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

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES PREVPAC X amox+clarith+lansoprazo, PYLERA PYLERA X 9.5 LAXATIVES AND CATHARTICS OSMOPREP X generic, HALFLYT, MOVIPRP,SUPREP 9.6 OTHER GI DRUGS anucort‐hc X balsalazide disodium X budesonide ec X hydrocortisone X hydrocortisone acetate X pancrelipase 5,000 X peg 3350‐electrolyte X proctosol‐hc X proctozone‐hc X sulfasalazine X trilyte with flavor packets X ursodiol X ANALPRAM ADVANCED X hydrocortisone/pramoxine cream ANALPRAM E X hydrocortisone/pramoxine cream ANALPRAM HC X hydrocortisone/pramoxine cream APRISO X balsalazide, ASACOL/HD, LIALDA, PENTASA ASACOL X ASACOL HD X CANASA X CREON X DIPENTUM X balsalazide, ASACOL/HD, LIALDA, PENTASA GOLYTELY X generics, HALFLYTELY, MOVIPREP, SUPREP HALFLYTELY‐BISACODYL X LIALDA X MOVIPREP X NULYTELY WITH FLAVOR PACKS X peg‐3350 w/flavor packs soln PANCREAZE X generics, CREON, ZENPEP PENTASA X PERTZYE X generics, CREON, ZENPEP PREPOPIK X generics, HALFLYTELY, MOVIPREP, SUPREP RELISTOR X SFROWASA X mesalamine 4 gm/60 ml enema SUPREP X ZENPEP X 9.7 IRRITABLE BOWEL DRUGS AMITIZA X LINZESS X TIER
TIER DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES CHAPTER 10: IMMUNOLOGICALS AND VACCINES 10.0 IMMUNOLOGICALS AND VACCINES SYNAGIS X ZOSTAVAX X 10.2.1 MYELOID STIMULANTS NEULASTA X NEUPOGEN X 10.2.2 ERYTHROID STIMULANTS ARANESP X PROCRIT X 10.2.3 INTERFERONS AVONEX PA X AVONEX ADMINISTRATION PACK PA X AVONEX PEN PA X BETASERON PA X COPAXONE X EXTAVIA PA X AVONEX, BETASERON, REBIF PEGASYS/PROCLICK X PEGINTRON/REDIPEN X REBIF PA X 10.2.4 GROWTH HORMONES AND RELATED DRUGS GENOTROPIN PA X HUMATROPE PA X NORDITROPIN FLEXPRO PA X GENOTROP,HUMATROP,NUTROPIN/AQ NORDITROPIN NORDIFLEX PA X GENOTROP,HUMATROP,NUTROPIN/AQ NUTROPIN/AQ/AQ NUSPIN PA X OMNITROPE PA X GENOTROP,HUMATROP,NUTROPIN/AQ SAIZEN PA X GENOTROP,HUMATROP,NUTROPIN/AQ TEV‐TROPIN PA X GENOTROP,HUMATROP,NUTROPIN/AQ 10.2.6 INTERLEUKIN RECEPTOR ANTAGONIST KINERET PA X ORENCIA 10.2.7 IMMUNOGLOBULIN ANTIBODIES XOLAIR X CHAPTER 11: MUSCULOSKELETAL MEDICATIONS 11.1.1 SALICYLATES AND RELATED DRUGS aspirin X aspirin ec X choline mag trisalicylate X diflunisal X salsalate X 11.1.2 NON‐STEROIDAL ANTIINFLAMMATORY AGENTS diclofenac potassium X diclofenac sodium X etodolac 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 15 and 16: TIER DRUG NAME 1 2 3 primidone X SU
Page 23: TIER DRUG NAME 1 2 3 ACTONEL ST X A
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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