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

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DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES exemestane X hydroxyurea X leflunomide X letrozole X leucovorin calcium X megestrol acetate X mercaptopurine X methotrexate X mycophenolate mofetil X tacrolimus X tamoxifen citrate X tretinoin X ARIMIDEX X anastrozole CELLCEPT X mycophenolate mofetil CIMZIA PA X ENBREL, HUMIRA CIMZIA PA X ENBREL, HUMIRA ELIGARD PA X ENBREL PA X FEMARA X letrozole GLEEVEC X HUMIRA PA X MEGACE ES X megestrol acetate MYFORTIC X ORENCIA PA X PROGRAF X tacrolimus RAPAMUNE X REVLIMID X SANDOSTATIN LAR X SIMPONI PA X ENBREL, HUMIRA SOMATULINE DEPOT X STELARA PA X STELARA PA X TYKERB X XELODA X CHAPTER 4: CARDIOVASCULAR MEDICATIONS 4.1 CARDIAC GLYCOSIDES digoxin X LANOXIN X digoxin 4.2 CALCIUM ANTAGONISTS amlodipine besylate X cartia xt X diltiazem/er X felodipine er X nifediac cc X TIER
DRUG NAME 1 2 3 SUGGESTED PREFFERED ALTERNATIVES nifedical xl X nifedipine er X nisoldipine X verapamil X verapamil er pm X CARDENE SR X immediate‐release nicardipine CARDIZEM LA X diltiazem 24 hr er SULAR X nisoldipine er 4.3.1 LOOP DIURETICS bumetanide X furosemide X torsemide X 4.3.2 THIAZIDE AND RELATED DRUGS chlorthalidone X hydrochlorothiazide X indapamide X metolazone X 4.3.3 POTASSIUM SPARING DIURETICS amiloride hcl X eplerenone X spironolactone X spironolactone‐hctz X triamterene‐hctz X triamterene‐hydrochlorothiazid X 4.4 BETA‐ADRENERGIC ANTAGONIST DRUGS acebutolol hcl X atenolol X bisoprolol fumarate X carvedilol X labetalol hcl X metoprolol succinate X metoprolol tartrate X nadolol X pindolol X propranolol hcl X timolol maleate X BYSTOLIC X COREG CR X TOPROL XL X metoprolol succinate er 4.5.1 VASODILATOR ANTIHYPERTENSIVES doxazosin mesylate X minoxidil X prazosin hcl X terazosin hcl 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: DRUG NAME 1 2 3 SUGGESTED PREFFERED
Page 11 and 12: 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 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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