4.3 HELICOBACTER PYLORI DRUGS HELIDAC X bismuth+metroni+tetracy, PYLERA OMECLAMOX‐PAK X omepraz+clarithro+amox, PYLERA
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 21: DRUG NAME 1 2 3 SUGGESTED PREFFERED
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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