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

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES junel fe X kariva X kelnor 1‐35 X leena X lessina X levora‐28 X loryna X low‐ogestrel X lutera X microgestin X microgestin fe X mononessa X necon X nortrel X ocella X ogestrel X portia X previfem X quasense X reclipsen X solia X sprintec X sronyx X syeda X tilia fe X tri‐legest fe X trinessa X tri‐previfem X tri‐sprintec X trivora‐28 X velivet X zarah X zenchent X zovia 1‐35e X zovia 1‐50e X BEYAZ X FEMCON FE X zenchent fe chewable, zeosa GENERESS FE X generics, BEYAZ, LOESTRIN 24/LO LOESTRIN, NATAZIA, NUVARING, SAFYRAL LO LOESTRIN FE X LOESTRIN 24 FE X LOSEASONIQUE X amethia lo, camrese lo NATAZIA X NUVARING X TIER
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES ORTHO EVRA X generics, BEYAZ, LOESTRIN 24/LO LOESTRIN, NATAZIA, NUVARING, SAFYRAL ORTHO TRI‐CYCLEN X trinesa, tri‐previ, tri‐sprint ORTHO TRI‐CYCLEN LO X generics, BEYAZ, LOESTRIN 24/LO LOESTRIN, NATAZIA, NUVARING, SAFYRAL SAFYRAL X SEASONIQUE X amethia, camrese YASMIN 28 X ocella,syeda,zarah YAZ X gianvi, loryna, vestura CHAPTER 14: OPHTHALMIC MEDICATIONS 14.1.1 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS bacitracin X bacitracin‐polymyxin X ciprofloxacin hcl X erythromycin X gentamicin sulfate X neomycin‐bacitracin‐polymyxin X ofloxacin X polymyxin b sul‐trimethoprim X sulfacetamide sodium X AZASITE X BESIVANCE X generic, MOXEZA, VIGAMOX, ZYMAXID MOXEZA X VIGAMOX X ZYMAXID X 14.1.2 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS trifluridine X 14.2 OPHTHALMIC CORTICOSTEROID DRUGS fluorometholone X prednisolone acetate X ALREX X azelastine, PATADAY, PATANOL DUREZOL X FML FORTE X generics, DUREZOL, LOTEMAX SOLN LOTEMAX X VEXOL X generics, DUREZOL, LOTEMAX SOLN 14.3 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS neomycin‐polymyxin‐dexameth X neomycin‐polymyxin‐hc X tobramycin‐dexamethasone X TOBRADEX X tobramycin sulfate/dexameth TOBRADEX ST X ZYLET X 14.5 ANTIGLAUCOMA DRUGS acetazolamide 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 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 29: DRUG NAME 1 2 3 SUGGESTED PREFFERED
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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