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

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES flurbiprofen X ibuprofen X indomethacin X ketoprofen X ketorolac tromethamine X meloxicam X nabumetone X naproxen X naproxen sodium X oxaprozin X piroxicam X sulindac X CAMBIA X diclofenac potassium CELEBREX X DUEXIS X ibuprofen plus famotidine NAPRELAN X naproxen sodium VIMOVO X 11.2 DRUGS TO PREVENT AND TREAT GOUT allopurinol X probenecid X COLCRYS X ULORIC ST X 11.3.1 DIRECT MUSCLE RELAXANTS baclofen X tizanidine hcl X 11.3.2 CNS MUSCLE RELAXANTS chlorzoxazone X cyclobenzaprine hcl X metaxalone X methocarbamol X orphenadrine citrate X AMRIX X immed‐release cyclobenzaprine SKELAXIN X metaxalone SOMA X metaxalone, tizanidine CHAPTER 12: NUTRITION,BLOOD 12.1.2 VITAMINS & MINERALS & RELATED PRODUCTS BIFERA RX X hemetab iron supplement tabs CEREFOLIN X folic acid CEREFOLIN NAC X folic acid 12.1.3 THERAPEUTIC VITAMINS & MINERALS calcitriol X calcium acetate X eliphos X folic acid X TIER
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES levocarnitine X vitamin d X DEPLIN X folic acid HECTOROL X NASCOBAL X PHOSLYRA X calcium acetate caps, ELIPHOS ZEMPLAR X 12.1.4 FLUORIDE PRODUCTS sodium fluoride X 12.2 POTASSIUM SUPPLEMENTS potassium chloride X 12.3.1 ORAL ANTICOAGULANTS, VITAMIN K warfarin sodium X COUMADIN X warfarin sodium 12.3.2 HEPARIN AND HEPARIN ANTAGONISTS enoxaparin sodium X fondaparinux sodium X heparin sodium X ARIXTRA X fondaparinux sodium FRAGMIN X enoxaparin, fondaparinux LOVENOX X enoxaparin 12.3.3 OTHER DRUGS AFFECTING COAGULATION XARELTO X 12.3.5 THROMBIN INHIBITORS PRADAXA X 12.4 ANTIPLATELET DRUGS cilostazol X dipyridamole X AGGRENOX X BRILINTA X EFFIENT X PLAVIX X clopidogrel 12.5 HEMOSTATICS LYSTEDA X 12.7 BLOOD DETOXICANTS enulose X lactulose X FOSRENOL X RENAGEL X RENVELA X CHAPTER 13: OBSTETRICAL & GYNECOLOGICAL MEDICATIONS 13.1.1 PRENATAL VITAMINS NEEVO DHA X generic Rx prenatal vitamans PREFERA OB X hemenatal ob tabs 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 23 and 24: TIER DRUG NAME 1 2 3 ACTONEL ST X A
Page 25: 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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