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

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TIER DRUG NAME 1 2 3 SOF‐SET X SOF‐SET MICRO X SURE‐T X SUGGESTED PREFFERED ALTERNATIVES 18.1 DIABETIC SUPPLIES ACCU‐CHEK X ACCU‐CHEK ACTIVE X ACCU‐CHEK AVIVA X ACCU‐CHEK AVIVA PLUS X ACCU‐CHEK COMFORT CURVE X ACCU‐CHEK COMPACT X ACCU‐CHEK COMPACT BLUE CONTROL X ACCU‐CHEK FASTCLIX X ACCU‐CHEK NANO SMARTVIEW X ACCU‐CHEK SMARTVIEW X ACCU‐CHEK SOFTCLIX X ASCENSIA AUTODISC X ACCU‐CHEK, ONE TOUCH AUTODISC NORMAL X ACCU‐CHEK, ONE TOUCH BREEZE 2 X ACCU‐CHEK, ONE TOUCH CONTOUR X ACCU‐CHEK, ONE TOUCH CONTOUR NEXT X ACCU‐CHEK, ONE TOUCH CONTOUR NEXT EZ X ACCU‐CHEK, ONE TOUCH CONTOUR USB X ACCU‐CHEK, ONE TOUCH CONTROL SOLUTION X ACCU‐CHEK, ONE TOUCH FORA LANCETS X FORA LANCING DEVICE X FORA TEST STRIP X ACCU‐CHEK, ONE TOUCH FORA V30A X ACCU‐CHEK, ONE TOUCH FREESTYLE FREEDOM LITE X ACCU‐CHEK, ONE TOUCH FREESTYLE INSULINX X ACCU‐CHEK, ONE TOUCH FREESTYLE INSULINX TEST STRIPS X ACCU‐CHEK, ONE TOUCH FREESTYLE LITE METER X ACCU‐CHEK, ONE TOUCH FREESTYLE LITE STRIPS X ACCU‐CHEK, ONE TOUCH FREESTYLE TEST STRIPS X ACCU‐CHEK, ONE TOUCH GLUCOSE TEST STRIP X ACCU‐CHEK, ONE TOUCH GUARDIAN RT STARTER KIT X NOVOFINE X NOVOFINE 32 X NOVOFINE AUTOCOVER X ONE TOUCH LANCETS X ONE TOUCH TEST STRIPS X ONE TOUCH ULTRA 2 X ONE TOUCH ULTRA SMART X ONE TOUCH ULTRA SYSTEM X ONE TOUCH ULTRA TEST STRIPS X
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES ONE TOUCH ULTRAMINI X ONE TOUCH VERIO X ONE TOUCH VERIO IQ X PRECISION X PRECISION XTRA X PRODIGY X ACCU‐CHEK, ONE TOUCH PRODIGY INSULIN SYRINGE X PRODIGY NO CODING X ACCU‐CHEK, ONE TOUCH PRODIGY PEN NEEDLE X PRODIGY POCKET X ACCU‐CHEK, ONE TOUCH PRODIGY VOICE X ACCU‐CHEK, ONE TOUCH SOFT TOUCH X SOFTCLIX X SURESTEP X TRUE2GO BLOOD GLUCOSE SYSTEM X ACCU‐CHEK, ONE TOUCH TRUERESULT BLOOD GLUCOSE SYSTM X ACCU‐CHEK, ONE TOUCH TRUETEST TEST STRIPS X ACCU‐CHEK, ONE TOUCH TRUETRACK SMART SYSTEM X ACCU‐CHEK, ONE TOUCH TRUETRACK TEST STRIP X ACCU‐CHEK, ONE TOUCH VGO 20 X VGO 30 X VGO 40 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 35: 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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