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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

The symbol [INJ] next to a drug name indicates that the drug is available in injectable form.<br />

The symbol [G] next to a drug name indicates that the drug may be available in a generic form.<br />

The symbol [LA] next to a drug name indicates that the drug has been noted as being restricted<br />

to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at<br />

specialty designated pharmacies able to appropriately handle the drugs.<br />

The symbol [PAR] in the Restrictions column indicates that prior authorization may apply.<br />

The symbol [QLL] in the Restrictions column indicates that quantities dispensed may be limited.<br />

The symbol [ST] in the Restrictions column indicates that step therapy may apply.<br />

General Drug Table<br />

<strong>ANESTHETICS</strong><br />

<strong>LOCAL</strong> <strong>ANESTHETICS</strong><br />

Drug Generic Tier Restrictions<br />

bupivacaine hcl injection [INJ] 1<br />

bupivacaine hcl-epinephrine [INJ] 1<br />

bupivacaine-dextrose [INJ] 1<br />

CARBOCAINE [INJ] mepivacaine 3<br />

chloroprocaine hcl [INJ] 1<br />

droperidol injection [INJ] 1<br />

INAPSINE [INJ] droperidol 3<br />

lidocaine hcl 0.5% vial, -1%<br />

abboject, -1% ampul, -1% syringe, -<br />

1% vial, -1.5% ampul, -2%<br />

abboject, -2% ampul, -2% luer-jet, -<br />

2% min-i-jet, -2% syringe, -2% vial,<br />

1<br />

-20% vial, -4% ampul [INJ]<br />

lidocaine hcl in 7.5% dextrose [INJ] 1<br />

lidocaine hcl-epinephrine [INJ] 1<br />

MARCAINE [INJ] bupivacaine 3<br />

MARCAINE SPINAL [INJ] bupivacaine hcl/dextrose-h2o 3<br />

MARCAINE WITH EPINEPHRINE<br />

[INJ][G]<br />

bupivacaine hydrochloride/epi 3<br />

MARCAINE-EPINEPHRINE [INJ] bupivacaine hydrochloride/epi 3<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

NAROPIN [INJ] ropivacaine 3<br />

NESACAINE [INJ] chloroprocaine 3<br />

NESACAINE-MPF [INJ] chloroprocaine 3<br />

NOVOCAIN [INJ] procaine 3<br />

POLOCAINE [INJ] mepivacaine 3<br />

SENSORCAINE [INJ] bupivacaine 3<br />

SENSORCAINE WITH DEXTROSE<br />

[INJ]<br />

bupivacaine hcl/dextrose-h2o 3<br />

SENSORCAINE WITH EPINEPHRINE<br />

[INJ]<br />

bupivacaine hydrochloride/epi 3<br />

SENSORCAINE-MPF [INJ][G] bupivacaine 3<br />

SENSORCAINE-MPF EPINEPHRINE<br />

[INJ][G]<br />

bupivacaine hydrochloride/epi 3<br />

XYLOCAINE 2% VIAL, -0.5% VIAL, -<br />

1% VIAL [INJ][G]<br />

lidocaine 3<br />

XYLOCAINE IV [INJ] lidocaine 3<br />

XYLOCAINE IV FOR CARDIAC [INJ] lidocaine 3<br />

XYLOCAINE WITH EPINEPHRINE<br />

[INJ]<br />

lidocaine hydrochloride/epi 3<br />

XYLOCAINE-MPF [INJ][G] lidocaine 3<br />

XYLOCAINE-MPF WITH<br />

EPINEPHRINE [INJ][G]<br />

lidocaine hydrochloride/epi 3<br />

TOPICAL <strong>ANESTHETICS</strong><br />

ANESTACON lidocaine 3<br />

EMLA [G] lidocaine/prilocaine 3<br />

LIDAMANTLE lidocaine 3<br />

lidocaine hcl cream, -jelly with<br />

prefilled applicator, -lotion, -<br />

1<br />

ointment, -solution non-oral<br />

lidocaine hcl viscous 1<br />

lidocaine-prilocaine 1<br />

LIDODERM lidocaine 2 [PAR]<br />

SYNERA lidocaine/tetracaine 3<br />

XYLOCAINE JEL, -SOLUTION NON-<br />

ORAL [G]<br />

lidocaine 3<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ANTIINFECTIVES<br />

AMEBICIDES<br />

paromomycin sulfate 1<br />

AMINOGLYCOSIDES<br />

amikacin sulfate injection [INJ] 1<br />

gentamicin 100 mg/ns 100 ml, -60<br />

mg/ns 50 ml pb, -70 mg/ns 50 ml<br />

pb, -80 mg/ns 50 ml pb, -90 mg/ns<br />

100 ml pb, -gentamicin 100 mg/100<br />

ml, -gentamicin 60 mg/50 ml, -<br />

gentamicin 80 mg/50 ml [INJ]<br />

1<br />

GENTAMICIN 60 MG/NS 100 ML PB,<br />

-80 MG/NS 100 ML PB, -<br />

GENTAMICIN 100 MG/50 ML, -<br />

GENTAMICIN 60 MG/100 ML, -<br />

GENTAMICIN 80 MG/100 ML [INJ]<br />

gentamicin/sodium chloride 3<br />

gentamicin sulfate injection [INJ] 1<br />

ISO GENTAMICIN 120 MG/100 ML, -<br />

GENTAMICIN 120 MG/50 ML, -<br />

GENTAMICIN 40 MG/100 ML, -<br />

GENTAMICIN 40 MG/50 ML [INJ]<br />

gentamicin/sodium chloride 2<br />

kanamycin sulfate [INJ] 1<br />

NEBCIN IN DEXTROSE [INJ] tobramycin 3<br />

NEO-FRADIN neomycin 2<br />

neomycin sulfate tablet 1<br />

tobramycin sulfate in ns [INJ] 1<br />

tobramycin sulfate injection [INJ] 1<br />

ANTHELMINTICS<br />

ALBENZA albendazole 2<br />

BILTRICIDE praziquantel 3<br />

mebendazole tablet chewable 1<br />

STROMECTOL ivermectin 2<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ANTIINFECTIVES SPECIALIZED INDICATIONS<br />

DAPSONE dapsone 2<br />

FLAGYL [G] metronidazole 3<br />

FLAGYL ER metronidazole 3<br />

metro iv [INJ] 1<br />

metronidazole capsule, -tablet 1<br />

metronidazole injection [INJ] 1<br />

metryl 1<br />

ANTIRETROVIRALS AND PROTEASE INH<br />

APTIVUS tipranavir/vitamin e tpgs 4<br />

ATRIPLA emtricitabine/tenofovir/efavir 4<br />

COMBIVIR lamivudine/zidovudine 4<br />

CRIXIVAN indinavir 2<br />

didanosine 1<br />

EMTRIVA emtricitabine 2<br />

EPIVIR lamivudine 2<br />

EPZICOM abacavir sulfate/lamivudine 4<br />

FUZEON [INJ] enfuvirtide 4<br />

INTELENCE etravirine 4<br />

INVIRASE saquinavir mesylate 4<br />

ISENTRESS raltegravir potassium 4<br />

KALETRA 100-25 MG TABLET ritonavir/lopinavir 2<br />

KALETRA 200-50 MG TABLET, - ritonavir/lopinavir 4<br />

SOLUTION<br />

LEXIVA SUSPENSION ORAL fosamprenavir calcium 2<br />

LEXIVA TABLET fosamprenavir calcium 4<br />

NORVIR CAPSULE, -TABLET ritonavir 2<br />

NORVIR SOLUTION ritonavir 4<br />

PREZISTA 150 MG TABLET, -300 MG<br />

TABLET, -75 MG TABLET<br />

darunavir ethanolate 2<br />

PREZISTA 400 MG TABLET, -600 MG<br />

TABLET<br />

darunavir ethanolate 4<br />

RESCRIPTOR delavirdine mesylate 2<br />

RETROVIR CAPSULE, -SYRUP, - zidovudine 3<br />

TABLET [G]<br />

RETROVIR INJECTION [INJ] zidovudine 2<br />

REYATAZ atazanavir sulfate 4<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

SELZENTRY maraviroc 4<br />

stavudine 1<br />

SUSTIVA efavirenz 2<br />

TRIZIVIR zidovudine/lamivudine/abacavir 4<br />

TRUVADA emtricitabine/tenofovir 4<br />

VIDEX didanosine 2<br />

VIDEX EC [G] didanosine 3<br />

VIRACEPT nelfinavir mesylate 2<br />

VIRAMUNE nevirapine 2<br />

VIREAD tenofovir disproxil fumarate 2<br />

ZERIT [G] stavudine 3<br />

ZIAGEN abacavir sulfate 2<br />

zidovudine 1<br />

ANTITUBERCULOSIS DRUGS<br />

CAPASTAT SULFATE [INJ] capreomycin 4<br />

CYCLOSERINE cycloserine 2<br />

ethambutol hcl tablet 1<br />

isonarif 1<br />

isoniazid injection [INJ] 1<br />

isoniazid syrup, -tablet 1<br />

MYAMBUTOL [G] ethambutol 3<br />

MYCOBUTIN rifabutin 2<br />

PASER aminosalicylic acid 2<br />

PRIFTIN rifapentine 2<br />

pyrazinamide 1<br />

RIFADIN CAPSULE rifampin 3<br />

RIFADIN INJECTION [INJ] rifampin 4<br />

RIFAMATE rifampin/isoniazid 3<br />

rifampin capsule 1<br />

rifampin injection [INJ] 4<br />

RIFATER rifampin/inh/pyrazinamide 3<br />

SEROMYCIN cycloserine 2<br />

STREPTOMYCIN SULFATE<br />

INJECTION [INJ]<br />

streptomycin 2<br />

TRECATOR ethionamide 2<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

CEPHALOSPORINS<br />

CEDAX ceftibuten 3<br />

cefaclor 1<br />

cefaclor er 1<br />

cefadroxil 1<br />

cefazolin 1 gm add-van vial, -1 gm<br />

vial, -1 gm-d5w bag, -10 gm vial, -<br />

1<br />

20 gm bulk vial, -500 mg vial [INJ]<br />

cefdinir 1<br />

cefepime [INJ] 1<br />

cefepime hcl [INJ] 1<br />

cefotaxime sodium [INJ] 1<br />

cefotetan [INJ] 1<br />

cefoxitin [INJ] 1<br />

cefoxitin sodium [INJ] 1<br />

cefpodoxime proxetil 1<br />

cefprozil 1<br />

ceftazidime [INJ] 1<br />

CEFTIN [G] cefuroxime axetil 3<br />

ceftriaxone [INJ] 1<br />

cefuroxime axetil 1<br />

cefuroxime injection [INJ] 1<br />

cefuroxime sod 1.5 gm vial, -sod 7.5<br />

1<br />

gm vial, -sod 750 mg vial [INJ]<br />

cefuroxime tablet 1<br />

cephalexin 1<br />

CLAFORAN [INJ][G] cefotaxime 3<br />

FORTAZ 1 GM ADD-VANTAGE VIAL,<br />

-1 GM VIAL, -2 GM VIAL, -6 GM<br />

VIAL [INJ][G]<br />

ceftazidime 3<br />

FORTAZ 2 GM ADD-VANTAGE VIAL<br />

[INJ]<br />

ceftazidime 4<br />

FORTAZ 500 MG VIAL [INJ] ceftazidime 2<br />

FORTAZ IN ISO-OSMOTIC<br />

DEXTROSE [INJ]<br />

ceftazidime 2<br />

KEFLEX [G] cephalexin 3<br />

MAXIPIME 1 GM ADD-VANTAGE VL,<br />

-2 GM ADD-VANTAGE VL, -1 GRAM<br />

VIAL, -2 GRAM VIAL [INJ][G]<br />

cefepime 3<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

MAXIPIME 500 MG VIAL [INJ] cefepime 2<br />

MEFOXIN [INJ][G] cefoxitin 3<br />

OMNICEF cefdinir 3<br />

RANICLOR cefaclor 3<br />

ROCEPHIN [INJ][G] ceftriaxone 3<br />

SPECTRACEF cefditoren pivoxil 3<br />

SUPRAX cefixime 2<br />

TAZICEF [INJ][G] ceftazidime 3<br />

VANTIN cefpodoxime 3<br />

ZINACEF [INJ][G] cefuroxime 3<br />

ZINACEF IN ISO-OSMOTIC WATER cefuroxime 3<br />

[INJ]<br />

ZINACEF ISO-OSMOTIC DEXTROSE<br />

[INJ]<br />

CHLORAMPHENICOLS<br />

cefuroxime 3<br />

chloramphenicol sod succinate [INJ] 1<br />

CLINDAMYCINS<br />

CLEOCIN HCL [G] clindamycin hcl 3<br />

CLEOCIN PALMITATE [G] clindamycin palmitate 2<br />

CLEOCIN PHOSPHATE [INJ][G] clindamycin phosphate 3<br />

CLEOCIN PHOSPHATE IN D5W [INJ] clindamycin phosphate 3<br />

clindamycin hcl capsule 1<br />

clindamycin palmitate hcl 1<br />

clindamycin phosphate injection<br />

[INJ]<br />

1<br />

ERYTHROMYCINS<br />

E.E.S. 200 erythromycin ethylsuccinate 3<br />

E.E.S. 400 [G] erythromycin ethylsuccinate 3<br />

ERYPED 200 erythromycin ethylsuccinate 3<br />

ERYPED 400 erythromycin ethylsuccinate 3<br />

ERY-TAB erythromycin base 2<br />

ERYTHROCIN LACTOBIONATE [INJ] erythromycin lactobionate 2<br />

erythrocin stearate 1<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

erythromycin capsule enteric coated,<br />

-tablet<br />

1<br />

erythromycin ethylsuccinate tablet 1<br />

PCE erythromycin base 3<br />

KETOLIDES<br />

KETEK telithromycin 3<br />

ORAL ANTIFUNGAL DRUGS<br />

ANCOBON flucytosine 4<br />

clotrimazole troche 1<br />

DIFLUCAN 100 MG TABLET, -200<br />

MG TABLET, -50 MG TABLET [G]<br />

fluconazole 3 [PAR]<br />

DIFLUCAN 150 MG TABLET [G] fluconazole 3 [QLL, 2/7]<br />

DIFLUCAN SUSPENSION [G] fluconazole 3<br />

fluconazole 100 mg tablet, -200 mg<br />

tablet, -50 mg tablet<br />

1 [PAR]<br />

fluconazole 150 mg tablet 1 [QLL, 2/7]<br />

fluconazole suspension 1<br />

GRIFULVIN V SUSPENSION ORAL griseofulvin microsize 3<br />

GRIFULVIN V TABLET griseofulvin microsize 2<br />

griseofulvin suspension oral 1<br />

GRIS-PEG griseofulvin ultramicrosize 2<br />

itraconazole capsule 1 [PAR]<br />

ketoconazole tablet 1<br />

LAMISIL PKT terbinafine 2<br />

LAMISIL TABLET [G] terbinafine 3 [PAR]<br />

MYCOSTATIN nystatin 3<br />

NOXAFIL posaconazole 4<br />

nystatin 150,000,000 units pwd, -<br />

50,000,000 units pwd, -500,000,000<br />

units pwd, -suspension oral, -tablet<br />

1<br />

ORAVIG miconazole 3<br />

SPORANOX CAPSULE [G] itraconazole 3 [PAR]<br />

SPORANOX SOLUTION itraconazole 2<br />

terbinafine hcl 1 [PAR]<br />

TERBINEX terbinafine/hydroxy chitosan 3 [PAR]<br />

VFEND voriconazole 4 [PAR]<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

OTHER ANTIINFECTIVE DRUGS<br />

Drug Generic Tier Restrictions<br />

ALINIA nitazoxanide 2<br />

AZACTAM 1 GM VIAL [INJ] aztreonam 2<br />

AZACTAM 2 GM VIAL [INJ][G] aztreonam 4<br />

AZACTAM-ISO-OSMOT 1 GM/50 ML<br />

[INJ]<br />

aztreonam/dextrose water 2<br />

AZACTAM-ISO-OSMOT 2 GM/50 ML aztreonam/dextrose water 4<br />

[INJ]<br />

aztreonam 1 gm vial [INJ] 1<br />

aztreonam 2 gm vial [INJ] 4<br />

baciim [INJ] 1<br />

bacitracin injection [INJ] 1<br />

colistimethate 150 mg vial [INJ] 4<br />

COLY-MYCIN M PARENTERAL<br />

[INJ][G]<br />

colistimethate, sodium 4<br />

CUBICIN [INJ] daptomycin 4<br />

DORIBAX [INJ] doripenem 4<br />

INVANZ 1 GM ADD-VANTAGE VIAL ertapenem sodium 3<br />

[INJ]<br />

INVANZ 1 GM VIAL [INJ] ertapenem sodium 2<br />

LINCOCIN [INJ] lincomycin 3<br />

lincoject [INJ] 1<br />

MEPRON atovaquone 4<br />

meropenem [INJ] 1<br />

MERREM IV 1 GM VIAL [INJ] meropenem 4<br />

MERREM IV 500 MG VIAL [INJ][G] meropenem 2<br />

PENTAM 300 [INJ][G] pentamidine 3<br />

pentamidine isethionate [INJ] 1<br />

polymyxin b sulfate injection [INJ] 1<br />

POLYMYXIN B SULFATE POWDER polymyxin b 3<br />

PRIMAXIN 250 MG VIAL [INJ] imipenem/cilastatin sodium 2<br />

PRIMAXIN 500 MG VIAL [INJ] imipenem/cilastatin sodium 4<br />

PRIMAXIN I.M. [INJ] imipenem/cilastatin sodium 4<br />

SYNERCID [INJ] quinupristin/dalfopristin 4<br />

TYGACIL [INJ] tigecycline 4<br />

VANCOCIN HCL vancomycin 4<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

vancomycin 1 gm add-van vial, -1<br />

gm vial, -10 gm vial, -5 gm vial, -<br />

500 mg a/v vial, -500 mg vial, -750<br />

mg vial [INJ]<br />

1<br />

VANCOMYCIN HCL 1G/200 ML BAG<br />

[INJ]<br />

vancomycin 3<br />

VANCOMYCIN-D5W [INJ] vancomycin 3<br />

VIBATIV [INJ] telavancin 4<br />

XIFAXAN 200 MG TABLET rifaximin 2<br />

XIFAXAN 550 MG TABLET rifaximin 4<br />

ZYVOX INJECTION [INJ] linezolid 4<br />

ZYVOX SUSPENSION<br />

RECONSTITUTED ORAL, -TABLET<br />

linezolid 4 [PAR]<br />

OTHER ANTIVIRAL DRUGS<br />

acyclovir capsule, -suspension oral, -<br />

tablet<br />

1<br />

acyclovir sodium [INJ] 1<br />

amantadine 1<br />

BARACLUDE SOLUTION entecavir 2<br />

BARACLUDE TABLET entecavir 4<br />

COPEGUS [G] ribavirin 4<br />

CYTOVENE [INJ][G] ganciclovir 2<br />

DENAVIR penciclovir 2<br />

EPIVIR HBV lamivudine 2<br />

famciclovir 125 mg tablet 1 [QLL,<br />

21/10]<br />

famciclovir 250 mg tablet 1 [QLL,<br />

68/34]<br />

famciclovir 500 mg tablet 1 [QLL, 21/7]<br />

FAMVIR 125 MG TABLET [G] famciclovir 3 [QLL,<br />

21/10]<br />

FAMVIR 250 MG TABLET [G] famciclovir 3 [QLL,<br />

68/34]<br />

FAMVIR 500 MG TABLET [G] famciclovir 3 [QLL, 21/7]<br />

FLUMADINE [G] rimantadine 3<br />

foscarnet sodium [INJ] 1<br />

FOSCAVIR [INJ] foscarnet 3<br />

ganciclovir 4<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ganciclovir sodium [INJ] 1<br />

HEPSERA adefovir dipivoxil 4<br />

REBETOL SOLUTION, -CAPSULE [G] ribavirin 4<br />

RELENZA zanamivir 2 [QLL,<br />

60/180]<br />

ribapak 4<br />

ribasphere 200 mg tablet 1<br />

ribasphere 400 mg tablet, -600 mg<br />

tablet, -capsule<br />

4<br />

RIBATAB [G] ribavirin 4<br />

ribavirin 200 mg tablet 1<br />

ribavirin 400 mg tablet, -600 mg<br />

4<br />

tablet, -capsule<br />

rimantadine hcl 1<br />

TAMIFLU 30 MG GELCAP oseltamivir phosphate 2 [QLL,<br />

84/180]<br />

TAMIFLU 45 MG GELCAP, -75 MG oseltamivir phosphate 2 [QLL,<br />

GELCAP<br />

42/180]<br />

TAMIFLU SUSPENSION oseltamivir phosphate 2 [QLL,<br />

900/180]<br />

TYZEKA telbivudine 2<br />

valacyclovir 1 [QLL,<br />

34/34]<br />

VALCYTE valganciclovir 4<br />

VALTREX [G] valacyclovir 3 [QLL,<br />

34/34]<br />

VIRAZOLE [INJ] ribavirin 2<br />

VISTIDE [INJ] cidofovir 4<br />

ZOVIRAX CAPSULE, -SUSPENSION<br />

ORAL, -TABLET [G]<br />

acyclovir 3<br />

ZOVIRAX CREAM, -OINTMENT acyclovir 2<br />

OTHER MACROLIDES<br />

azithromycin 100 mg/5 ml susp 1 [QLL, 30<br />

ml/5]<br />

azithromycin 200 mg/5 ml susp 1 [QLL, 90<br />

ml/5]<br />

azithromycin 250 mg tablet 1 [QLL, 8/7]<br />

azithromycin 500 mg tablet 1 [QLL, 4/4]<br />

azithromycin 600 mg tablet, -packet 1<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

azithromycin injection [INJ] 1<br />

BIAXIN [G] clarithromycin 3<br />

BIAXIN XL [G] clarithromycin 3<br />

clarithromycin 1<br />

clarithromycin er 1<br />

ZITHROMAX 100 MG/5 ML SUSP [G] azithromycin 3 [QLL, 30<br />

ml/5]<br />

ZITHROMAX 200 MG/5 ML SUSP [G] azithromycin 3 [QLL, 68<br />

ml/5]<br />

ZITHROMAX 250 MG TABLET, -250<br />

MG Z-PAK TABLET [G]<br />

azithromycin 3 [QLL, 8/7]<br />

ZITHROMAX 500 MG TABLET [G] azithromycin 3 [QLL, 4/4]<br />

ZITHROMAX INJECTION [INJ][G] azithromycin 3<br />

ZITHROMAX PACKET, -600 MG azithromycin 3<br />

TABLET [G]<br />

ZITHROMAX TRI-PAK [G] azithromycin 3 [QLL, 4/4]<br />

ZMAX azithromycin 3 [QLL, 60<br />

ml/1]<br />

ZMAX ADULT-PEDIATRIC azithromycin 3 [QLL, 60/1]<br />

ZMAX PEDIATRIC azithromycin 3 [QLL, 60/1]<br />

OTHER TOPICAL ANTIFUNGALS<br />

ciclopirox cream, -gel, -kit, -<br />

shampoo, -suspension topical<br />

1<br />

ciclopirox solution non-oral 1 [PAR]<br />

clotrimazole 1% cream, -1%<br />

solution, -af 1% cream<br />

1<br />

CNL 8 ciclopirox/nail lacquer remov 3<br />

econazole nitrate cream 1<br />

ERTACZO sertaconazole nitrate 3<br />

EXELDERM sulconazole nitrate 3<br />

EXTINA ketoconazole 3<br />

ketoconazole cream, -shampoo 1<br />

KURIC [G] ketoconazole 3<br />

LAMISIL SOLUTION terbinafine 3<br />

LOPROX [G] ciclopirox 3<br />

MENTAX butenafine 3<br />

NAFTIN naftifine 3<br />

NIZORAL [G] ketoconazole 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

nyamyc 1<br />

nystatin 100,000 unit/gm powd, -<br />

cream, -ointment<br />

1<br />

nystop 1<br />

OXISTAT oxiconazole 3<br />

pedi-dri 1<br />

PENLAC [G] ciclopirox 3 [PAR]<br />

VUSION miconazole nitrate/zinc oxide 3<br />

XOLEGEL ketoconazole 3<br />

PARENTERAL ANTIFUNGALS<br />

ABELCET [INJ] amphotericin b lipid complex 4<br />

AMBISOME [INJ] amphotericin b liposome 4<br />

AMPHOTEC 100 MG VIAL [INJ] ampho b c-s 2<br />

AMPHOTEC 50 MG VIAL [INJ] ampho b c-s 3<br />

amphotericin b injection [INJ] 1<br />

CANCIDAS [INJ] caspofungin acetate 4<br />

DIFLUCAN IN DEXTROSE [INJ] fluconazole/dextrose-water 3<br />

DIFLUCAN IN SALINE [INJ][G] fluconazole/sodium chloride 3<br />

ERAXIS (ALCOHOL DILUENT) [INJ] anidulafungin 3<br />

ERAXIS (WATER DILUENT) [INJ] anidulafungin 3<br />

fluconazole in dextrose [INJ] 1<br />

fluconazole in saline [INJ] 1<br />

MYCAMINE [INJ] micafungin sodium 4<br />

VFEND IV [INJ] voriconazole 4<br />

PENICILLINS<br />

amoclan 1<br />

amox tr-potassium clavulanate 1<br />

amoxicillin 1<br />

amoxicillin-clavulanate er 1<br />

AMOXIL 125 MG/5 ML SUSPENSION amoxicillin 2<br />

[INJ]<br />

AMOXIL 400 MG/5 ML SUSPENSION,<br />

-50 MG/ML PED DROPS, -CAPSULE,<br />

-250 MG/5 ML SUSPENSION [G]<br />

amoxicillin 2<br />

ampicillin sodium [INJ] 1<br />

ampicillin trihydrate 1<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ampicillin-sulbactam [INJ] 1<br />

AUGMENTIN 125-31.25 SUSPEN, -<br />

TABLET CHEWABLE<br />

amoxicillin clavulanate 2<br />

AUGMENTIN 400-57 MG/5 ML, -250-<br />

62.5 MG/5 ML, -TABLET [G]<br />

amoxicillin clavulanate 3<br />

AUGMENTIN ES-600 amoxicillin clavulanate 3<br />

AUGMENTIN XR [G] amoxicillin clavulanate 3<br />

BACTOCILL oxacillin 3<br />

BICILLIN C-R [INJ] pen g procaine/pen g benz 2<br />

BICILLIN L-A [INJ] penicillin g benzathine 2<br />

dicloxacillin sodium 1<br />

MOXATAG amoxicillin 3<br />

NAFCILL IN DEXTROSE [INJ] nafcillin 4<br />

nafcillin [INJ] 4<br />

nafcillin sodium [INJ] 4<br />

NALLPEN [INJ] nafcillin 4<br />

NALLPEN IN DEXTROSE [INJ] nafcillin 4<br />

NALLPEN-ISO-OSMOTIC DEXTROSE<br />

[INJ]<br />

nafcillin 4<br />

oxacillin [INJ] 4<br />

oxacillin 1 gm add-vantage vl, -10<br />

gm vial, -2 gm add-vantage vl, -2<br />

gm vial [INJ]<br />

4<br />

oxacillin 1 gm vial [INJ] 1<br />

penicillin g potassium [INJ] 1<br />

PENICILLIN G POTASSIUM IN D5W<br />

[INJ]<br />

pen g pot/dextrose-water 2<br />

penicillin g procaine [INJ] 1<br />

penicillin g sodium [INJ] 1<br />

PENICILLIN GK-ISO-OSM<br />

DEXTROSE [INJ]<br />

pen g pot/dextrose-water 2<br />

penicillin v potassium 1<br />

PFIZERPEN [INJ][G] penicillin g potassium 3<br />

piperacillin [INJ] 1<br />

piperacillin-tazobactam [INJ] 1<br />

PIPRACIL IN DEXTROSE [INJ] piperacillin 2<br />

TIMENTIN [INJ] ticarcillin/k clavulanate 2<br />

TOTACILLIN-N [INJ] ampicillin sodium 3<br />

UNASYN [INJ][G] ampicillin sodium/sulbactam na 3<br />

ZOSYN [INJ][G] piperacillin/tazobactam sodium 3<br />

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Open Comprehensive Formulary<br />

PLASMODICIDES<br />

Drug Generic Tier Restrictions<br />

ARALEN PHOSPHATE [G] chloroquine phosphate 3<br />

chloroquine phosphate tablet 1<br />

COARTEM artemether/lumefantrine 2<br />

DARAPRIM pyrimethamine 2<br />

FANSIDAR pyrimethamine/sulfadoxine 2<br />

HALFAN halofantrine 2<br />

hydroxychloroquine sulfate tablet 1<br />

MALARONE atovaquone/proguanil hcl 2<br />

mefloquine hcl 1<br />

PLAQUENIL [G] hydroxychloroquine 3<br />

PRIMAQUINE primaquine 2<br />

QUALAQUIN quinine sulfate 2<br />

QUINOLONES<br />

AVELOX moxifloxacin 2<br />

AVELOX ABC PACK moxifloxacin 2<br />

AVELOX IV [INJ] moxifloxacin 2<br />

CIPRO [G] ciprofloxacin 3<br />

CIPRO I.V. [INJ][G] ciprofloxacin 3<br />

CIPRO XR ciprofloxacin 3<br />

ciprofloxacin [INJ] 1<br />

ciprofloxacin er 1<br />

ciprofloxacin hcl tablet 1<br />

ciprofloxacin-d5w [INJ] 1<br />

FACTIVE gemifloxacin 3 [QLL, 7/7]<br />

FLOXIN I.V. [INJ] ofloxacin 3<br />

LEVAQUIN INJECTION [INJ] levofloxacin 3<br />

LEVAQUIN SOLUTION, -TABLET levofloxacin 3<br />

NOROXIN norfloxacin 3<br />

ofloxacin tablet 1<br />

PROQUIN XR ciprofloxacin 3<br />

SULFONAMIDES<br />

BACTRIM [G] sulfamethoxazole/trimethoprim 3<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

BACTRIM DS [G] sulfamethoxazole/trimethoprim 3<br />

erythromycin-sulfisoxazole 1<br />

GANTRISIN sulfisoxazole acetyl 2<br />

SEPTRA [G] sulfamethoxazole/trimethoprim 3<br />

SEPTRA DS [G] sulfamethoxazole/trimethoprim 3<br />

sulfadiazine tablet 1<br />

sulfamethoxazole-trimethoprim<br />

injection [INJ]<br />

1<br />

sulfamethoxazole-trimethoprim<br />

suspension oral, -tablet<br />

1<br />

sulfatrim 1<br />

TETRACYCLINES<br />

ADOXA [G] doxycycline monohydrate 3<br />

ADOXA PAK [G] doxycycline monohydrate 3<br />

AVIDOXY doxycycline monohydrate 3<br />

demeclocycline hcl 1<br />

DORYX doxycycline hyclate 3<br />

doxycycline 1<br />

doxycycline hyclate 100 mg tab, -<br />

1<br />

capsule, -capsule enteric coated<br />

doxycycline hyclate injection [INJ] 1<br />

doxycycline monohydrate 1<br />

doxy-lemmon 1<br />

DYNACIN [G] minocycline 3<br />

MINOCIN COMBINATION PACKAGE,<br />

-KIT, -CAPSULE [G]<br />

minocycline 3<br />

MINOCIN INJECTION [INJ] minocycline 3<br />

minocycline hcl capsule, -tablet, -<br />

1<br />

tablet sustained release 24hr<br />

MONODOX [G] doxycycline monohydrate 3<br />

ORACEA doxycycline monohydrate 3<br />

SOLODYN [G] minocycline 3<br />

TERRAMYCIN [INJ] oxytetracycline 3<br />

TERRAMYCIN IM [INJ] oxytetracycline 3<br />

tetracycline hcl capsule 1<br />

VIBRAMYCIN 50 MG CAPSULE [INJ] doxycycline hyclate 3<br />

VIBRAMYCIN SUSPENSION, -SYRUP,<br />

-100 MG CAPSULE [G]<br />

doxycycline hyclate 3<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

VIBRA-TABS doxycycline hyclate 3<br />

TOPICAL ANTIBACTERIAL DRUGS<br />

ALTABAX retapamulin 2<br />

BACTROBAN [G] mupirocin 3<br />

BACTROBAN NASAL mupirocin calcium 2<br />

CENTANY mupirocin 3<br />

CORTISPORIN CREAM, -OINTMENT neomycin/bacitracin/poly/hc 3<br />

gentamicin 0.1% ointment, -cream 1<br />

mupirocin ointment 1<br />

PHISOHEX hexachlorophene 3<br />

SILVADENE [G] silver sulfadiazine 3<br />

silver sulfadiazine 1<br />

ssd 1<br />

ssd af 1<br />

SULFAMYLON mafenide acetate 2<br />

thermazene 1<br />

TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.<br />

clotrimazole-betamethasone 1<br />

LOTRISONE [G] clotrimazole/betamethasone 3<br />

nystatin-triamcinolone 1<br />

URINARY ANTIINFECTIVES<br />

FURADANTIN nitrofurantoin 2<br />

HIPREX [G] methenamine hippurate 3<br />

MACROBID [G] nitrofurantoin/nitrofuran mac 3<br />

MACRODANTIN [G] nitrofurantoin macrocrystal 3<br />

methenamine hippurate 1<br />

methenamine mandelate 1<br />

MONUROL fosfomycin tromethamine 2<br />

nitrofurantoin capsule 1<br />

nitrofurantoin macrocrystal 1<br />

nitrofurantoin mono-macro 1<br />

PRIMSOL trimethoprim 2<br />

trimethoprim tablet 1<br />

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Drug Generic Tier Restrictions<br />

UROQID-ACID NO.2 methenamine mandelate 3<br />

utac 1<br />

visqid a-a 1<br />

VAGINAL ANTIFUNGALS<br />

GYNAZOLE-1 butoconazole 3<br />

miconazole 3 200 mg vag supp 1 [QLL, 3/3]<br />

nystatin tablet 1<br />

TERAZOL 3 80 MG SUPPOSITORY terconazole 3 [QLL, 3/3]<br />

[G]<br />

TERAZOL 3 CREAM [G] terconazole 3 [QLL, 20<br />

gm/3]<br />

TERAZOL 7 [G] terconazole 3 [QLL, 45<br />

gm/7]<br />

terconazole 0.4% cream 1 [QLL, 45<br />

gm/7]<br />

terconazole 0.8% cream 1 [QLL, 20<br />

gm/3]<br />

terconazole 80 mg suppository 1 [QLL, 3/3]<br />

ZAZOLE 0.8% VAGINAL CREAM terconazole 3 [QLL, 20<br />

gm/3]<br />

ZAZOLE 80 MG VAGINAL SUPP [G] terconazole 3 [QLL, 3/3]<br />

ZAZOLE VAGINAL 0.4% CREAM [G] terconazole 3 [QLL, 45<br />

gm/7]<br />

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS<br />

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS<br />

AFINITOR everolimus 4<br />

AGRYLIN [G] anagrelide 3<br />

ALIMTA [INJ] pemetrexed disodium 4<br />

AMEVIVE [INJ][LA] alefacept 4 [PAR]<br />

amifostine [INJ] 4<br />

anagrelide hcl 1<br />

anastrozole tablet 1<br />

ARAVA [G] leflunomide 3 [QLL,<br />

34/34]<br />

ARIMIDEX [G] anastrozole 2<br />

AROMASIN exemestane 2<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

AVASTIN [INJ] bevacizumab 2 [PAR]<br />

AZASAN azathioprine 2 [PAR]<br />

azathioprine sodium [INJ] 1 [PAR]<br />

azathioprine tablet 1 [PAR]<br />

bicalutamide 1<br />

CAMPATH [INJ] alemtuzumab 4<br />

CASODEX [G] bicalutamide 3<br />

CEENU lomustine 2<br />

CELLCEPT CAPSULE [G] mycophenolate mofetil 3 [PAR]<br />

CELLCEPT INJECTION [INJ] mycophenolate mofetil 2 [PAR]<br />

CELLCEPT TABLET, -SUSPENSION mycophenolate mofetil 4 [PAR]<br />

RECONSTITUTED ORAL [G]<br />

CIMZIA [INJ] certolizumab pegol 4 [PAR]<br />

cyclophosphamide tablet 1 [PAR]<br />

cyclosporine capsule, -solution 1 [PAR]<br />

cyclosporine injection [INJ] 1 [PAR]<br />

cyclosporine modified 1 [PAR]<br />

DEPO-PROVERA 400 MG/ML VIAL medroxyprogesterone 2<br />

[INJ]<br />

DROXIA hydroxyurea 2<br />

ELIGARD [INJ] leuprolide 2 [PAR]<br />

ELITEK [INJ] rasburicase 4<br />

EMCYT estramustine phosphate sodium 2<br />

ENBREL [INJ] etanercept 4 [PAR]<br />

ETHYOL [INJ][G] amifostine 4<br />

FARESTON toremifene 2<br />

FASLODEX [INJ] fulvestrant 4<br />

FEMARA letrozole 2<br />

floxuridine [INJ] 1<br />

flutamide 1<br />

fudr [INJ] 1<br />

gengraf 1 [PAR]<br />

GLEEVEC imatinib mesylate 4<br />

HEXALEN altretamine 4<br />

HUMIRA 20 MG/0.4 ML SYRINGE, - adalimumab 4 [PAR][QLL,<br />

40 MG/0.8 ML SYRINGE [INJ]<br />

HUMIRA 40 MG/0.8 ML PEN, -<br />

CROHN'S STARTER PACK, -<br />

PSORIASIS STARTER PACK [INJ]<br />

5/35]<br />

adalimumab 4 [PAR][QLL,<br />

6/180]<br />

HYDREA [G] hydroxyurea 3<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

hydroxyurea capsule 1<br />

IMURAN [G] azathioprine 3 [PAR]<br />

IRESSA [LA] gefitinib 4<br />

leflunomide 1 [QLL,<br />

34/34]<br />

leucovorin calcium injection [INJ] 1<br />

leucovorin calcium tablet 1<br />

LEUKERAN chlorambucil 2<br />

LYSODREN mitotane 4<br />

MATULANE procarbazine 4<br />

MEGACE [G] megestrol 3<br />

MEGACE ES megestrol 2<br />

megestrol acetate suspension oral, -<br />

1<br />

tablet<br />

mercaptopurine tablet 1<br />

MESNEX TABLET mesna 4<br />

methotrexate injection [INJ] 1 [PAR]<br />

methotrexate tablet 1 [PAR]<br />

mitoxantrone hcl injection [INJ] 4 [PAR]<br />

MUSTARGEN [INJ] mechlorethamine 2<br />

mycophenolate mofetil capsule 1 [PAR]<br />

mycophenolate mofetil tablet 4 [PAR]<br />

MYFORTIC mycophenolate sodium 2 [PAR]<br />

NEORAL [G] cyclosporine 3 [PAR]<br />

NEXAVAR [LA] sorafenib tosylate 4<br />

NILANDRON nilutamide 2<br />

NOVANTRONE [INJ][G] mitoxantrone 4 [PAR]<br />

octreotide 1,000 mcg/ml vial, -acet<br />

100 mcg/ml amp, -acet 100 mcg/ml<br />

vl, -acet 200 mcg/ml vl, -acet 500<br />

mcg/ml amp, -acet 500 mcg/ml vl<br />

[INJ]<br />

4<br />

octreotide acet 50 mcg/ml amp, -<br />

acet 50 mcg/ml vial [INJ]<br />

1<br />

ORENCIA [INJ] abatacept/maltose 4 [PAR]<br />

ORTHOCLONE OKT-3 [INJ] muronab-cd3 2 [PAR]<br />

PROGRAF 0.5 MG CAPSULE, -1 MG tacrolimus 3 [PAR]<br />

CAPSULE [G]<br />

PROGRAF 5 MG CAPSULE [G] tacrolimus 4 [PAR]<br />

PROGRAF INJECTION [INJ] tacrolimus 2 [PAR]<br />

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Drug Generic Tier Restrictions<br />

PURINETHOL [G] mercaptopurine 3<br />

RAPAMUNE sirolimus 2 [PAR]<br />

RAPTIVA [INJ] efalizumab 4<br />

REMICADE [INJ] infliximab 4 [PAR]<br />

REVLIMID [LA] lenalidomide 4<br />

RHEUMATREX methotrexate 3 [PAR]<br />

RITUXAN [INJ] rituximab 4 [PAR]<br />

SANDIMMUNE CAPSULE, -<br />

SOLUTION [G]<br />

cyclosporine 3 [PAR]<br />

SANDIMMUNE INJECTION [INJ][G] cyclosporine 3 [PAR]<br />

SANDOSTATIN [INJ][G] octreotide 4<br />

SANDOSTATIN LAR 10 MG KIT, -30 octreotide 4 [QLL, 1/28]<br />

MG KIT [INJ]<br />

SANDOSTATIN LAR 20 MG KIT [INJ] octreotide 4 [QLL, 2/28]<br />

SIMPONI [INJ] golimumab 4 [PAR]<br />

SIMULECT [INJ] basiliximab 2 [PAR]<br />

SOMATULINE DEPOT [INJ] lanreotide acetate 4<br />

SPRYCEL dasatinib 4<br />

STELARA [INJ] ustekinumab 4 [PAR]<br />

SUTENT sunitinib malate 4<br />

tacrolimus 0.5 mg capsule, -1 mg<br />

1 [PAR]<br />

capsule<br />

tacrolimus 5 mg capsule 4 [PAR]<br />

tamoxifen citrate tablet 1<br />

TARCEVA erlotinib hcl 4<br />

TARGRETIN bexarotene 4<br />

TASIGNA nilotinib hydrochloride 4<br />

THERACYS [INJ] bcg vaccine 2<br />

THIOGUANINE thioguanine 2<br />

TRELSTAR 11.25 MG SYRINGE, -<br />

3.75 MG SYRINGE [INJ][LA]<br />

triptorelin pamoate 2<br />

TRELSTAR 22.5 MG SYRINGE, -22.5 triptorelin pamoate 4<br />

MG VIAL [INJ][LA]<br />

TRELSTAR DEPOT [INJ][LA] triptorelin pamoate 2<br />

TRELSTAR LA [INJ][LA] triptorelin pamoate 2<br />

tretinoin capsule 4<br />

TREXALL methotrexate sodium 2 [PAR]<br />

TYKERB lapatinib ditosylate 4<br />

TYSABRI [INJ][LA] natalizumab 4 [PAR]<br />

VANTAS [INJ] histrelin ac 2<br />

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Drug Generic Tier Restrictions<br />

VELCADE [INJ] bortezomib 4<br />

VESANOID tretinoin 4<br />

VIDAZA [INJ] azacitidine 4<br />

VOTRIENT pazopanib 4<br />

ZOLADEX [INJ] goserelin acetate 2<br />

ZOLINZA vorinostat 4<br />

ZORTRESS 0.25 MG TABLET everolimus 2 [PAR]<br />

ZORTRESS 0.5 MG TABLET, -0.75<br />

MG TABLET<br />

everolimus 4 [PAR]<br />

AUTONOMIC AND CNS MEDICATIONS<br />

ANALGESICS<br />

BUPRENEX [INJ] buprenorphine 3<br />

buprenorphine injection [INJ] 1<br />

butorphanol tartrate injection [INJ] 1<br />

nalbuphine hcl [INJ] 1<br />

PRIALT [INJ] ziconotide acetate 2<br />

RYBIX ODT tramadol 3 [QLL,<br />

272/34][ST]<br />

RYZOLT tramadol 3 [QLL,<br />

34/34][ST]<br />

sufenta [INJ] 1<br />

sufentanil citrate injection [INJ] 1<br />

TALWIN INJECTION [INJ] pentazocine 3<br />

tramadol hcl tablet 1 [QLL,<br />

272/34]<br />

tramadol hcl tablet sustained release<br />

1 [QLL,<br />

24hr<br />

34/34]<br />

tramadol hcl-acetaminophen 1 [QLL,<br />

272/34]<br />

ULTIVA [INJ] remifentanil 2<br />

ULTRACET [G] tramadol/apap 3 [QLL,<br />

272/34][ST]<br />

ULTRAM [G] tramadol 3 [QLL,<br />

272/34][ST]<br />

ULTRAM ER [G] tramadol 3 [QLL,<br />

34/34][ST]<br />

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Drug Generic Tier Restrictions<br />

ANTIDEMENTIA DRUGS<br />

ARICEPT 10 MG TABLET, -5 MG<br />

TABLET<br />

donepezil 2<br />

ARICEPT 23 MG TABLET donepezil 3<br />

ARICEPT ODT donepezil 2<br />

COGNEX tacrine 3<br />

EXELON [G] rivastigmine tartrate 2<br />

galantamine hbr 1<br />

galantamine hydrobromide 1<br />

NAMENDA memantine hcl 2<br />

RAZADYNE [G] galantamine 3<br />

RAZADYNE ER [G] galantamine 3<br />

rivastigmine 1<br />

ANTIMANIA DRUGS<br />

ESKALITH [INJ] lithium carbonate 3<br />

lithium 1<br />

lithium carbonate capsule, -tablet, -<br />

tablet sustained action<br />

1<br />

lithium citrate 1<br />

LITHOBID [G] lithium carbonate 3<br />

ANTIPARKINSON ANTICHOLINERGIC DRUGS<br />

benztropine mesylate injection [INJ] 1<br />

benztropine mesylate tablet 1<br />

COGENTIN [INJ][G] benztropine 3<br />

trihexyphenidyl hcl 1<br />

ANTIPSYCHOTIC DRUGS<br />

ABILIFY DISCMELT aripiprazole 2 [QLL,<br />

68/34]<br />

ABILIFY INJECTION [INJ] aripiprazole 2<br />

ABILIFY SOLUTION aripiprazole 2<br />

ABILIFY TABLET aripiprazole 2 [QLL,<br />

34/34]<br />

chlorpromazine hcl injection [INJ] 1<br />

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Drug Generic Tier Restrictions<br />

chlorpromazine hcl tablet 1<br />

clozapine 1<br />

CLOZARIL [G] clozapine 3<br />

FANAPT 1 MG TABLET, -10 MG<br />

TABLET, -12 MG TABLET, -2 MG<br />

TABLET, -4 MG TABLET, -6 MG<br />

TABLET, -8 MG TABLET<br />

iloperidone 2 [QLL,<br />

68/34]<br />

FANAPT TITRATION PACK iloperidone 2 [QLL, 1/34]<br />

FAZACLO clozapine 2<br />

fluphenazine decanoate [INJ] 1<br />

fluphenazine hcl elixir, -solution, -<br />

1<br />

tablet<br />

fluphenazine hcl injection [INJ] 1<br />

GEODON CAPSULE ziprasidone 2 [QLL,<br />

68/34]<br />

GEODON INJECTION [INJ] ziprasidone 2<br />

HALDOL [INJ] haloperidol 3<br />

HALDOL DECANOATE 100 [INJ] haloperidol decanoate 3<br />

HALDOL DECANOATE 50 [INJ] haloperidol decanoate 3<br />

haloperidol decanoate [INJ] 1<br />

haloperidol lactate injection [INJ] 1<br />

haloperidol lactate solution 1<br />

haloperidol tablet 1<br />

INVEGA ER 1.5 MG TABLET, -ER 3 paliperidone 2 [QLL,<br />

MG TABLET, -ER 9 MG TABLET<br />

34/34]<br />

INVEGA ER 6 MG TABLET paliperidone 2 [QLL,<br />

INVEGA SUSTENNA 117 MG PREF<br />

SY, -156 MG PREF SY, -234 MG<br />

PREF SY [INJ]<br />

INVEGA SUSTENNA 39 MG PREF<br />

SYR, -78 MG PREF SYR [INJ]<br />

paliperidone 4<br />

paliperidone 2<br />

loxapine 1<br />

LOXITANE [G] loxapine succinate 3<br />

MOBAN molindone 2<br />

NAVANE [G] thiothixene 3<br />

ORAP pimozide 2<br />

perphenazine 1<br />

RISPERDAL CONSTA 12.5 MG SYR, -<br />

25 MG SYR [INJ]<br />

risperidone 2<br />

68/34]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

RISPERDAL CONSTA 37.5 MG SYR, -<br />

50 MG SYR [INJ]<br />

risperidone 4<br />

RISPERDAL M-TAB [G] risperidone 3 [QLL,<br />

68/34]<br />

RISPERDAL SOLUTION [G] risperidone 3 [QLL, 544<br />

ml/34]<br />

RISPERDAL TABLET [G] risperidone 3 [QLL,<br />

68/34]<br />

risperidone m-tab 1 [QLL,<br />

68/34]<br />

risperidone odt 1 [QLL,<br />

68/34]<br />

risperidone solution 1 [QLL, 544<br />

ml/34]<br />

risperidone tablet 1 [QLL,<br />

68/34]<br />

SAPHRIS asenapine 2 [QLL,<br />

68/34]<br />

SEROQUEL 100 MG TABLET, -200 quetiapine fumarate 2 [QLL,<br />

MG TABLET, -25 MG TABLET, -50<br />

MG TABLET<br />

102/34]<br />

SEROQUEL 300 MG TABLET, -400 quetiapine fumarate 2 [QLL,<br />

MG TABLET<br />

68/34]<br />

SEROQUEL XR 150 MG TABLET, - quetiapine fumarate 2 [QLL,<br />

200 MG TABLET<br />

34/34]<br />

SEROQUEL XR 300 MG TABLET, - quetiapine fumarate 2 [QLL,<br />

400 MG TABLET, -50 MG TABLET<br />

68/34]<br />

SYMBYAX olanzapine/fluoxetine hcl 3<br />

thioridazine hcl 1<br />

thiothixene 1<br />

trifluoperazine hcl 1<br />

ZYPREXA INJECTION [INJ] olanzapine 2<br />

ZYPREXA RELPREVV [INJ][LA] olanzapine pamoate 4<br />

ZYPREXA TABLET olanzapine 2 [QLL,<br />

34/34]<br />

ZYPREXA ZYDIS olanzapine 2 [QLL,<br />

34/34]<br />

ANTIVERTIGO AND ANTIEMETIC DRUGS<br />

ALOXI [INJ] palonosetron hcl 4<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ANTIVERT [G] meclizine hcl 3<br />

ANZEMET INJECTION [INJ] dolasetron mesylate 3<br />

ANZEMET TABLET dolasetron mesylate 3 [PAR][QLL,<br />

1/1]<br />

CESAMET nabilone 4 [QLL, 30/5]<br />

COMPAZINE INJECTION [INJ] prochlorperazine edisylate 3<br />

COMPAZINE SYRUP prochlorperazine edisylate 2<br />

compro 1<br />

dimenhydrinate injection [INJ] 1<br />

dronabinol 10 mg capsule, -5 mg<br />

capsule<br />

4 [PAR]<br />

dronabinol 2.5 mg capsule 1 [PAR]<br />

EMEND 125 MG CAPSULE, -40 MG aprepitant 2 [PAR][QLL,<br />

CAPSULE<br />

1/1]<br />

EMEND 80 MG CAPSULE aprepitant 2 [PAR][QLL,<br />

2/2]<br />

EMEND INJECTION [INJ] aprepitant 2<br />

EMEND TRIFOLD PACK aprepitant 2 [PAR][QLL,<br />

3/3]<br />

granisetron hcl injection [INJ] 1<br />

granisetron hcl tablet 1 [PAR][QLL,<br />

2/1]<br />

granisol 1 [PAR][QLL,<br />

30 ml/3]<br />

KYTRIL INJECTION [INJ][G] granisetron 4<br />

KYTRIL TABLET [G] granisetron 4 [PAR][QLL,<br />

2/1]<br />

MARINOL 10 MG CAPSULE, -5 MG<br />

CAPSULE [G]<br />

dronabinol 4 [PAR]<br />

MARINOL 2.5 MG CAPSULE [G] dronabinol 3 [PAR]<br />

meclizine 12.5 mg tablet, -25 mg<br />

tablet<br />

1<br />

ondansetron hcl 24 mg tablet 1 [PAR][QLL,<br />

ondansetron hcl 4 mg tablet, -8 mg<br />

1 [PAR][QLL,<br />

tablet<br />

12/5]<br />

ondansetron hcl in dextrose [INJ] 1<br />

ondansetron hcl injection [INJ] 1<br />

ondansetron hcl solution 1 [PAR][QLL,<br />

150 ml/5]<br />

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1/1]


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ondansetron odt 1 [PAR][QLL,<br />

12/5]<br />

phenadoz 1<br />

prochlorperazine edisylate [INJ] 1<br />

prochlorperazine maleate<br />

1<br />

suppository rectal, -tablet<br />

promethazine hcl suppository rectal 1<br />

promethegan 1<br />

SANCUSO granisetron 4 [QLL, 1/7]<br />

TIGAN CAPSULE [G] trimethobenzamide 3<br />

TIGAN INJECTION [INJ] trimethobenzamide 3<br />

TRANSDERM-SCOP scopolamine 3<br />

trimethobenzamide hcl capsule 1<br />

trimethobenzamide hcl injection<br />

1<br />

[INJ]<br />

ZOFRAN INJECTION [INJ][G] ondansetron 3<br />

ZOFRAN ODT [G] ondansetron 3 [PAR][QLL,<br />

12/5]<br />

ZOFRAN SOLUTION [G] ondansetron 3 [PAR][QLL,<br />

150 ml/5]<br />

ZOFRAN TABLET [G] ondansetron 3 [PAR][QLL,<br />

12/5]<br />

ZUPLENZ ondansetron 3 [PAR][QLL,<br />

12/5]<br />

ANXIOLYTICS<br />

BUSPAR buspirone 3<br />

buspirone hcl tablet 1<br />

meprobamate 1<br />

CARBAMAZEPINES<br />

carbamazepine suspension oral, -<br />

tablet, -tablet chewable<br />

1<br />

carbamazepine xr 1<br />

CARBATROL carbamazepine 3<br />

epitol 1<br />

EQUETRO carbamazepine 3<br />

oxcarbazepine 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

TEGRETOL [G] carbamazepine 3<br />

TEGRETOL XR 100 MG TABLET carbamazepine 2<br />

TEGRETOL XR 200 MG TABLET, -<br />

400 MG TABLET [G]<br />

carbamazepine 3<br />

TRILEPTAL [G] oxcarbazepine 3<br />

CLASS II NARCOTICS<br />

ACTIQ [G] fentanyl citrate 4 [PAR][QLL,<br />

120/30]<br />

ALFENTA [INJ] alfentanil 3<br />

alfentanil hydrochloride [INJ] 1<br />

ASTRAMORPH-PF [INJ][G] morphine 3<br />

AVINZA morphine 3 [QLL,<br />

60/30][ST]<br />

codeine phosphate injection [INJ] 1<br />

codeine sulfate 1<br />

COMBUNOX oxycodone/ibuprofen 3<br />

DAZIDOX oxycodone 3<br />

DEMEROL [INJ] meperidine 3<br />

DILAUDID INJECTION [INJ] hydromorphone 3<br />

DILAUDID TABLET [G] hydromorphone 3<br />

DILAUDID-5 hydromorphone 3<br />

DILAUDID-HP [INJ][G] hydromorphone 3<br />

diskets 1<br />

DOLOPHINE HCL [G] methadone 3<br />

DURAGESIC [G] fentanyl 3<br />

DURAMORPH [INJ][G] morphine 3<br />

EMBEDA morphine sulfate/naltrexone 3 [QLL,<br />

90/30][ST]<br />

endocet 1<br />

endodan 1<br />

eth-oxydose 1<br />

EXALGO hydromorphone 3 [QLL,<br />

60/30][ST]<br />

fentanyl 1<br />

fentanyl citrate injection [INJ] 1<br />

fentanyl citrate loz 4 [PAR][QLL,<br />

120/30]<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

FENTORA fentanyl citrate 4 [PAR][QLL,<br />

112/28]<br />

hydromorphone hcl injection [INJ] 1<br />

hydromorphone hcl suppository<br />

1<br />

rectal, -tablet<br />

INFUMORPH [INJ] morphine 3<br />

KADIAN morphine 3 [QLL,<br />

90/30][ST]<br />

levorphanol tartrate tablet 1<br />

MAGNACET oxycodone/acetaminophen 3<br />

meperidine hcl injection [INJ] 1<br />

methadone hcl injection [INJ] 1<br />

methadone hcl solution, -tablet, -<br />

1<br />

tablet soluble<br />

methadone intensol 1<br />

methadose 1<br />

morphine sulfate in dextrose [INJ] 1<br />

morphine sulfate injection [INJ] 1<br />

morphine sulfate solution, -<br />

suppository rectal, -tablet<br />

1<br />

morphine sulfate tablet sustained<br />

1 [QLL,<br />

action<br />

120/30]<br />

MS CONTIN [G] morphine 3 [QLL,<br />

120/30][ST]<br />

NUCYNTA tapentadol hcl 3 [QLL,<br />

205/34]<br />

NUMORPHAN [INJ] oxymorphone 2<br />

ONSOLIS [LA] fentanyl citrate 4 [PAR][QLL,<br />

120/30]<br />

OPANA oxymorphone 3<br />

OPANA ER oxymorphone 2 [QLL,<br />

90/30][ST]<br />

OPIUM opium 3<br />

ORAMORPH SR morphine 3 [QLL,<br />

120/30][ST]<br />

oxycodone hcl 1<br />

oxycodone hcl-acetaminophen 1<br />

oxycodone hcl-ibuprofen 1<br />

oxycodone-acetaminophen 1<br />

oxycodone-aspirin 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

OXYCONTIN [G] oxycodone 2 [QLL,<br />

90/30][ST]<br />

PERCOCET [G] oxycodone/acetaminophen 3<br />

PERCODAN [G] oxycodone/aspirin 3<br />

PRIMALEV oxycodone/acetaminophen 3<br />

PRIMLEV oxycodone/acetaminophen 3<br />

ROXICET SOLUTION oxycodone/acetaminophen 3<br />

roxicet tablet 1<br />

ROXICODONE [G] oxycodone 3<br />

ROXICODONE INTENSOL oxycodone 3<br />

sublimaze [INJ] 1<br />

TYLOX oxycodone/acetaminophen 3<br />

XOLOX oxycodone/acetaminophen 3<br />

CLASS III NARCOTICS<br />

acetaminophen-codeine 1<br />

apap-caffeine-dihydrocodeine 1<br />

buprenorphine hcl tablet sublingual 1<br />

CAPITAL W-CODEINE codeine phosphate/apap 2<br />

co-gesic 1<br />

DOLOREX FORTE [INJ] hydrocodone bitartrate/apap 3<br />

HYCET hydrocodone bitartrate/apap 3<br />

hydrocodone bit-ibuprofen 1<br />

hydrocodone-acetaminophen 1<br />

hydrogesic 1<br />

IBUDONE hydrocodone bitartrate/ibuprof 3<br />

LORCET 10-650 [G] hydrocodone bitartrate/apap 3<br />

LORCET PLUS [G] hydrocodone bitartrate/apap 3<br />

LORTAB [G] hydrocodone bitartrate/apap 3<br />

margesic h 1<br />

MAXIDONE [G] hydrocodone bitartrate/apap 3<br />

NORCO [G] hydrocodone bitartrate/apap 3<br />

PANLOR DC dihydrocodeine/apap/caffeine 3<br />

PANLOR SS [G] dihydrocodeine/apap/caffeine 3<br />

reprexain 1<br />

stagesic 1<br />

SUBOXONE buprenorphine/naloxone 2 [QLL,<br />

102/34]<br />

SUBUTEX [G] buprenorphine 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

SYNALGOS-DC dihydrocodeine/asa/caffeine 3<br />

trezix 1<br />

TYLENOL-CODEINE NO.3 [G] codeine phosphate/apap 3<br />

TYLENOL-CODEINE NO.4 [G] codeine phosphate/apap 3<br />

VICODIN [G] hydrocodone bitartrate/apap 3<br />

VICODIN ES [G] hydrocodone bitartrate/apap 3<br />

VICODIN HP [G] hydrocodone bitartrate/apap 3<br />

VICOPROFEN [G] hydrocodone bitartrate/ibuprof 3<br />

VOPAC codeine phosphate/apap 3<br />

XODOL 10-300 hydrocodone bitartrate/apap 3<br />

XODOL 5-300 hydrocodone bitartrate/apap 3<br />

XODOL 7.5-300 hydrocodone bitartrate/apap 3<br />

zamicet 1<br />

ZERLOR [G] dihydrocodeine/apap/caffeine 3<br />

ZYDONE hydrocodone bitartrate/apap 3<br />

CNS STIMULANT DRUGS<br />

ADDERALL [G] amphetamine/dextroamphetamine 3<br />

ADDERALL XR amphetamine/dextroamphetamine 3<br />

amphetamine salt combo 1<br />

CAFCIT INJECTION [INJ] caffeine citrated 3<br />

caffeine citrate injection [INJ] 1<br />

CONCERTA methylphenidate 2<br />

DAYTRANA methylphenidate 3<br />

DESOXYN [G] methamphetamine 3<br />

DEXEDRINE [G] d-amphetamine 3<br />

dexmethylphenidate hcl 1<br />

dextroamphetamine sulfate 1<br />

dextroamphetamine-amphetamine 1<br />

FOCALIN [G] dexmethylphenidate 3<br />

FOCALIN XR dexmethylphenidate 3<br />

liquadd 1<br />

METADATE CD methylphenidate 2<br />

METADATE ER 10 MG TABLET SA methylphenidate 2<br />

metadate er 20 mg tablet 1<br />

methamphetamine hcl 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

METHYLIN 10 MG CHEWABLE<br />

TABLET, -2.5 MG CHEWABLE TAB, -<br />

5 MG CHEWABLE TABLET, -<br />

SOLUTION<br />

methylphenidate 3<br />

methylin 10 mg tablet, -20 mg<br />

tablet, -5 mg tablet<br />

1<br />

methylin er 1<br />

methylphenidate er 1<br />

methylphenidate hcl solution, -tablet 1<br />

methylphenidate sr 1<br />

NUVIGIL armodafinil 3 [PAR]<br />

PROCENTRA d-amphetamine 3<br />

PROVIGIL modafinil 2 [PAR]<br />

RITALIN [G] methylphenidate 3<br />

RITALIN LA methylphenidate 3<br />

RITALIN-SR [G] methylphenidate 3<br />

VYVANSE lisdexamfetamine dimesylate 3<br />

DRUGS TO PREVENT AND TREAT HEADACHES<br />

AMERGE [G] naratriptan 3 [QLL,<br />

18/28]<br />

ascomp with codeine 1<br />

AXERT 12.5 MG TABLET almotriptan 3 [QLL,<br />

24/28]<br />

AXERT 6.25 MG TABLET almotriptan 3 [QLL,<br />

18/28]<br />

butalbital compound-codeine 1<br />

butalbital-caff-apap-codeine 1<br />

butorphanol tartrate aerosol spray 1 [QLL, 5<br />

ml/3]<br />

CAFERGOT [G] ergotamine tartrate/caffeine 3<br />

D.H.E.45 [INJ][G] dihydroergotamine 4<br />

dihydroergotamine mesylate<br />

1<br />

injection [INJ]<br />

ERGOMAR ergotamine 3<br />

ergotamine-caffeine 1<br />

FIORICET WITH CODEINE [G] codeine/apap/caffeine/butalb 3<br />

FIORINAL WITH CODEINE #3 [G] codeine/asa/caffeine/butalb 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

FROVA frovatriptan 2 [QLL,<br />

27/28]<br />

IMITREX 20 MG NASAL SPRAY sumatriptan 3 [QLL, 18<br />

nasal<br />

sprayers/28]<br />

IMITREX 4 MG/0.5 ML SYRNG KIT, - sumatriptan 3 [QLL, 8/28]<br />

6 MG/0.5 ML SYRNG KIT [INJ]<br />

IMITREX 5 MG NASAL SPRAY sumatriptan 3 [QLL, 36<br />

nasal<br />

IMITREX 6 MG/0.5 ML VIAL, -4<br />

MG/0.5 ML KIT REFILL, -6 MG/0.5<br />

ML KIT REFILL [INJ][G]<br />

sprayers/28]<br />

sumatriptan 3 [QLL, 8<br />

vials/28]<br />

IMITREX TABLET [G] sumatriptan 3 [QLL,<br />

18/28]<br />

MAXALT rizatriptan benzoate 2 [QLL,<br />

27/28]<br />

MAXALT MLT rizatriptan benzoate 2 [QLL,<br />

27/28]<br />

migergot 1<br />

MIGRANAL dihydroergotamine 2 [QLL, 16<br />

mg/28]<br />

naratriptan hcl 1 [QLL,<br />

18/28]<br />

RELPAX eletriptan 3 [QLL,<br />

18/28]<br />

SUMATRIPTAN 20 MG NASAL SPRAY sumatriptan 3 [QLL,<br />

sumatriptan 4 mg/0.5 ml kit, -4<br />

mg/0.5 ml refill, -4 mg/0.5 ml syrng,<br />

-6 mg/0.5 ml kit, -6 mg/0.5 ml refill,<br />

-6 mg/0.5 ml syrng [INJ]<br />

sumatriptan 4 mg/0.5 ml vial, -6<br />

mg/0.5 ml vial [INJ]<br />

18/28]<br />

1 [QLL, 8/28]<br />

1 [QLL, 8<br />

ml/28]<br />

SUMATRIPTAN 5 MG NASAL SPRAY sumatriptan 3 [QLL,<br />

36/28]<br />

sumatriptan succinate tablet 1 [QLL,<br />

18/28]<br />

TREXIMET sumatriptan suc/naproxen sod 3 [QLL,<br />

18/28]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ZOMIG SPRAY NON-AEROSOL zolmitriptan 2 [QLL, 18<br />

nasal<br />

sprayers/28]<br />

ZOMIG TABLET zolmitriptan 3 [QLL,<br />

18/28]<br />

ZOMIG ZMT zolmitriptan 3 [QLL,<br />

18/28]<br />

HYDANTOINS<br />

CEREBYX [INJ] fosphenytoin 3<br />

DILANTIN 100 MG CAPSULE [G] phenytoin sodium 3<br />

DILANTIN 30 MG CAPSULE, -30 MG<br />

KAPSEAL, -TABLET CHEWABLE<br />

phenytoin 2<br />

DILANTIN-125 [G] phenytoin sodium 3<br />

fosphenytoin sodium [INJ] 1<br />

PEGANONE ethotoin 2<br />

PHENYTEK [G] phenytoin sodium 3<br />

phenytoin sodium extended 1<br />

phenytoin sodium injection [INJ] 1<br />

phenytoin suspension oral 1<br />

MAO INHIBITORS<br />

EMSAM selegiline 2<br />

MARPLAN isocarboxazid 2<br />

NARDIL phenelzine 2<br />

PARNATE tranylcypromine 3<br />

tranylcypromine sulfate 1<br />

OTHER ANTICONVULSANTS<br />

BANZEL 200 MG TABLET rufinamide 2<br />

BANZEL 400 MG TABLET rufinamide 4<br />

FELBATOL felbamate 2<br />

gabapentin capsule, -tablet 1<br />

GABITRIL tiagabine 2<br />

KEPPRA INJECTION [INJ][G] levetiracetam 2<br />

KEPPRA SOLUTION, -TABLET [G] levetiracetam 3 [ST]<br />

KEPPRA XR levetiracetam 3 [ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

LAMICTAL [G] lamotrigine 3 [ST]<br />

LAMICTAL (BLUE) lamotrigine 3 [ST]<br />

LAMICTAL (GREEN) [G] lamotrigine 3 [ST]<br />

LAMICTAL (ORANGE) [G] lamotrigine 3 [ST]<br />

LAMICTAL ODT lamotrigine 3 [ST]<br />

LAMICTAL ODT (BLUE) lamotrigine 3 [ST]<br />

LAMICTAL ODT (GREEN) lamotrigine 3 [ST]<br />

LAMICTAL ODT (ORANGE) lamotrigine 3 [ST]<br />

LAMICTAL XR lamotrigine 3 [ST]<br />

LAMICTAL XR (BLUE) lamotrigine 3 [ST]<br />

LAMICTAL XR (GREEN) lamotrigine 3 [ST]<br />

LAMICTAL XR (ORANGE) lamotrigine 3 [ST]<br />

lamotrigine 1<br />

levetiracetam injection [INJ] 1<br />

levetiracetam solution, -tablet 1<br />

LYRICA pregabalin 2 [ST]<br />

MYSOLINE [G] primidone 3<br />

NEURONTIN CAPSULE, -TABLET [G] gabapentin 3<br />

NEURONTIN SOLUTION gabapentin 2<br />

primidone 1<br />

SABRIL [LA] vigabatrin 4<br />

TOPAMAX [G] topiramate 3 [PAR]<br />

topiragen 1 [PAR]<br />

topiramate capsule sprinkle, -tablet 1 [PAR]<br />

VIMPAT INJECTION [INJ] lacosamide 2<br />

VIMPAT SOLUTION, -TABLET lacosamide 2<br />

ZONEGRAN [G] zonisamide 3 [PAR]<br />

zonisamide 1 [PAR]<br />

OTHER ANTIDEPRESSANTS<br />

amitriptyline-chlordiazepoxide 1<br />

APLENZIN bupropion hbr 3 [QLL,<br />

34/34][ST]<br />

budeprion sr 1 [QLL,<br />

68/34]<br />

budeprion xl 1 [QLL,<br />

34/34]<br />

bupropion hcl 1<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

bupropion hcl sr 100 mg tab, -100<br />

1 [QLL,<br />

mg tablet, -200 mg tab<br />

68/34]<br />

bupropion sr 150 mg tablet 1<br />

bupropion xl 1 [QLL,<br />

34/34]<br />

CYMBALTA 20 MG CAPSULE, -60 MG duloxetine 2 [QLL,<br />

CAPSULE<br />

68/34][ST]<br />

CYMBALTA 30 MG CAPSULE duloxetine 2 [QLL,<br />

34/34][ST]<br />

EFFEXOR venlafaxine 3 [QLL,<br />

102/34][ST]<br />

EFFEXOR XR 150 MG CAPSULE, - venlafaxine 2 [QLL,<br />

37.5 MG CAPSULE [G]<br />

34/34][ST]<br />

EFFEXOR XR 75 MG CAPSULE [G] venlafaxine 2 [QLL,<br />

102/34][ST]<br />

LIMBITROL amitriptyline/chlordiazepoxide 3<br />

maprotiline hcl 1<br />

mirtazapine 1<br />

nefazodone hcl 1<br />

OLEPTRO ER trazodone 3<br />

perphenazine-amitriptyline 1<br />

PRISTIQ desvenlafaxine succinate 2 [QLL,<br />

34/34][ST]<br />

REMERON [G] mirtazapine 3<br />

SAVELLA 100 MG TABLET, -12.5 MG milnacipran hcl 2 [QLL,<br />

TABLET, -25 MG TABLET, -50 MG<br />

TABLET<br />

68/34][ST]<br />

SAVELLA TITRATION PACK milnacipran hcl 2 [QLL,<br />

1/34][ST]<br />

trazodone hcl tablet 1<br />

venlafaxine hcl 1 [QLL,<br />

102/34]<br />

venlafaxine hcl er capsule sustained<br />

1 [QLL,<br />

release 24 hr<br />

34/34]<br />

VENLAFAXINE HCL ER TAB SA venlafaxine 3 [QLL,<br />

34/34][ST]<br />

WELLBUTRIN bupropion 3<br />

WELLBUTRIN SR [G] bupropion 3 [QLL,<br />

68/34][ST]<br />

WELLBUTRIN XL [G] bupropion 3 [QLL,<br />

34/34][ST]<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

OTHER ANTIPARKINSON DRUGS<br />

APOKYN [INJ][LA] apomorphine hcl 4<br />

AZILECT rasagiline mesylate 2<br />

bromocriptine mesylate capsule, -<br />

tablet<br />

1<br />

carbidopa-levodopa 1<br />

COMTAN entacapone 2<br />

ELDEPRYL selegiline 3<br />

LODOSYN carbidopa 2<br />

MIRAPEX [G] pramipexole 3<br />

MIRAPEX ER pramipexole 3<br />

PARCOPA [G] carbidopa/levodopa 3<br />

PARLODEL [G] bromocriptine mesylate 3<br />

pramipexole dihydrochloride 1<br />

REQUIP [G] ropinirole 3<br />

REQUIP XL ropinirole 2<br />

ropinirole hcl 1<br />

selegiline hcl capsule, -tablet 1<br />

SINEMET 10-100 [G] carbidopa/levodopa 3<br />

SINEMET 25-100 [G] carbidopa/levodopa 3<br />

SINEMET 25-250 [G] carbidopa/levodopa 3<br />

SINEMET CR [G] carbidopa/levodopa 3<br />

STALEVO 100 carbidopa/levodopa/entacap 2<br />

STALEVO 125 carbidopa/levodopa/entacap 2<br />

STALEVO 150 carbidopa/levodopa/entacap 2<br />

STALEVO 200 carbidopa/levodopa/entacap 2<br />

STALEVO 50 carbidopa/levodopa/entacap 2<br />

STALEVO 75 carbidopa/levodopa/entacap 2<br />

TASMAR tolcapone 2<br />

ZELAPAR selegiline 3<br />

OTHER CNS/AUTONOMIC DRUGS<br />

ANTABUSE disulfiram 2<br />

atropine sulfate injection [INJ] 1<br />

CAMPRAL acamprosate calcium 3<br />

depade 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ENLON [INJ] edrophonium 2<br />

ENLON-PLUS [INJ] edrophonium/atropine sulfate 2<br />

flumazenil [INJ] 1<br />

guanidine hcl 1<br />

INTUNIV guanfacine 3 [ST]<br />

MESTINON SYRUP, -TABLET pyridostigmine 2<br />

SUSTAINED ACTION<br />

MESTINON TABLET [G] pyridostigmine 3<br />

MYTELASE ambenonium chloride 3<br />

naloxone hcl injection [INJ] 1<br />

naltrexone hcl tablet 1<br />

neostigmine methylsulfate [INJ] 1<br />

physostigmine salicylate injection<br />

1<br />

[INJ]<br />

PROSTIGMIN neostigmine bromide 2<br />

pyridostigmine bromide 1<br />

REGONOL [INJ] pyridostigmine 3<br />

REVIA [G] naltrexone 3<br />

ROMAZICON [INJ] flumazenil 3<br />

STRATTERA atomoxetine 2 [ST]<br />

VIVITROL [INJ] naltrexone microspheres 4<br />

XENAZINE [LA] tetrabenazine 4 [PAR]<br />

XYREM [LA] sodium oxybate 4<br />

SECONDARY AMINES<br />

amoxapine 1<br />

desipramine hcl 1<br />

NORPRAMIN [G] desipramine 3<br />

nortriptyline hcl capsule, -solution 1<br />

PAMELOR [G] nortriptyline 3<br />

protriptyline hcl 1<br />

VIVACTIL [G] protriptyline 3<br />

SEDATIVE/HYPNOTIC DRUGS<br />

AMBIEN [G] zolpidem 3 [QLL,<br />

34/34][ST]<br />

AMBIEN CR zolpidem 2 [QLL,<br />

34/34][ST]<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

EDLUAR zolpidem 3 [QLL,<br />

34/34][ST]<br />

LUNESTA eszopiclone 2 [QLL,<br />

34/34][ST]<br />

ROZEREM ramelteon 2 [QLL,<br />

34/34][ST]<br />

SONATA 10 MG CAPSULE [G] zaleplon 3 [QLL,<br />

68/34][ST]<br />

SONATA 5 MG CAPSULE [G] zaleplon 3 [QLL,<br />

34/34][ST]<br />

zaleplon 10 mg capsule 1 [QLL,<br />

68/34]<br />

zaleplon 5 mg capsule 1 [QLL,<br />

34/34]<br />

zolpidem tartrate 1 [QLL,<br />

34/34]<br />

SELECTIVE SEROTONIN REUPTAKE INHIBITORS<br />

CELEXA SOLUTION citalopram 3 [ST]<br />

CELEXA TABLET [G] citalopram 3 [QLL,<br />

34/34][ST]<br />

citalopram 1<br />

citalopram hbr 1 [QLL,<br />

34/34]<br />

fluoxetine dr 1 [QLL, 5/34]<br />

fluoxetine hcl 10 mg capsule, -10<br />

1 [QLL,<br />

mg tablet<br />

34/34]<br />

fluoxetine hcl 20 mg capsule, -20<br />

1<br />

mg tablet, -solution<br />

fluoxetine hcl 40 mg capsule 1 [QLL,<br />

68/34]<br />

fluvoxamine maleate 100 mg tab 1 [QLL,<br />

102/34]<br />

fluvoxamine maleate 25 mg tab 1 [QLL,<br />

34/34]<br />

fluvoxamine maleate 50 mg tab 1 [QLL,<br />

68/34]<br />

LEXAPRO SOLUTION escitalopram oxalate 2 [ST]<br />

LEXAPRO TABLET escitalopram oxalate 2 [QLL,<br />

34/34][ST]<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

LUVOX CR fluvoxamine 3 [QLL,<br />

68/34][ST]<br />

paroxetine hcl 10 mg tablet, -40 mg<br />

1 [QLL,<br />

tablet<br />

34/34]<br />

paroxetine hcl 20 mg tablet, -30 mg<br />

1 [QLL,<br />

tablet, -tablet sustained release 24hr<br />

68/34]<br />

paroxetine hcl suspension oral 1<br />

PAXIL 10 MG TABLET, -40 MG paroxetine 3 [QLL,<br />

TABLET [G]<br />

34/34][ST]<br />

PAXIL 20 MG TABLET, -30 MG paroxetine 3 [QLL,<br />

TABLET [G]<br />

68/34][ST]<br />

PAXIL CR [G] paroxetine 3 [QLL,<br />

68/34][ST]<br />

PAXIL SUSPENSION ORAL [G] paroxetine 3 [ST]<br />

PEXEVA 10 MG TABLET, -40 MG paroxetine mesylate 3 [QLL,<br />

TABLET<br />

34/34][ST]<br />

PEXEVA 20 MG TABLET, -30 MG paroxetine mesylate 3 [QLL,<br />

TABLET<br />

68/34][ST]<br />

PROZAC 10 MG PULVULE [G] fluoxetine 3 [QLL,<br />

34/34][ST]<br />

PROZAC 20 MG PULVULE, -<br />

SOLUTION [G]<br />

fluoxetine 3 [ST]<br />

PROZAC 40 MG PULVULE [G] fluoxetine 3 [QLL,<br />

68/34][ST]<br />

PROZAC WEEKLY [G] fluoxetine 3 [QLL,<br />

5/34][ST]<br />

rapiflux 20 mg tablet 1<br />

SARAFEM 10 MG TABLET fluoxetine 3 [QLL,<br />

35/14][ST]<br />

SARAFEM 15 MG TABLET fluoxetine 3 [ST]<br />

SARAFEM 20 MG TABLET fluoxetine 3 [QLL,<br />

140/14][ST]<br />

selfemra 10 mg capsule 1 [QLL,<br />

35/14]<br />

selfemra 20 mg capsule 1 [QLL,<br />

140/14]<br />

sertraline hcl 100 mg tablet, -50 mg<br />

1 [QLL,<br />

tablet<br />

68/34]<br />

sertraline hcl 25 mg tablet 1 [QLL,<br />

34/34]<br />

sertraline hcl solution 1<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ZOLOFT 100 MG TABLET, -50 MG sertraline 3 [QLL,<br />

TABLET [G]<br />

68/34][ST]<br />

ZOLOFT 25 MG TABLET [G] sertraline 3 [QLL,<br />

34/34][ST]<br />

ZOLOFT SOLUTION [G] sertraline 3 [ST]<br />

SMOKING CESSATION PRODUCTS<br />

buproban 1<br />

CHANTIX varenicline tartrate 2<br />

NICOTROL nicotine inhaler 2<br />

NICOTROL NS nicotine ns 2<br />

ZYBAN [G] bupropion 3<br />

SUCCINIMIDES<br />

CELONTIN methsuximide 2<br />

ethosuximide 1<br />

ZARONTIN [G] ethosuximide 3<br />

TERTIARY AMINES<br />

amitriptyline hcl tablet 1<br />

ANAFRANIL [G] clomipramine 3<br />

clomipramine hcl capsule 1<br />

doxepin hcl capsule, -solution 1<br />

imipramine hcl tablet 1<br />

imipramine pamoate 1<br />

SURMONTIL trimipramine 2<br />

TOFRANIL [G] imipramine hcl 3<br />

TOFRANIL-PM [G] imipramine pamoate 3<br />

trimipramine maleate 1<br />

VALPROIC ACID AND DERIVATIVES<br />

DEPACON [INJ][G] valproate sodium 3<br />

DEPAKENE [G] valproic acid 3 [ST]<br />

DEPAKOTE [G] divalproex 3 [ST]<br />

DEPAKOTE ER [G] divalproex 3 [ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

DEPAKOTE SPRINKLE [G] divalproex 3 [ST]<br />

divalproex sodium 1<br />

divalproex sodium er 1<br />

STAVZOR valproic acid 3 [ST]<br />

valproate sodium injection [INJ] 1<br />

valproic acid capsule, -syrup 1<br />

CARDIOVASCULAR MEDICATIONS<br />

AMIODARONES<br />

amiodarone hcl injection [INJ] 1<br />

amiodarone hcl tablet 1<br />

CORDARONE [G] amiodarone 3<br />

PACERONE 100 MG TABLET, -400<br />

MG TABLET [G]<br />

amiodarone 3<br />

pacerone 200 mg tablet 1<br />

ANGIOTENSIN CONVERTING ENZYME INHIBITORS<br />

ACCUPRIL [G] quinapril 3 [ST]<br />

ACEON [G] perindopril erbumine 3 [ST]<br />

ALTACE [G] ramipril 3 [ST]<br />

benazepril hcl 1<br />

CAPOTEN captopril 3 [ST]<br />

captopril tablet 1<br />

enalapril maleate tablet 1<br />

enalaprilat [INJ] 1<br />

fosinopril sodium 1<br />

lisinopril tablet 1<br />

LOTENSIN [G] benazepril 3 [ST]<br />

MAVIK [G] trandolapril 3 [ST]<br />

moexipril hcl 1<br />

MONOPRIL fosinopril 3 [ST]<br />

perindopril erbumine 1<br />

PRINIVIL [G] lisinopril 3 [ST]<br />

quinapril hcl 1<br />

ramipril 1<br />

trandolapril 1<br />

UNIVASC [G] moexipril 3 [ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

VASOTEC [G] enalapril 3 [ST]<br />

ZESTRIL [G] lisinopril 3 [ST]<br />

ANGIOTENSIN II RECEPTOR ANTAGONISTS<br />

ATACAND candesartan cilexetil 3 [ST]<br />

AVAPRO irbesartan 3 [ST]<br />

BENICAR olmesartan medoxomil 2 [ST]<br />

COZAAR [G] losartan 3 [ST]<br />

DIOVAN valsartan 2 [ST]<br />

losartan potassium 1 [ST]<br />

MICARDIS telmisartan 3 [ST]<br />

TEVETEN eprosartan mesylate 3 [ST]<br />

ANTIDYSRHYTHMIC DRUGS<br />

flecainide acetate 1<br />

mexiletine hcl capsule 1<br />

procainamide hcl injection [INJ] 1<br />

PRONESTYL procainamide 3<br />

propafenone hcl 1<br />

quinidine gluconate injection [INJ] 1<br />

quinidine gluconate tablet sustained<br />

action<br />

1<br />

quinidine sulfate tablet, -tablet<br />

1<br />

sustained action<br />

RYTHMOL [G] propafenone 3<br />

RYTHMOL SR propafenone 2<br />

TAMBOCOR [G] flecainide 3<br />

BETA-ADRENERGIC ANTAGONIST DRUGS<br />

acebutolol hcl capsule 1<br />

atenolol tablet 1<br />

betaxolol hcl tablet 1<br />

bisoprolol fumarate 1<br />

BYSTOLIC nebivolol hcl 2<br />

carvedilol 1<br />

COREG [G] carvedilol 3<br />

COREG CR carvedilol 2<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

CORGARD [G] nadolol 3<br />

INDERAL LA [G] propranolol 3<br />

INNOPRAN XL propranolol 3<br />

KERLONE [G] betaxolol 3<br />

labetalol hcl injection [INJ] 1<br />

labetalol hcl tablet 1<br />

LEVATOL penbutolol 3<br />

LOPRESSOR INJECTION [INJ][G] metoprolol tartrate 3<br />

LOPRESSOR TABLET [G] metoprolol tartrate 3<br />

metoprolol succinate 1<br />

metoprolol tartrate injection [INJ] 1<br />

metoprolol tartrate tablet 1<br />

nadolol 1<br />

pindolol 1<br />

propranolol hcl cap sa, -solution, -<br />

1<br />

tablet<br />

propranolol hcl injection [INJ] 1<br />

SECTRAL [G] acebutolol 3<br />

TENORMIN [G] atenolol 3<br />

timolol maleate tablet 1<br />

TOPROL XL [G] metoprolol succinate 3<br />

TRANDATE [G] labetalol 3<br />

ZEBETA [G] bisoprolol 3<br />

CALCIUM ANTAGONISTS<br />

ADALAT CC [G] nifedipine 3 [ST]<br />

afeditab cr 1<br />

amlodipine besylate 1<br />

CALAN [G] verapamil 3 [ST]<br />

CALAN SR [G] verapamil 3 [ST]<br />

CARDIZEM [G] diltiazem 3<br />

CARDIZEM CD [G] diltiazem 3<br />

CARDIZEM LA diltiazem 3<br />

cartia xt 1<br />

COVERA-HS verapamil 3 [ST]<br />

DILACOR XR [G] diltiazem 3<br />

dilt-cd 1<br />

diltia xt 1<br />

diltiazem 24hr er 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

diltiazem er 1<br />

diltiazem hcl injection [INJ] 1<br />

diltiazem hcl tablet 1<br />

dilt-xr 1<br />

diltzac er 1<br />

DYNACIRC CR isradipine 3 [ST]<br />

felodipine er 1<br />

ISOPTIN SR [G] verapamil 3 [ST]<br />

isradipine 1<br />

nicardipine hcl capsule 1<br />

nicardipine hcl injection [INJ] 1<br />

nifediac cc 1<br />

nifedical xl 1<br />

nifedipine capsule 1<br />

nifedipine er 1<br />

nimodipine 4<br />

NIMOTOP [INJ] nimodipine 3<br />

NISOLDIPINE ER 17 MG TABLET, -<br />

ER 25.5 MG TABLET, -ER 34 MG<br />

TABLET, -ER 8.5 MG TABLET<br />

nisoldipine 3 [ST]<br />

nisoldipine er 20 mg tablet, -er 30<br />

1<br />

mg tablet, -er 40 mg tablet<br />

NORVASC [G] amlodipine 3 [ST]<br />

PROCARDIA [G] nifedipine 3 [ST]<br />

PROCARDIA XL [G] nifedipine 3 [ST]<br />

SULAR nisoldipine 3 [ST]<br />

taztia xt 1<br />

TIAZAC [G] diltiazem 3<br />

verapamil 360 mg cap pellet 1<br />

verapamil er 1<br />

verapamil hcl capsule 24hr sustained<br />

release pellets, -er 120 mg capsule,<br />

-er 180 mg capsule, -er 240 mg<br />

capsule, -tablet, -tablet sustained<br />

1<br />

action<br />

verapamil hcl injection [INJ] 1<br />

VERELAN [G] verapamil 3 [ST]<br />

VERELAN PM [G] verapamil 3 [ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

CARDIAC GLYCOSIDES<br />

digoxin injection [INJ] 1<br />

digoxin solution, -tablet 1<br />

LANOXIN INJECTION [INJ][G] digoxin 3<br />

LANOXIN PEDIATRIC [INJ] digoxin 2<br />

LANOXIN TABLET [G] digoxin 3<br />

milrinone in 5% dextrose [INJ] 1<br />

milrinone lactate [INJ] 1<br />

CENTRALLY ACTING ANTIHYPERTENSIVES<br />

CATAPRES [G] clonidine 3<br />

CATAPRES-TTS 1 [G] clonidine 3 [QLL, 5/35]<br />

CATAPRES-TTS 2 [G] clonidine 3 [QLL, 5/35]<br />

CATAPRES-TTS 3 [G] clonidine 3 [QLL, 5/35]<br />

clonidine 1 [QLL, 5/35]<br />

clonidine hcl injection [INJ] 1<br />

clonidine hcl tablet 1<br />

DURACLON [INJ] clonidine 2<br />

guanabenz acetate 1<br />

guanfacine hcl 1<br />

methyldopa 1<br />

methyldopate hcl [INJ] 1<br />

TENEX [G] guanfacine 3<br />

DRUGS FOR PHEOCHROMOCYTOMA<br />

DEMSER metyrosine 2<br />

DIBENZYLINE phenoxybenzamine 2<br />

PHENTOLAMINE MESYLATE<br />

INJECTION [INJ]<br />

phentolamine 2<br />

ENDOTHELIN RECPTR ANTAGONIST<br />

LETAIRIS [LA] ambrisentan 4 [PAR]<br />

TRACLEER [LA] bosentan 4 [PAR]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

HMG-COA REDUCTASE INHIBITORS<br />

ADVICOR 1,000 MG-20 MG TABLET,<br />

-1,000 MG-40 MG TABLET, -750 MG-<br />

20 MG TABLET<br />

lovastatin/niacin 2 [QLL,<br />

68/34]<br />

ADVICOR 500 MG-20 MG TABLET lovastatin/niacin 2 [QLL,<br />

34/34]<br />

ALTOPREV lovastatin 3 [QLL,<br />

34/34][ST]<br />

CADUET amlodipine/atorvast cal 3 [QLL,<br />

34/34][ST]<br />

CRESTOR 10 MG TABLET, -20 MG rosuvastatin calcium 2 [QLL,<br />

TABLET, -40 MG TABLET<br />

34/34]<br />

CRESTOR 5 MG TABLET rosuvastatin calcium 2 [QLL,<br />

34/34][ST]<br />

LESCOL 20 MG CAPSULE fluvastatin 3 [QLL,<br />

34/34][ST]<br />

LESCOL 40 MG CAPSULE fluvastatin 3 [QLL,<br />

68/34][ST]<br />

LESCOL XL fluvastatin 3 [QLL,<br />

34/34][ST]<br />

LIPITOR atorvastatin calcium 2 [QLL,<br />

34/34][ST]<br />

LIVALO pitavastatin calcium 3 [QLL,<br />

34/34][ST]<br />

lovastatin 10 mg tablet 1 [QLL,<br />

34/34]<br />

lovastatin 20 mg tablet, -40 mg<br />

1 [QLL,<br />

tablet<br />

68/34]<br />

MEVACOR [G] lovastatin 3 [QLL,<br />

68/34][ST]<br />

PRAVACHOL [G] pravastatin 3 [QLL,<br />

34/34][ST]<br />

pravastatin sodium 1 [QLL,<br />

34/34]<br />

SIMCOR 1,000-20 MG TABLET, - niacin/simvastatin 2 [QLL,<br />

750-20 MG TABLET<br />

68/34]<br />

SIMCOR 500-20 MG TABLET niacin/simvastatin 2 [QLL,<br />

34/34]<br />

simvastatin tablet 1 [QLL,<br />

34/34]<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

VYTORIN 10-10 MG TABLET ezetimibe/simvastatin 2 [QLL,<br />

34/34][ST]<br />

VYTORIN 10-20 MG TABLET, -10-40 ezetimibe/simvastatin 2 [QLL,<br />

MG TABLET, -10-80 MG TABLET<br />

34/34]<br />

ZOCOR [G] simvastatin 3 [QLL,<br />

34/34][ST]<br />

HYPOLIPOPROTEINEMICS<br />

ANTARA fenofibrate 3 [ST]<br />

cholestyramine 1<br />

cholestyramine light 1<br />

COLESTID [G] colestipol 3<br />

colestipol hcl 1<br />

fenofibrate 1<br />

FENOFIBRIC ACID fenofibric acid 3 [ST]<br />

FENOGLIDE fenofibrate 3 [ST]<br />

FIBRICOR fenofibric acid 3 [ST]<br />

gemfibrozil 1<br />

LIPOFEN fenofibrate 3 [ST]<br />

LOFIBRA [G] fenofibrate 3 [ST]<br />

LOPID [G] gemfibrozil 3<br />

LOVAZA omega-3 acid ethyl esters 2<br />

NIACOR niacin 3<br />

NIASPAN niacin 2<br />

prevalite 1<br />

QUESTRAN [G] cholestyramine/sucrose 3<br />

QUESTRAN LIGHT [G] cholestyramine/aspartame 3<br />

TRICOR fenofibrate 2 [ST]<br />

TRIGLIDE fenofibrate 3 [ST]<br />

TRILIPIX fenofibric acid 2 [ST]<br />

WELCHOL colesevelam 2 [ST]<br />

ZETIA ezetimibe 2 [ST]<br />

LOOP DIURETICS<br />

bumetanide injection [INJ] 1<br />

bumetanide tablet 1<br />

DEMADEX [G] torsemide 3<br />

EDECRIN ethacrynic acid 3<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

furosemide injection [INJ] 1<br />

furosemide solution, -tablet 1<br />

LASIX [G] furosemide 3<br />

SODIUM EDECRIN [INJ] ethacrynate sodium 3<br />

torsemide injection [INJ] 1<br />

torsemide tablet 1<br />

NITRATES<br />

DILATRATE-SR isosorbide dinitrate 2<br />

IMDUR [G] isosorbide mononitrate 3<br />

ISMO [G] isosorbide mononitrate 3<br />

ISOCHRON [G] isosorbide dinitrate 3<br />

ISORDIL isosorbide dinitrate 3<br />

ISORDIL TITRADOSE [G] isosorbide dinitrate 3<br />

isosorbide dinitrate 1<br />

isosorbide mononitrate 1<br />

MINITRAN [G] nitroglycerin 3<br />

MONOKET [G] isosorbide mononitrate 3<br />

nitro-bid 1<br />

NITRO-DUR [G] nitroglycerin 3<br />

nitroglycerin in d5w [INJ] 1<br />

nitroglycerin injection [INJ] 1<br />

nitroglycerin patch 1<br />

nitroglycerin tablet sublingual 1<br />

NITROLINGUAL nitroglycerin 2<br />

NITROMIST nitroglycerin 3<br />

nitroquick 1<br />

NITROSTAT nitroglycerin 2<br />

OTHER ANTIARRHYTHMICS<br />

BETAPACE [G] sotalol 3<br />

BETAPACE AF [G] sotalol 3<br />

CORVERT [INJ] ibutilide fumarate 2<br />

ibutilide fumarate [INJ] 1<br />

lidocaine hcl 10% vial [INJ] 1<br />

MULTAQ dronedarone 3<br />

sorine 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

sotalol 1<br />

sotalol af 1<br />

SOTALOL HCL [INJ] sotalol 3<br />

TIKOSYN dofetilide 2<br />

OTHER ANTIHYPERTENSIVES<br />

ACCURETIC [G] quinapril/hctz 3 [ST]<br />

amlodipine besylate-benazepril 1<br />

ATACAND HCT candesartan cilexetil/hctz 3 [ST]<br />

atenolol-chlorthalidone 1<br />

AVALIDE irbesartan/hctz 3 [ST]<br />

AZOR amlodipine bes/olmesartan med 2 [ST]<br />

benazepril hcl-hctz 1<br />

benazepril-hydrochlorothiazide 1<br />

BENICAR HCT olmesartan medoxomil/hctz 2 [ST]<br />

bisoprolol fumarate-hctz 1<br />

bisoprolol-hydrochlorothiazide 1<br />

captopril-hydrochlorothiazide 1<br />

CLORPRES clonidine hcl/chlorthalidone 2<br />

CORLOPAM [INJ] fenoldopam mesylate 3<br />

CORZIDE [G] bendroflumethiazide/nadolol 3<br />

DIOVAN HCT hctz/valsartan 2 [ST]<br />

enalapril-hydrochlorothiazide 1<br />

EXFORGE amlodipine/valsartan 2 [ST]<br />

EXFORGE HCT amlodipine/valsartan/hctz 2 [ST]<br />

fosinopril-hydrochlorothiazide 1<br />

hydra-zide 1<br />

HYZAAR [G] losartan /hctz 3 [ST]<br />

lisinopril-hctz 1<br />

lisinopril-hydrochlorothiazide 1<br />

LOPRESSOR HCT [G] hctz/metoprolol 3<br />

losartan-hydrochlorothiazide 1 [ST]<br />

LOTENSIN HCT [G] benazepril/hctz 3 [ST]<br />

LOTREL [G] benazepril/amlodipine besylate 3 [ST]<br />

methyldopa-hydrochlorothiazide 1<br />

metoprolol-hydrochlorothiazide 1<br />

MICARDIS HCT telmisartan/hctz 3 [ST]<br />

moexipril-hydrochlorothiazide 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

nadolol-bendroflumethiazide 1<br />

PRINZIDE [G] lisinopril/hctz 3 [ST]<br />

propranolol-hydrochlorothiazid 1<br />

quinapril-hydrochlorothiazide 1<br />

quinaretic 1<br />

reserpine 1<br />

TARKA [G] trandolapril/verapamil 3 [ST]<br />

TEKTURNA aliskiren hemifumarate 2 [ST]<br />

TEKTURNA HCT aliskiren/hydrochlorothiazid 2 [ST]<br />

TENORETIC 100 [G] chlorthalidone/atenolol 3<br />

TENORETIC 50 [G] chlorthalidone/atenolol 3<br />

TEVETEN HCT eprosartan mesylate/hctz 3 [ST]<br />

trandolapril-verapamil 1<br />

TRIBENZOR olmesartan med/amlodipine/hct 3 [ST]<br />

TWYNSTA telmisartan/amlodipine 3 [ST]<br />

UNIRETIC [G] moexipril/hctz 3 [ST]<br />

VALTURNA aliskiren/valsartan 3 [ST]<br />

VASERETIC [G] enalapril maleate/hctz 3 [ST]<br />

ZESTORETIC [G] lisinopril/hctz 3 [ST]<br />

ZIAC [G] hctz/bisoprolol fumarate 3<br />

OTHER CARDIOVASCULAR DRUGS<br />

alprostadil injection [INJ] 1<br />

dobutamine hcl [INJ] 1<br />

dobutamine hcl in dextrose [INJ] 1<br />

dopamine hcl [INJ] 1<br />

dopamine hcl in 5% dextrose [INJ] 1<br />

isoproterenol hcl [INJ] 1<br />

ISUPREL [INJ] isoproterenol hcl 3<br />

midodrine hcl 1<br />

norepinephrine bitartrate [INJ] 1<br />

pentopak 1<br />

pentoxifylline tablet sustained action 1<br />

pentoxil 1<br />

PROAMATINE [G] midodrine 3<br />

PROSTIN VR PEDIATRIC [INJ] alprostadil 3<br />

RANEXA ranolazine 2<br />

TRENTAL [G] pentoxifylline 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

OTHER VASODILATING DRUGS<br />

Drug Generic Tier Restrictions<br />

ADCIRCA adcirca (tadalafil) 4 [PAR][QLL,<br />

68/34]<br />

BIDIL isosorb dinit/hydralazine hcl 3<br />

epoprostenol sodium [INJ] 1<br />

FLOLAN [INJ] epoprostenol na 3<br />

NATRECOR [INJ] nesiritide 3<br />

REMODULIN [INJ][LA] treprostinil sodium 4<br />

REVATIO INJECTION [INJ] revatio (sildenafil citrate) 4<br />

REVATIO TABLET revatio (sildenafil citrate) 4 [PAR][QLL,<br />

102/34]<br />

POTASSIUM SPARING DIURETICS<br />

ALDACTAZIDE [G] spironolactone/hctz 3<br />

ALDACTONE [G] spironolactone 3<br />

amiloride hcl tablet 1<br />

amiloride-hydrochlorothiazide 1<br />

DYAZIDE [G] hctz/triamterene 3<br />

DYRENIUM triamterene 3<br />

eplerenone 1<br />

INSPRA [G] eplerenone 3<br />

MAXZIDE [G] hctz/triamterene 3<br />

MAXZIDE-25 MG [G] hctz/triamterene 3<br />

MIDAMOR amiloride hydrochloride 3<br />

spironolactone tablet 1<br />

spironolactone-hctz 1<br />

triamterene-hctz 1<br />

THIAZIDE AND RELATED DRUGS<br />

chlorothiazide 1<br />

chlorothiazide sodium [INJ] 4<br />

chlorthalidone 1<br />

DIURIL chlorothiazide 3<br />

DIURIL SODIUM [INJ][G] chlorothiazide sodium 3<br />

hydrochlorothiazide capsule, -tablet 1<br />

indapamide 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

methyclothiazide tablet 1<br />

metolazone 1<br />

MICROZIDE [G] hydrochlorothiazide 3<br />

NATURETIN-5 bendroflumethiazide 3<br />

THALITONE chlorthalidone 3<br />

ZAROXOLYN [G] metolazone 3<br />

VASODILATOR ANTIHYPERTENSIVES<br />

CARDURA 1 MG TABLET, -2 MG doxazosin 3 [QLL,<br />

TABLET, -4 MG TABLET [G]<br />

34/34]<br />

CARDURA 8 MG TABLET [G] doxazosin 3 [QLL,<br />

68/34]<br />

CARDURA XL doxazosin 3 [QLL,<br />

34/34]<br />

doxazosin mesylate 1 mg tab, -2 mg<br />

1 [QLL,<br />

tab, -4 mg tab<br />

34/34]<br />

doxazosin mesylate 8 mg tab 1 [QLL,<br />

68/34]<br />

hydralazine hcl injection [INJ] 1<br />

hydralazine hcl tablet 1<br />

MINIPRESS [G] prazosin 3<br />

minoxidil tablet 1<br />

prazosin hcl 1<br />

terazosin 1 mg capsule, -2 mg<br />

1 [QLL,<br />

capsule, -5 mg capsule<br />

34/34]<br />

terazosin 10 mg capsule 1 [QLL,<br />

68/34]<br />

DERMATOLOGICAL MEDICATIONS<br />

ANTIACNE DRUGS<br />

ACANYA clindamycin phos/benz per 3<br />

ACZONE dapsone 3<br />

adapalene 1 [PAR]<br />

AKNE-MYCIN erythromycin base 3<br />

ATRALIN tretinoin 3 [PAR]<br />

AVAR sulfacetamide/sulfur 3<br />

AVAR LS sulfacetamide/sulfur 3<br />

AVAR-E sulfacetamide/sulfur 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

AVAR-E GREEN sulfacetamide/sulfur 3<br />

AVAR-E LS CREAM sulfacetamide/sulfur 3<br />

AVITA [G] tretinoin 3 [PAR]<br />

AZELEX azelaic acid 3<br />

BENZACLIN clindamycin/benz per/hyalur na 3<br />

BENZAMYCIN erythromycin base/benz per 3<br />

BENZAMYCINPAK erythromycin base/benz per 3<br />

bp 10-1 1<br />

CLARIFOAM EF sulfacetamide/sulfur 3<br />

clenia cleanser 1<br />

CLENIA CREAM sulfacetamide/sulfur 3<br />

CLEOCIN T [G] clindamycin phosphate 3<br />

clinda-derm 1<br />

CLINDAGEL clindamycin phosphate 3<br />

CLINDAMAX GEL, -LOTION [INJ] clindamycin phosphate 3<br />

clindamycin phosphate foam, -gel, -<br />

lotion, -solution non-oral, -swab<br />

1<br />

medicated<br />

clindamycin-benzoyl peroxide 1<br />

CLINDAREACH clindamycin phosphate 3<br />

CLINDETS [INJ] clindamycin phosphate 3<br />

DIFFERIN [G] adapalene 3 [PAR]<br />

DUAC CS clindamycin/benzoyl prx/skn #5 3<br />

EMGEL [INJ] erythromycin base 3<br />

EPIDUO adapalene/benzoyl peroxide 3 [PAR]<br />

ery 1<br />

erythromycin gel, -solution non-oral 1<br />

erythromycin-benzoyl peroxide 1<br />

EVOCLIN [G] clindamycin phosphate 3<br />

FINACEA azelaic acid 2<br />

METROCREAM [G] metronidazole 3<br />

METROGEL metronidazole 2<br />

METROLOTION [G] metronidazole 3<br />

metronidazole cream, -gel, -lotion 1<br />

NORITATE metronidazole 3<br />

PLEXION sulfacetamide/sulfur 3<br />

prascion 1<br />

prascion fc 1<br />

prascion ts 1<br />

RETIN-A [G] tretinoin 3 [PAR]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

RETIN-A MICRO tretinoin 3 [PAR]<br />

RETIN-A MICRO PUMP tretinoin 3 [PAR]<br />

rosaderm cleanser 1<br />

sodium sulfacetamide-sulfur<br />

cleanser, -foam, -pads medicated, -<br />

sulfacetamide-sulfur lotn, -sulf-sulfur<br />

1<br />

wash, -suspensions, (not oral)<br />

sulfatol c 1<br />

sulzee 1<br />

SUMAXIN sulfacetamide/sulfur 3<br />

topisulf 1<br />

tretinoin 0.025% cream, -0.05%<br />

1 [PAR]<br />

cream, -0.1% cream, -gel<br />

TRETIN-X tretinoin/emol cmb9/skin cln1 3 [PAR]<br />

vitazol 1<br />

ZIANA clindamycin/tretinoin 3 [PAR]<br />

ANTIPRURITIC DRUGS<br />

hydroxyzine hcl injection [INJ] 1<br />

hydroxyzine hcl syrup, -tablet 1 [PAR]<br />

hydroxyzine pamoate capsule 1 [PAR]<br />

VISTARIL [G] hydroxyzine pamoate 3 [PAR]<br />

ANTIPSORIASIS AND ANTIECZEMA DRUGS<br />

calcipotriene 1<br />

DOVONEX CREAM calcipotriene 2<br />

DOVONEX SOLUTION calcipotriene 3<br />

DRITHOCREME HP anthralin 2<br />

DRITHO-SCALP anthralin 3<br />

KLARON [G] sulfacetamide sodium 3<br />

seb-prev 10% cream, -10% gel 1<br />

selenium sulfide 2.25% shampoo, -<br />

1<br />

2.5% lotion, -sulf 2.5% shampoo<br />

selenos 1<br />

SELSEB selenium sulfide 3<br />

SORIATANE acitretin 4<br />

SORIATANE CK 10 MG KIT acitretin/emollient comb 2<br />

SORIATANE CK 25 MG KIT acitretin/emollient comb 4<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

sulfacetamide sodium lotion, -<br />

suspension topical<br />

1<br />

TACLONEX betamet diprop/calcipotriene 3<br />

TACLONEX SCALP betamet diprop/calcipotriene 3<br />

TAZORAC tazarotene 2 [PAR]<br />

TERSI FOAM selenium sulfide 3<br />

VECTICAL calcitriol 3<br />

ZITHRANOL-RR anthralin 3<br />

KERATOLYTIC DRUGS<br />

CONDYLOX GEL podofilox 2<br />

CONDYLOX SOLUTION NON-ORAL<br />

[G]<br />

podofilox 3<br />

podofilox 1<br />

ORAL DERMATOLOGICAL DRUGS<br />

8-MOP methoxsalen 4<br />

ACCUTANE isotretinoin 3<br />

amnesteem 1<br />

claravis 1<br />

OXSORALEN-ULTRA methoxsalen 4<br />

sotret 1<br />

SCABICIDES<br />

acticin 1<br />

ELIMITE permethrin 3<br />

EURAX crotamiton 2<br />

LINDANE benzene hexachloride gamma 2<br />

malathion 1<br />

OVIDE [G] malathion 3<br />

permethrin cream 1<br />

ULESFIA benzyl alcohol 3<br />

TOPICAL ANTI-INFLAMMATORY DRUGS<br />

FLECTOR diclofenac epolamine 2 [QLL,<br />

60/34][ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

PENNSAID diclofenac sodium 3 [ST]<br />

VOLTAREN GEL diclofenac sodium 2 [ST]<br />

TOPICAL CORTICOSTEROID DRUGS<br />

ACLOVATE [G] alclometasone 3 [ST]<br />

ALA-CORT [G] hydrocortisone 3 [ST]<br />

ALA-SCALP HP hydrocortisone 3 [ST]<br />

alclometasone dipropionate 1<br />

amcinonide 1<br />

ANAMANTLE HC CREAM WITH hc acetate/lidocaine hcl 3<br />

APPLICATOR, -KIT<br />

ANAMANTLE HC FORTE hc acetate/lidocaine hcl 3<br />

APEXICON [INJ] diflorasone 3<br />

APEXICON E diflorasone 3 [ST]<br />

betamethasone dipropionate cream,<br />

-gel, -lotion, -ointment<br />

1<br />

betamethasone valerate cream, -<br />

1<br />

lotion, -ointment<br />

betanate 1<br />

beta-val 1<br />

CAPEX SHAMPOO fluocinolone acetonide 3<br />

CARMOL HC hydrocortisone acetate/urea 3 [ST]<br />

clobetasol emollient 1<br />

clobetasol propionate cream, -foam,<br />

1<br />

-gel, -ointment, -solution non-oral<br />

CLOBEX clobetasol propionate 3 [ST]<br />

CLODERM clocortolone pivalate 3 [ST]<br />

CORDRAN LOTION, -OINTMENT flurandrenolide 3 [ST]<br />

CORDRAN SP flurandrenolide 3 [ST]<br />

CORDRAN TAPE MEDICATED flurandrenolide 3 [QLL, 900<br />

square<br />

cm/34][ST]<br />

cormax 1<br />

CUTIVATE [G] fluticasone propionate 3 [ST]<br />

del-beta 1<br />

DERMA-SMOOTHE-FS fluocinolone acetonide 3 [ST]<br />

DERMATOP [G] prednicarbate 3 [ST]<br />

DESONATE desonide 3 [ST]<br />

desonide cream, -lotion, -ointment 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

DESOWEN desonide/emollient combo #30 3 [ST]<br />

desoximetasone cream, -gel, -<br />

ointment<br />

1<br />

diflorasone diacetate 1<br />

DIPROLENE [G] betameth/propylene glycol 3 [ST]<br />

DIPROLENE AF [G] betameth/propylene glycol 3 [ST]<br />

DIPROSONE betamethasone dipropionate 3 [ST]<br />

ELOCON [G] mometasone 3 [ST]<br />

FIRST-HYDROCORTISONE hydrocortisone 3<br />

fluocinolone acetonide cream, -<br />

ointment, -solution non-oral<br />

1<br />

fluocinonide cream, -gel, -ointment,<br />

-solution non-oral<br />

1<br />

fluocinonide emollient 1<br />

fluocinonide-e 1<br />

fluticasone propionate cream, -<br />

ointment<br />

1<br />

halobetasol propionate 1<br />

HALOG halcinonide 3 [ST]<br />

HALONATE halobetasol prop/amonium lac 3 [ST]<br />

halonate pac 1<br />

hydrocortisone 1% absorbase, -1%<br />

cream, -1% lotion, -1% oin, -1%<br />

oint, -1% ointment, -2.5% cream, -<br />

2.5% lotion, -2.5% ointment, -aloe<br />

1% cream, -plus 1% cream<br />

1<br />

hydrocortisone butyrate 1<br />

hydrocortisone valerate 1<br />

KENALOG triamcinolone acetonide 3 [ST]<br />

LIDAMANTLE HC hc acetate/lidocaine hcl 3<br />

lidazone hc 1<br />

lidocaine-hc 1<br />

lidocaine-hydrocortisone cream, -<br />

cream with applicator, -kit, -lotion<br />

1<br />

LOCOID [G] hydrocortisone butyrate 3 [ST]<br />

LOCOID LIPOCREAM hydrocortisone butyrate 3 [ST]<br />

LOKARA [G] desonide 3 [ST]<br />

LUXIQ betamethasone valerate 3 [ST]<br />

mometasone furoate 1<br />

MOMEXIN mometasone furoat/ammonium l 3 [ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

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Drug Generic Tier Restrictions<br />

OLUX clobetasol propionate 3 [ST]<br />

OLUX-E clobetasol propionate 3 [ST]<br />

OLUX-OLUX-E clobetasol propionate 3 [ST]<br />

PANDEL hydrocortisone buteprate 3 [ST]<br />

PEDIADERM HC hydrocortisone/emol no.45 3 [ST]<br />

PERANEX HC PADS MEDICATED hc acetate/lidocaine hcl 3<br />

prednicarbate 1<br />

SCALACORT hydrocortisone 3 [ST]<br />

TEMOVATE [G] clobetasol propionate 3 [ST]<br />

TEMOVATE EMOLLIENT clobetasol propionate 3 [ST]<br />

TEXACORT hydrocortisone 3 [ST]<br />

TOPICORT [G] desoximetasone 3 [ST]<br />

TOPICORT LP [G] desoximetasone 3 [ST]<br />

triamcinolone acetonide cream, -<br />

1<br />

lotion, -ointment<br />

triderm 1<br />

TRIDESILON desonide 3 [ST]<br />

U-CORT hydrocortisone acetate/urea 3 [ST]<br />

ULTRAVATE [G] halobetasol propionate 3 [ST]<br />

ULTRAVATE PAC halobetasol prop/amonium lac 3<br />

VANOS fluocinonide 3 [ST]<br />

VERDESO desonide 3 [ST]<br />

WESTCORT [G] hydrocortisone valerate 3 [ST]<br />

TOPICAL DERMATOLOGICAL DRUGS<br />

ALDARA [G] imiquimod 3<br />

ammonium lactate 12% cream, -<br />

12% lotion<br />

1<br />

CARAC fluorouracil 3<br />

cerovel 1<br />

DRYSOL aluminum chloride hexahydrate 3<br />

EFUDEX [G] fluorouracil 3<br />

ELIDEL pimecrolimus 2 [ST]<br />

FLUOROPLEX fluorouracil 2<br />

fluorouracil cream, -solution nonoral<br />

1<br />

GORDO-UREA urea 3<br />

HYDRO 35 urea 3<br />

HYDRO 40 urea 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

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Drug Generic Tier Restrictions<br />

hypercare 1<br />

imiquimod 1<br />

KERAFOAM urea 3<br />

keratol 40 1<br />

keratol plus 1<br />

LAC-HYDRIN [G] lactate, ammonium 3<br />

LACLOTION [G] lactate, ammonium 3<br />

LEVULAN aminolevulinic acid hcl 3<br />

METVIXIA methyl aminolevulinate hcl 3<br />

OXSORALEN methoxsalen 2<br />

PANRETIN alitretinoin 4<br />

PROTOPIC tacrolimus 2 [ST]<br />

PRUDOXIN doxepin 2<br />

REGRANEX becaplermin 2 [PAR][QLL,<br />

30 gm/34]<br />

remeven 1<br />

re-u40 1<br />

SANTYL collagenase 2<br />

SOLARAZE diclofenac sodium 2 [PAR]<br />

u-kera e urea emollient 1<br />

UMECTA urea 3<br />

UMECTA PD urea 3<br />

URAMAXIN urea 3<br />

urea 40 1<br />

urea 40% cream, -40% nail film<br />

susp, -45% cream, -50% cream, -<br />

50% nail stick, -50% nailstik, -foam,<br />

-gel, -kit, -lotion, -ointment, -<br />

towelette<br />

1<br />

urealac cream, -gel, -lotion, -soln,<br />

1<br />

top<br />

VEREGEN sinecatechins 3<br />

XERAC AC aluminum chloride hexahydrate 3<br />

x-viate 1<br />

ZONALON doxepin 2<br />

ZYCLARA imiquimod 2<br />

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Drug Generic Tier Restrictions<br />

DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS<br />

DIAGNOSTIC PRODUCTS<br />

CHEMET succimer 2<br />

EXJADE [LA] deferasirox 4<br />

MISCELLANEOUS DRUGS<br />

ADAGEN [INJ][LA] pegademase bovine 4<br />

AMICAR SYRUP [INJ] aminocaproic acid 3<br />

AMICAR TABLET aminocaproic acid 3<br />

aminocaproic acid injection [INJ] 1<br />

aminocaproic acid syrup, -tablet 1<br />

AMMONUL [INJ] sodium benzoate/na ph-acetate 3<br />

AMPYRA [LA] dalfampridine 4 [PAR]<br />

ANTIZOL [INJ][G] fomepizole 3<br />

BUPHENYL sodium phenylbutyrate 4<br />

COPAXONE [INJ] glatiramer acetate 4 [PAR][QLL,<br />

30 ml/30]<br />

CYKLOKAPRON [INJ] tranexamic acid 2<br />

ENDRATE [INJ] endrate disodium 3<br />

ergoloid mesylates tablet 1<br />

fomepizole [INJ] 1<br />

HESPAN [INJ] hetastarch/na chlor 0.9% 3<br />

hetastarch in ns [INJ] 1<br />

HEXTEND LACTATED ELECTROLYTE hetastarch/e-lytes,lactate 3<br />

[INJ]<br />

LYSTEDA tranexamic acid 3<br />

ORFADIN [LA] nitisinone 4<br />

PANHEMATIN [INJ] hemin 3<br />

PROTOPAM CHLORIDE [INJ] pralidoxime chloride 2<br />

SOTRADECOL [INJ] sodium tetradecyl sulfate 3<br />

THALOMID thalidomide 4<br />

VOLUVEN [INJ] hetastarch/na chlor 0.9% 3<br />

XIAFLEX [INJ][LA] collagenase clostridium hist. 4<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

EAR-NOSE-THROAT MEDICATIONS<br />

DRUGS AFFECTING THE EAR<br />

aabp 1<br />

a-b otic 1<br />

acetasol hc 1<br />

acetic acid solution non-oral 1<br />

acetic acid-aluminum 1<br />

acetic acid-hydrocortisone 1<br />

antipyrine-benzocaine 1<br />

aurodex 1<br />

aurodex ear drops 1<br />

auroguard 1<br />

BENZOTIC antipyrine/benzocaine 3<br />

borofair 1<br />

chloroxylenol-pramoxine hcl 1<br />

CIPRO HC ciprofloxacin/hc 3<br />

CIPRODEX ciprofloxacin/dexameth 2<br />

COLY-MYCIN S neomycin sulfate/colist sul/hc 3<br />

CORTISPORIN SUSPENSION DROPS,<br />

-SOLUTION NON-ORAL [G]<br />

neomycin sulfate/polymyxin/hc 3<br />

CORTISPORIN-TC neomycin/colist sul/hc/thonz 3<br />

cortomycin solution non-oral, -<br />

1<br />

suspension drops<br />

DERMOTIC fluocinolone acetonide 2<br />

DOMEBORO DROPS [INJ] acetic acid/aluminum acetate 3<br />

FLOXIN ofloxacin 3<br />

neomycin-polymyxin-hc solution, -<br />

solution non-oral, -suspension drops<br />

1<br />

ofloxacin drops 1<br />

otic edge 1<br />

oticin hc ear solution, -suspension<br />

1<br />

drops<br />

otocidin 1<br />

otomycet-hc 1<br />

PEDIOTIC neomycin suf/polymy/buffers/hc 3<br />

pr otic solution 1<br />

PRAMOTIC pramoxine hcl/chloroxylenol 3<br />

treagan otic 1<br />

VOSOL [G] acetic acid 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

VOSOL HC [INJ] acetic acid/hydrocortisone 3<br />

DRUGS AFFECTING THE NOSE<br />

ASTELIN [G] azelastine hcl 3 [QLL, 60<br />

ml/34]<br />

ASTEPRO 0.15% NASAL SPRAY azelastine hcl 2 [QLL, 60<br />

ml/34]<br />

ASTEPRO 137 MCG NASAL SPRAY azelastine hcl 2 [QLL,<br />

60/34]<br />

ATROVENT 0.03% SPRAY [G] ipratropium 3 [QLL, 60<br />

ml/34]<br />

ATROVENT 0.06% SPRAY [G] ipratropium 3 [QLL, 30<br />

ml/34]<br />

azelastine hcl aerosol spray w/pump 1 [QLL, 60<br />

ml/34]<br />

BECONASE AQ beclomethasone 3 [QLL, 50<br />

gm/34]<br />

FLONASE [G] fluticasone propionate 3 [QLL, 32<br />

gm/34]<br />

flunisolide 0.025% spray 1 [QLL, 75<br />

ml/34]<br />

flunisolide 29 mcg-0.025% spr 1 [QLL,<br />

75/34]<br />

fluticasone propionate nasal inhaled<br />

1 [QLL, 32<br />

steroids<br />

gm/34]<br />

ipratropium 0.03% spray 1 [QLL, 60<br />

ml/34]<br />

ipratropium 0.06% spray 1 [QLL, 30<br />

ml/34]<br />

NASACORT AQ triamcinolone acetonide 2 [QLL, 33<br />

gm/34]<br />

NASAREL flunisolide 3 [QLL,<br />

75/34]<br />

NASONEX mometasone 3 [QLL, 51<br />

gm/34]<br />

OMNARIS ciclesonide 3 [QLL, 25<br />

gm/34]<br />

PATANASE olopatadine hcl 3 [QLL, 61<br />

gm/34]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

RHINOCORT AQUA budesonide 3 [QLL, 26<br />

gm/34]<br />

TYZINE tetrahydrozoline 2<br />

VERAMYST fluticasone furoate 2 [QLL, 20<br />

gm/34]<br />

DRUGS AFFECTING THE THROAT AND MOUTH<br />

APHTHASOL amlexanox 3<br />

ARESTIN minocycline 3<br />

chlorhexidine gluconate mouthwash 1<br />

DEBACTEROL sulfuric acid/sulf phenol 3<br />

doxycycline hyclate 20 mg tab 1<br />

EVOXAC cevimeline 3<br />

FIRST-MOUTHWASH BLM mag hydrox/alh/smc/dpha/lido 2<br />

ORALONE triamcinolone acetonide 3<br />

ORASEP b-caine/tan ac/menth/cpyrd 3<br />

oraxyl 1<br />

periogard 1<br />

PERIOSTAT [G] doxycycline hyclate 3<br />

perisol 1<br />

pilocarpine hcl tablet 1<br />

SALAGEN [G] pilocarpine hcl 3<br />

triamcinolone acetonide paste 1<br />

XYLOCAINE 2% VIAL [INJ] lidocaine 3<br />

ENDOCRINE MEDICATIONS<br />

ANTITHYROID DRUGS<br />

methimazole tablet 1<br />

northyx 1<br />

propylthiouracil 1<br />

TAPAZOLE [G] methimazole 3<br />

GLUCOCORTICOID DRUGS<br />

A-HYDROCORT [INJ] hydrocortisone sod succinate 3<br />

a-methapred [INJ] 1<br />

ARISTOSPAN [INJ] triamcinolone hexacetonide 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

baycadron 1<br />

betamethasone acetate-sod phos<br />

[INJ]<br />

1<br />

CELESTONE INJECTION [INJ] betamethasone/betamethasone 2<br />

CELESTONE SOLUTION ORAL betamethasone 2<br />

CORTEF [G] hydrocortisone 3<br />

cortisone tablet 1<br />

DEPO-MEDROL [INJ][G] methylprednisolone acetate 3<br />

dexamethasone elixir, -solution oral,<br />

-tablet<br />

1<br />

dexamethasone intensol 1<br />

dexamethasone sodium phosphate<br />

injection [INJ]<br />

1<br />

DEXPAK [G] dexamethasone 3<br />

hydrocortisone tablet 1<br />

KENALOG-10 [INJ] triamcinolone acetonide 3<br />

KENALOG-40 [INJ] triamcinolone acetonide 3<br />

MEDROL [G] methylprednisolone 3<br />

meprolone unipak 1<br />

methylprednisolone acetate injection<br />

[INJ]<br />

1<br />

methylprednisolone sod succ [INJ] 1<br />

methylprednisolone tablet, -tablet<br />

dose pack<br />

1<br />

MILLIPRED prednisolone 3<br />

MILLIPRED DP prednisolone 3<br />

ORAPRED [G] prednisolone sod phosphate 3<br />

ORAPRED ODT prednisolone sod phosphate 3<br />

PEDIAPRED [G] prednisolone sod phosphate 3<br />

prednisolone sodium phosphate<br />

solution<br />

1<br />

prednisolone solution oral 1<br />

prednisone intensol 1<br />

prednisone solution, -tablet, -tablet<br />

dose pack<br />

1<br />

PRELONE [G] prednisolone 3<br />

SOLU-CORTEF [INJ] hydrocortisone sod succinate 3<br />

SOLU-CORTEF (PF) [INJ] hydrocortisone sod succinate 3<br />

SOLU-MEDROL [INJ][G] methylprednisolone sod succ 3<br />

SOLU-MEDROL (PF) [INJ] methylprednisolone sod succ 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

STERAPRED prednisone 3<br />

STERAPRED DS prednisone 3<br />

triamcinolone acetonide injection<br />

1<br />

[INJ]<br />

veripred 20 1<br />

zema-pak 1<br />

GLUCOSE ELEVATING DRUGS<br />

GLUCAGEN [INJ] glucagon, human recombinant 2<br />

GLUCAGON EMERGENCY KIT [INJ] glucagon, human recombinant 2<br />

PROGLYCEM diazoxide 2<br />

HYPOGLYCEMIC DRUGS<br />

BYETTA 10 MCG DOSE PEN INJ exenatide 2 [PAR][QLL,<br />

[INJ]<br />

5 ml/34]<br />

BYETTA 5 MCG DOSE PEN INJ [INJ] exenatide 2 [PAR][QLL,<br />

2 ml/34]<br />

SYMLIN [INJ] pramlintide acetate 2 [PAR][QLL,<br />

35 ml/34]<br />

SYMLINPEN 120 [INJ] pramlintide acetate 2 [PAR][QLL,<br />

22 ml/34]<br />

SYMLINPEN 60 [INJ] pramlintide acetate 2 [PAR][QLL,<br />

12 pens/34]<br />

VICTOZA 2-PAK [INJ] liraglutide 3 [PAR][QLL,<br />

3/30]<br />

VICTOZA 3-PAK [INJ] liraglutide 3 [PAR][QLL,<br />

3 pens/30]<br />

INSULIN<br />

APIDRA [INJ] 3<br />

APIDRA SOLOSTAR [INJ] 3<br />

HUMALOG [INJ] 2<br />

HUMALOG MIX 50-50 [INJ] 2<br />

HUMALOG MIX 75-25 [INJ] 2<br />

HUMULIN 50-50 [INJ] 2<br />

HUMULIN 70-30 [INJ] 2<br />

HUMULIN N [INJ] 2<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

HUMULIN R [INJ] 2<br />

LANTUS [INJ] 2<br />

LANTUS SOLOSTAR [INJ] 2<br />

LEVEMIR [INJ] 2<br />

NOVOLIN 70-30 100 UNIT/ML VIAL,<br />

-U100 CARTRIDGE [INJ]<br />

2<br />

NOVOLIN 70-30 INNOLET [INJ] 2<br />

NOVOLIN N 100 UNIT/ML INNOLET,<br />

-100 UNITS/ML CARTRDG, -100<br />

2<br />

UNITS/ML VIAL [INJ]<br />

NOVOLIN R 100 UNIT/ML<br />

CARTRIDG, -100 UNIT/ML INNOLET,<br />

-100 UNITS/ML VIAL [INJ]<br />

2<br />

NOVOLOG [INJ] 2<br />

NOVOLOG MIX 70-30 [INJ] 2<br />

RELION NOVOLIN 70-30 VIAL, -<br />

RELION VIAL [INJ]<br />

3<br />

RELION NOVOLIN N 100 UNITS/ML,<br />

3<br />

-RELION 100 UNITS/ML [INJ]<br />

RELION NOVOLIN R 100 UNITS/ML<br />

[INJ]<br />

MINERALOCORTICOID DRUGS<br />

fludrocortisone acetate tablet 1<br />

ORAL HYPOGLYCEMICS AND COMBOS<br />

acarbose 1<br />

ACTOPLUS MET pioglitazone hcl/metformin hc 2 [QLL,<br />

102/34][ST]<br />

ACTOPLUS MET XR 15-1,000 MG TB pioglitazone hcl/metformin hc 2 [QLL,<br />

68/34][ST]<br />

ACTOPLUS MET XR 30-1,000 MG TB pioglitazone hcl/metformin hc 2 [QLL,<br />

34/34][ST]<br />

ACTOS pioglitazone hcl 2 [QLL,<br />

34/34][ST]<br />

AMARYL [G] glimepiride 3<br />

AVANDAMET rosiglitazone/metformin hcl 2 [QLL,<br />

68/34][ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

AVANDARYL rosiglitazone maleate/glimepir 2 [QLL,<br />

34/34][ST]<br />

AVANDIA 2 MG TABLET, -4 MG rosiglitazone maleate 2 [QLL,<br />

TABLET<br />

68/34][ST]<br />

AVANDIA 8 MG TABLET rosiglitazone maleate 2 [QLL,<br />

34/34][ST]<br />

DIABETA glyburide 3<br />

DUETACT pioglitazone/glimepiride 2 [QLL,<br />

34/34][ST]<br />

FORTAMET metformin 3 [ST]<br />

glimepiride 1<br />

glipizide er 1<br />

glipizide tablet 1<br />

glipizide xl 1<br />

glipizide-metformin 1<br />

GLUCOPHAGE [G] metformin 3 [ST]<br />

GLUCOPHAGE XR [G] metformin 3 [ST]<br />

GLUCOTROL [G] glipizide 3<br />

GLUCOTROL XL [G] glipizide 3<br />

GLUCOVANCE [G] glyburide/metformin hcl 3<br />

GLUMETZA metformin 3 [ST]<br />

glyburide 1<br />

glyburide micronized 1<br />

glyburide-metformin hcl 1<br />

glycron 1<br />

GLYNASE [G] glyburide 3<br />

GLYSET miglitol 3<br />

JANUMET sitagliptin phos/metformin hcl 2 [QLL,<br />

68/34]<br />

JANUVIA sitagliptin phosphate 2 [QLL,<br />

34/34]<br />

METAGLIP [G] glipizide/metformin hcl 3<br />

metformin hcl 1<br />

metformin hcl er 1<br />

nateglinide 1<br />

ONGLYZA saxagliptin hydrochloride 2 [QLL,<br />

34/34]<br />

PRANDIMET repaglinide/metformin hcl 3 [QLL,<br />

170/34]<br />

PRANDIN repaglinide 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

PRECOSE [G] acarbose 3<br />

RIOMET metformin 2 [ST]<br />

STARLIX [G] nateglinide 3<br />

tolazamide 1<br />

tolbutamide 1<br />

OTHER ENDOCRINE DRUGS<br />

ACTHAR H.P. [INJ] corticotropin 4<br />

ACTHREL [INJ] corticorelin ovine triflutate 3<br />

ACTONEL 150 MG TABLET risedronate 2 [QLL,<br />

1/34][ST]<br />

ACTONEL 30 MG TABLET, -5 MG risedronate 2 [QLL,<br />

TABLET<br />

34/34][ST]<br />

ACTONEL 35 MG TABLET risedronate 2 [QLL,<br />

5/35][ST]<br />

ACTONEL 75 MG TABLET risedronate 2 [QLL,<br />

2/34][ST]<br />

ACTONEL WITH CALCIUM risedron sod/calcium carbona 2 [QLL,<br />

35/35][ST]<br />

ALDURAZYME [INJ][LA] laronidase 4<br />

alendronate sodium 10 mg tab, -40<br />

1 [QLL,<br />

mg tab, -5 mg tablet<br />

34/34]<br />

alendronate sodium 35 mg tab, -70<br />

1 [QLL, 5/35]<br />

mg tab<br />

AREDIA 30 MG VIAL [INJ][G] pamidronate disodium 3<br />

AREDIA 90 MG VIAL [INJ][G] pamidronate disodium 4<br />

BONIVA 150 MG TABLET ibandronate 2 [QLL,<br />

1/34][ST]<br />

BONIVA 2.5 MG TABLET ibandronate 2 [QLL,<br />

34/34][ST]<br />

BONIVA INJECTION [INJ] ibandronate 3 [PAR]<br />

cabergoline 1 [QLL,<br />

20/34]<br />

calcitonin-salmon 1<br />

CEREDASE [INJ][LA] alglucerase 4<br />

CEREZYME [INJ][LA] imiglucerase 4 [PAR]<br />

DDAVP 4 MCG/ML AMPUL [INJ][G] desmopressin acetate 4<br />

DDAVP 4 MCG/ML VIAL [INJ][G] desmopressin acetate 3<br />

DDAVP SOLUTION, -AEROSOL<br />

SPRAY W/PUMP, -TABLET [G]<br />

desmopressin acetate 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

desmopressin acetate aerosol spray<br />

w/pump, -solution, -tablet<br />

1<br />

desmopressin acetate injection [INJ] 1<br />

DIDRONEL [G] etidronate 3<br />

ELAPRASE [INJ][LA] idursulfase 4<br />

etidronate disodium 1<br />

EVISTA raloxifene 2<br />

FABRAZYME [INJ][LA] agalsidase 4 [PAR]<br />

FORTEO [INJ] teriparatide 2 [PAR][QLL,<br />

1/28]<br />

fortical 1<br />

FOSAMAX 10 MG TABLET, -40 MG alendronate 3 [QLL,<br />

TABLET, -5 MG TABLET [G]<br />

34/34][ST]<br />

FOSAMAX 35 MG TABLET, -70 MG alendronate 3 [QLL,<br />

TABLET [G]<br />

5/35][ST]<br />

FOSAMAX PLUS D alendronate/vitamin d3 3 [QLL,<br />

5/35][ST]<br />

FOSAMAX SOLUTION alendronate 3 [QLL, 375<br />

ml/35][ST]<br />

KUVAN [LA] sapropterin dihydrochloride 4<br />

LUMIZYME [INJ][LA] alglucosidase alfa 4<br />

MIACALCIN AEROSOL SPRAY<br />

W/PUMP [G]<br />

calcitonin 3<br />

MIACALCIN INJECTION [INJ] calcitonin 2<br />

MYOZYME [INJ][LA] alglucosidase alfa 4<br />

NAGLAZYME [INJ][LA] galsulfase 4<br />

pamidronate disodium [INJ] 1<br />

PROLIA [INJ] denosumab 3<br />

RECLAST [INJ] zoledronic acid 4 [PAR]<br />

SAMSCA tolvaptan 4 [PAR][QLL,<br />

68/34]<br />

SENSIPAR cinacalcet hcl 2<br />

SKELID tiludronate 3<br />

SOMAVERT [INJ][LA] pegvisomant 4<br />

STIMATE desmopressin acetate 3<br />

VPRIV [INJ] velaglucerase alfa 4<br />

ZAVESCA [LA] miglustat 4<br />

ZOMETA [INJ] zoledronic acid 4<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

THYROID SUPPLEMENTS<br />

ARMOUR THYROID thyroid 2<br />

CYTOMEL [G] liothyronine 3<br />

levothroid 1<br />

levothyroxine sodium injection [INJ] 1<br />

levothyroxine sodium tablet 1<br />

levoxyl 1<br />

liothyronine sodium injection [INJ] 1<br />

liothyronine sodium tablet 1<br />

nature-throid 1<br />

SYNTHROID [G] levothyroxine 3<br />

thyroid tablet 1<br />

THYROLAR-1 liotrix 2<br />

THYROLAR-1/2 liotrix 2<br />

THYROLAR-1/4 liotrix 2<br />

THYROLAR-2 liotrix 2<br />

THYROLAR-3 liotrix 2<br />

TIROSINT levothyroxine 3<br />

TRIOSTAT [INJ] liothyronine 3<br />

unithroid 1<br />

westhroid 1<br />

GASTROINTESTINAL MEDICATIONS<br />

ANTIDIARRHEAL DRUGS<br />

diphenoxylate-atropine 1<br />

LOMOTIL [G] diphenoxylate/atropine sulfate 3<br />

lonox 1<br />

loperamide capsule 1<br />

MOTOFEN difenoxin/atropine sulfate 3<br />

paregoric 1<br />

ANTISPASMODICS/DRUGS AFFECT GI MOTILITY<br />

BENTYL CAPSULE, -SYRUP, -TABLET<br />

[G]<br />

dicyclomine 3<br />

BENTYL INJECTION [INJ] dicyclomine 3<br />

CANTIL mepenzolate 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

dicyclomine hcl capsule, -syrup, -<br />

tablet<br />

1<br />

dicyclomine hcl injection [INJ] 1<br />

glycopyrrolate injection [INJ] 1<br />

glycopyrrolate tablet 1<br />

methscopolamine bromide 1<br />

metoclopramide hcl injection [INJ] 1<br />

metoclopramide hcl solution oral, -<br />

tablet<br />

1<br />

METOZOLV ODT metoclopramide 3<br />

PAMINE [G] methscopolamine 3<br />

PAMINE FORTE [G] methscopolamine 3<br />

propantheline bromide 1<br />

REGLAN INJECTION [INJ][G] metoclopramide 3<br />

REGLAN TABLET [G] metoclopramide 3<br />

ROBINUL FORTE [G] glycopyrrolate 3<br />

ROBINUL INJECTION [INJ][G] glycopyrrolate 3<br />

ROBINUL TABLET [G] glycopyrrolate 3<br />

SCOPOLAMINE HYDROBROMIDE<br />

INJECTION [INJ]<br />

scopolamine 3<br />

ANTIULCER DRUGS<br />

AXID [G] nizatidine 3<br />

cimetidine 200 mg tablet, -300 mg<br />

tablet, -400 mg tablet, -800 mg<br />

tablet, -solution<br />

1<br />

cimetidine injection [INJ] 1<br />

famotidine 20 mg tablet, -40 mg<br />

tablet, -suspension oral<br />

1<br />

famotidine injection [INJ] 1<br />

nizatidine 1<br />

PEPCID INJECTION [INJ] famotidine 3<br />

PEPCID SUSPENSION ORAL, -<br />

TABLET [G]<br />

famotidine 3<br />

ranitidine 150 mg tablet, -300 mg<br />

tablet, -capsule, -syrup<br />

1<br />

ranitidine hcl injection [INJ] 1<br />

ZANTAC 25 ranitidine 3<br />

ZANTAC INJECTION [INJ][G] ranitidine 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ZANTAC SYRUP, -TABLET [G] ranitidine 3<br />

IRRITABLE BOWEL DRUGS<br />

AMITIZA lubiprostone 2<br />

LOTRONEX alosetron 4<br />

LAXATIVES AND CATHARTICS<br />

glycerin liquid 1<br />

OSMOPREP sodium phosphate/na biphos 2<br />

polyethylene glycol 3350, -pkt, -<br />

powd<br />

1<br />

VISICOL sodium phosphate/na biphos 2<br />

OTHER ANTIULCER DRUGS<br />

CARAFATE SUSPENSION ORAL sucralfate 2<br />

CARAFATE TABLET [G] sucralfate 3<br />

CYTOTEC [G] misoprostol 3<br />

misoprostol 1<br />

sucralfate suspension oral, -tablet 1<br />

OTHER GI DRUGS<br />

ACTIGALL [G] ursodiol 3<br />

ANUSOL-HC [G] hydrocortisone 3<br />

APRISO mesalamine 2<br />

ASACOL mesalamine 2<br />

ASACOL HD mesalamine 2<br />

AZULFIDINE [G] sulfasalazine 3<br />

balsalazide disodium 1<br />

CANASA mesalamine 2<br />

CHENODAL [LA] chenodiol 4<br />

COLAZAL [G] balsalazide disodium 3<br />

COLOCORT [G] hydrocortisone 3<br />

COLYTE electrolyte solution/peg's 3<br />

COLYTE WITH FLAVOR PACKETS<br />

[INJ]<br />

electrolyte solution/peg's 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

CORTENEMA [G] hydrocortisone 3<br />

CORTIFOAM hydrocortisone acetate 2<br />

CREON amylase/lipase/protease 2<br />

DIPENTUM olsalazine 3<br />

ENTOCORT EC budesonide 2<br />

ENZYMAX 500 MG TABLET enzymes, digestive 2<br />

gavilyte-c 1<br />

gavilyte-g 1<br />

gavilyte-n 1<br />

GOLYTELY [G] electrolyte solution/peg's 3<br />

HALFLYTELY-BISACODYL electrolyte solution/peg's 3<br />

HELIDAC tetracyc hcl/bis ss/metronid 3<br />

hydrocortisone enema 1<br />

LIALDA mesalamine 3<br />

mesalamine 1<br />

MOVIPREP electrolyte solution/peg's 2<br />

NULYTELY WITH FLAVOR PACKS [G] electrolyte solution/peg's 3<br />

OCL electrolyte solution/peg's 2<br />

PANCREAZE amylase/lipase/protease 3<br />

PANCRELIPASE 5,000 amylase/lipase/protease 3<br />

peg 3350-electrolyte 1<br />

peg-3350 and electrolytes 1<br />

peg-3350 with flavor packs 1<br />

PENTASA mesalamine 2<br />

PREVPAC lansoprazole/amox tr/clarith 3 [QLL,<br />

14/14]<br />

PROCTOCORT [G] hydrocortisone 3<br />

PROCTOCREAM-HC [G] hydrocortisone 3<br />

procto-pak 1<br />

proctosol-hc 1<br />

proctozone-hc 1<br />

PYLERA bismuth/metronid/tetracyclin 2<br />

RELISTOR [INJ] methylnaltrexone bromide 2<br />

ROWASA [G] mesalamine 3<br />

SFROWASA [INJ] mesalamine 3<br />

sulfasalazine dr 1<br />

sulfasalazine tablet 1<br />

sulfazine 1<br />

sulfazine ec 1<br />

trilyte with flavor packets 1<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

URSO [G] ursodiol 3<br />

URSO FORTE [G] ursodiol 3<br />

ursodiol capsule, -tablet 1<br />

ZENPEP amylase/lipase/protease 3<br />

PROTON PUMP INHIBITORS<br />

ACIPHEX rabeprazole sodium 3 [ST]<br />

DEXILANT DR 30 MG CAPSULE dexlansoprazole 3 [QLL,<br />

34/34][ST]<br />

DEXILANT DR 60 MG CAPSULE dexlansoprazole 3 [ST]<br />

KAPIDEX DR 30 MG CAPSULE dexlansoprazole 3 [QLL,<br />

34/34][ST]<br />

KAPIDEX DR 60 MG CAPSULE dexlansoprazole 3 [ST]<br />

lansoprazole dr 15 mg capsule 1 [QLL,<br />

34/34]<br />

lansoprazole dr 30 mg capsule 1<br />

NEXIUM 10 MG PACKET, -20 MG esomeprazole mag trihyd 2 [QLL,<br />

CAPSULE, -20 MG PACKET<br />

34/34][ST]<br />

NEXIUM 40 MG CAPSULE, -40 MG esomeprazole mag trihyd 2 [ST]<br />

PACKET<br />

NEXIUM I.V. [INJ] esomeprazole mag trihyd 2<br />

omeprazole dr 10 mg capsule 1 [QLL,<br />

34/34]<br />

omeprazole dr 20 mg capsule, -dr<br />

1<br />

40 mg capsule<br />

omeprazole-bicarb 20-1,100 cap 1 [QLL,<br />

34/34]<br />

omeprazole-bicarb 40-1,100 cap 1<br />

pantoprazole sod dr 20 mg tab 1 [QLL,<br />

34/34][ST]<br />

pantoprazole sod dr 40 mg tab 1 [ST]<br />

PREVACID 30 MG CAPSULE DR, -30<br />

MG SOLUTAB, -DR 30 MG CAPSULE<br />

lansoprazole 3 [ST]<br />

PREVACID DR 15 MG CAPSULE, -15 lansoprazole 3 [QLL,<br />

MG SOLUTAB [G]<br />

34/34][ST]<br />

PRILOSEC DR 10 MG CAPSULE, -DR omeprazole 3 [QLL,<br />

20 MG CAPSULE [G]<br />

PRILOSEC DR 40 MG CAPSULE, -PKT<br />

[G]<br />

omeprazole magnesium-legend 3<br />

34/34][ST]<br />

[ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

PROTONIX DR 20 MG TABLET [G] pantoprazole 3 [QLL,<br />

34/34][ST]<br />

PROTONIX DR 40 MG TABLET, -PKT pantoprazole 3 [ST]<br />

[G]<br />

PROTONIX IV [INJ] pantoprazole 3<br />

ZEGERID 20 MG CAPSULE [G] omeprazole/sodium bicarbonat 3 [QLL,<br />

34/34][ST]<br />

ZEGERID 20 MG PACKET omeprazole/sodium bicarbonat 3 [QLL,<br />

34/34][ST]<br />

ZEGERID 40 MG CAPSULE [G] omeprazole/sodium bicarbonat 3 [ST]<br />

ZEGERID 40 MG PACKET omeprazole/sodium bicarbonat 3 [ST]<br />

IMMUNOLOGICALS AND VACCINES<br />

GROWTH HORMONES AND RELATED DRUGS<br />

GENOTROPIN 12 MG CARTRIDGE, -<br />

5 MG CARTRIDGE [INJ]<br />

somatropin 4 [PAR]<br />

GENOTROPIN MINIQUICK 0.2 MG, -<br />

MINIQUICK 0.4 MG, -MINIQUICK<br />

0.6 MG, -MINIQUICK 0.8 MG, -<br />

MINIQUICK 1 MG, -MINIQUICK 1.2<br />

MG, -MINIQUICK 1.4 MG, -<br />

MINIQUICK 1.6 MG, -MINIQUICK<br />

1.8 MG, -MINIQUICK 2 MG [INJ]<br />

somatropin 3 [PAR]<br />

HUMATROPE [INJ] somatropin 4 [PAR]<br />

NORDITROPIN [INJ] somatropin 4 [PAR]<br />

NORDITROPIN FLEXPRO [INJ] somatropin 4 [PAR]<br />

NORDITROPIN NORDIFLEX [INJ] somatropin 4 [PAR]<br />

NUTROPIN [INJ] somatropin 4 [PAR]<br />

NUTROPIN AQ [INJ] somatropin 4 [PAR]<br />

NUTROPIN AQ NUSPIN [INJ] somatropin 4 [PAR]<br />

OMNITROPE [INJ] somatropin 4 [PAR]<br />

SAIZEN [INJ] somatropin 4 [PAR]<br />

SEROSTIM [INJ][LA] somatropin 4 [PAR]<br />

TEV-TROPIN [INJ] somatropin 4 [PAR]<br />

ZORBTIVE [INJ][LA] somatropin 4 [PAR]<br />

IMMUNOLOGICALS AND VACCINES<br />

ACTHIB [INJ] haemophilus b-tet toxoid 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ADACEL [INJ] diphther,pertuss,tetanus vac 2<br />

ARANESP 100 MCG/0.5 ML<br />

AUTOINJ, -100 MCG/0.5 ML<br />

SYRINGE, -100 MCG/ML VIAL, -150<br />

MCG/0.3 ML AUTOINJ, -150<br />

MCG/0.3 ML SYRINGE, -150<br />

MCG/0.75 ML VIAL, -200 MCG/0.4<br />

ML AUTOINJ, -200 MCG/0.4 ML<br />

SYRINGE, -200 MCG/ML VIAL, -300<br />

MCG/0.6 ML AUTOINJ, -300<br />

MCG/0.6 M [INJ]<br />

darbepoetin alfa 4 [PAR]<br />

ARANESP 25 MCG/0.42 ML<br />

AUTOINJ, -25 MCG/0.42 ML<br />

SYRING, -25 MCG/ML VIAL, -40<br />

MCG/0.4 ML AUTOINJ, -40 MCG/0.4<br />

ML SYRINGE, -40 MCG/ML VIAL<br />

[INJ]<br />

darbepoetin alfa 2 [PAR]<br />

ATGAM [INJ] lymphocyte immune globulin 4 [PAR]<br />

ATTENUVAX VACCINE WITH<br />

DILUENT [INJ]<br />

measles vaccine,atten 2<br />

BOOSTRIX [INJ] diphther,pertuss,tetanus vac 2<br />

CARIMUNE NF NANOFILTERED [INJ] immune globulin - iv 4 [PAR]<br />

CERVARIX [INJ] human papillomav vacc bival/pf 2<br />

COMVAX [INJ] hepatitis b/haemophilus b vacc 2<br />

DAPTACEL [INJ] diphther,pertuss,tetanus vac 2<br />

DIPHTHERIA-TETANUS TOXOID<br />

[INJ]<br />

tetanus,diphtheria toxoid 2<br />

ENGERIX-B [INJ] hepatitis b virus vaccine 2<br />

EPOGEN 10,000 UNITS/ML VIAL, -<br />

20,000 UNITS/2 ML VIAL, -20,000<br />

UNITS/ML VIAL, -40,000 UNITS/ML<br />

VIAL [INJ]<br />

epoetin alfa 4 [PAR]<br />

EPOGEN 2,000 UNITS/ML VIAL, -<br />

3,000 UNITS/ML VIAL, -4,000<br />

UNITS/ML VIAL [INJ]<br />

epoetin alfa 3 [PAR]<br />

GAMASTAN S-D [INJ] immune globulin - im 2<br />

GAMMAGARD LIQUID [INJ] immune globulin - iv 4 [PAR]<br />

GAMMAGARD S-D [INJ] immune globulin - iv 4 [PAR]<br />

GAMUNEX [INJ] immune globulin - iv 4 [PAR]<br />

GARDASIL [INJ] human papillomavirus vacc 2<br />

HAVRIX [INJ] hepatatis a virus vaccine 2<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

HEPAGAM B [INJ] hep.b immune glob/maltose 3<br />

HIBERIX [INJ] haemophilus b-tet toxoid 3<br />

HIBTITER [INJ] haemophilus b vaccine 2<br />

HIZENTRA 1 GRAM/5 ML VIAL [INJ] immune globulin- sq 2 [PAR]<br />

HIZENTRA 2 GRAM/10 ML VIAL, -4 immune globulin- sq 4 [PAR]<br />

GRAM/20 ML VIAL [INJ]<br />

HYPERHEP B S-D [INJ] hepatitis b immune globulin 2<br />

HYPERRAB S-D [INJ] rabies immune globulin 3<br />

HYPERRHO S-D [INJ] rho(d) immune globulin 2<br />

HYPERTET S-D [INJ] tetanus immune globulin 3<br />

IMOGAM RABIES-HT [INJ] rabies immune globulin 2<br />

IMOVAX RABIES VACCINE [INJ] rabies vaccine,human diploid 2<br />

INFANRIX [INJ] diphther,pertuss,tetanus vac 2<br />

IPOL [INJ] poliomyelitis vac,killed 2<br />

IXIARO [INJ] japanese encephalitis vaccine 2<br />

JE-VAX [INJ] japanese encephalitis vaccine 2<br />

KEPIVANCE [INJ][LA] palifermin 4<br />

MENACTRA [INJ] meningococcal vac a,c,y,w-135 2<br />

MENOMUNE-A-C-Y-W-135 [INJ] meningococcal vac a,c,y,w-135 2<br />

MENVEO A-C-Y-W-135-DIP mening vac a,c,y,w-135 dip 3<br />

MERUVAX II VACCINE W-DILUENT rubella vaccine 2<br />

[INJ]<br />

MICRHOGAM [INJ] rho(d) immune globulin 3<br />

MICRHOGAM PLUS [INJ] rho(d) immune globulin 3<br />

M-M-R II VACCINE [INJ] measles,mumps&rubella vaccine 2<br />

MOZOBIL [INJ] plerixafor 4<br />

MUMPSVAX VACCINE W-DILUENT mumps vaccine,live 2<br />

[INJ]<br />

OCTAGAM [INJ] immune globulin - iv 4 [PAR]<br />

PEDIARIX [INJ] hep b vaccine/dp (a) t-polio 2<br />

PEDVAXHIB [INJ] haemophilus b vaccine 2<br />

PENTACEL [INJ] dp (a) t-polio/hib conj-tet/pf 3<br />

PRIVIGEN [INJ] immune globulin - iv 4 [PAR]<br />

PROCRIT 10,000 UNITS/ML VIAL, -<br />

2,000 UNITS/ML VIAL, -3,000<br />

UNITS/ML VIAL, -4,000 UNITS/ML<br />

VIAL [INJ]<br />

epoetin alfa 2 [PAR]<br />

PROCRIT 20,000 UNITS/ML VIAL, -<br />

40,000 UNITS/ML VIAL [INJ]<br />

epoetin alfa 4 [PAR]<br />

PROQUAD [INJ] measles,mumps,rub,varicella 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

RABAVERT [INJ] rabies vac,pf chick-emb cell 2<br />

RECOMBIVAX HB [INJ] hepatitis b virus vaccine 2<br />

RHOGAM rho(d) immune globulin 3<br />

RHOGAM PLUS [INJ] rho(d) immune globulin 3<br />

RHOPHYLAC [INJ] rho(d) immune globulin 3<br />

ROTARIX rotavirus vac, live att, 89-12 3<br />

ROTATEQ rotavirus vac, live pentav 2<br />

SYNAGIS [INJ][LA] palivizumab 4<br />

TETANUS DIPHTHERIA TOXOIDS<br />

[INJ]<br />

tetanus,diphtheria toxoid 2<br />

tetanus toxoid adsorbed [INJ] 1<br />

TETANUS-DIPHTERIA-DECAVAC tetanus,diphtheria toxoid 2<br />

[INJ]<br />

THYMOGLOBULIN [INJ] lymphocyte immune globulin 4 [PAR]<br />

TICE BCG [INJ] bcg vaccine 2<br />

TRIHIBIT [INJ] dp (a) ped/hib conj-tet 2<br />

TRIPEDIA [INJ] diphther,pertuss,tetanus vac 2<br />

TWINRIX [INJ] hep b vir recomb/hep a vir 2<br />

TYPHIM VI [INJ] typhoid vaccine 2<br />

VAQTA [INJ] hepatatis a virus vaccine 2<br />

VARIVAX VACCINE [INJ] varicella virus vaccine live 2<br />

VIVAGLOBIN [INJ] immune globulin- sq 4 [PAR]<br />

WINRHO SDF [INJ] rho(d) immune globulin 3<br />

YF-VAX [INJ] yellow fever vaccine 2<br />

ZOSTAVAX [INJ] varicella vacc/pf 2<br />

INSULIN LIKE GROWTH FACTORS-1<br />

INCRELEX [INJ][LA] mecasermin 4 [PAR]<br />

INTERFERONS<br />

ACTIMMUNE [INJ][LA] interferon gamma-1b,recomb. 4<br />

AVONEX [INJ] interferon beta-1a 4 [PAR][QLL,<br />

4 kits/28]<br />

AVONEX ADMINISTRATION PACK interferon beta-1a 4 [PAR][QLL,<br />

[INJ]<br />

4 kits/28]<br />

BETASERON [INJ] interferon beta-1b 4 [PAR][QLL,<br />

15/30]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

EXTAVIA [INJ] interferon beta-1b 4 [PAR][QLL,<br />

15 trays/30]<br />

INFERGEN [INJ] interferon alfacon-1 4<br />

INTRON A 10 MILLION UNIT PEN, -<br />

10 MILLION UNIT/ML, -18 MILLION<br />

UNITS VIAL, -5 MILLION UNIT/ML<br />

PEN, -50 MILLION UNITS VIAL, -6<br />

MILLION UNIT/ML VL [INJ]<br />

interferon alfa-2b , recomb. 4<br />

INTRON A 10 MILLION UNITS VIAL, interferon alfa-2b , recomb. 2<br />

-3 MILLION UNIT/ML PEN [INJ]<br />

PEGASYS 180 MCG/0.5 ML CONV.PK<br />

[INJ]<br />

peginterferon alfa-2a 4 [PAR][QLL,<br />

4<br />

syringes/28]<br />

PEGASYS 180 MCG/ML VIAL [INJ] peginterferon alfa-2a 4 [PAR][QLL,<br />

4/28]<br />

PEGINTRON 120 MCG KIT, -150 peginterferon alfa-2b 4 [PAR][QLL,<br />

MCG KIT, -80 MCG KIT [INJ]<br />

5/34]<br />

PEGINTRON 50 MCG KIT [INJ] peginterferon alfa-2b 4 [PAR][QLL,<br />

5 kits/34]<br />

PEGINTRON REDIPEN [INJ] peginterferon alfa-2b 4 [PAR][QLL,<br />

5 pens/34]<br />

REBIF 22 MCG/0.5 ML SYRINGE, -44 interferon beta-1a/albumin 4 [PAR][QLL,<br />

MCG/0.5 ML SYRINGE [INJ]<br />

8<br />

syringes/35]<br />

REBIF TITRATION PACK [INJ] interferon beta-1a/albumin 4 [PAR][QLL,<br />

12<br />

syringes/28]<br />

INTERLEUKIN RECPTR ANTAGONIST<br />

ACTEMRA 200 MG/10 ML VIAL, -400<br />

MG/20 ML VIAL [INJ]<br />

tocilizumab 4 [PAR]<br />

ACTEMRA 80 MG/4 ML VIAL [INJ] tocilizumab 2 [PAR]<br />

ARCALYST [INJ][LA] rilonacept 4 [PAR]<br />

ILARIS [INJ] canakinumab 2<br />

KINERET [INJ] anakinra 4 [PAR]<br />

INTERLEUKINS<br />

NEUMEGA [INJ] oprelvekin 4 [QLL, 21<br />

vials/21]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

PROLEUKIN [INJ] aldesleukin 4<br />

ZENAPAX [INJ] daclizumab 4 [PAR]<br />

MYELOID STIMULANTS<br />

LEUKINE [INJ] sargramostim 4<br />

NEULASTA [INJ] pegfilgrastim 4 [PAR][QLL,<br />

2/30]<br />

NEUPOGEN [INJ] filgrastim 4 [PAR]<br />

THROMBOPOIETIC AGENTS<br />

PROMACTA [LA] eltrombopag olamine 4<br />

MEDICAL (MISCELLANEOUS) SUPPLIES<br />

DIABETIC SUPPLIES<br />

1ST TIER UNIFINE PENTIPS 2<br />

ACCUSURE 2<br />

AIMSCO ULTRA THIN II 2<br />

ALCOHOL PREP PADS 2<br />

ALCOHOL PREP SWABS 2<br />

ALCOHOL SWABS 2<br />

ALCOHOL WIPES 2<br />

ANTI-STICK INSULIN 2<br />

AUTO INJECTOR 2<br />

AUTOJECT 2 2<br />

AUTOPEN 2<br />

CURAD GAUZE PADS misc supp (dress,tape,gauze) 2<br />

CURITY ALCOHOL PREPS 2<br />

CURITY GAUZE SPONGES misc supp (dress,tape,gauze) 2<br />

EASY COMFORT INSULIN SYRINGE 2<br />

EASY TOUCH NEEDLE DISPOSABLE,<br />

-SYRINGE EMPTY DISPOSABLE<br />

2<br />

EXEL INSULIN SYRINGE 2<br />

GLUCOPRO SYRINGE EMPTY<br />

2<br />

DISPOSABLE<br />

HUMAPEN LUXURA HD 2<br />

HUMAPEN MEMOIR 2<br />

IN CONTROL PEN NEEDLE 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

INJECT-EASE 2<br />

INSULIN PEN NEEDLE 2<br />

INSULIN SYRINGE 2<br />

INSUMED 2<br />

INSUPEN 2<br />

INTEGRA SYRINGE SYRINGE EMPTY<br />

DISPOSABLE<br />

2<br />

LISCO SPONGES misc supp (dress,tape,gauze) 2<br />

LITE TOUCH INSULIN PEN NEEDLES 2<br />

LITE TOUCH SYRINGE EMPTY<br />

DISPOSABLE<br />

2<br />

LUER-LOK SYRINGE SYRINGE<br />

2<br />

EMPTY DISPOSABLE<br />

MEDI-JECTOR NEEDLE-FREE SYR A 2<br />

MEDI-JECTOR NEEDLE-FREE SYR B 2<br />

MEDI-JECTOR NEEDLE-FREE SYR C 2<br />

MEDI-JECTOR VISION 2<br />

MONOJECT 0.5 ML SYRN 28GX1/2 2<br />

MONOJECT INSULIN SAFETY SYRNG 2<br />

MONOJECT INSULIN SYRINGE 2<br />

NANO PEN NEEDLE 3<br />

NORDIPEN 15 2<br />

NORDIPEN 5 2<br />

NOVOFINE 32 2<br />

NOVOFINE AUTOCOVER 2<br />

NOVOPEN 3 2<br />

NOVOPEN JR 2<br />

ORSINI INSULIN SYRINGE 2<br />

PEN 12MM 29G NEEDLES, -<br />

31GX3/16, -31GX5/16, -6MM 31G, -<br />

8MM 31G NEEDLES, -AURORA 6MM<br />

31G, -AURORA S 12MM 29G, -<br />

AURORA S 8MM 31G, -BD 29GX1/2,<br />

-BD 29GX3/16, -BD 29GX5/16, -BD<br />

MINI 31GX3/16, -BD ORIG 29GX1/2,<br />

-BD SHORT 31GX5/16, -LIVE<br />

BETTER 6MM 31G, -LIVE B<br />

2<br />

PEN NEEDLES 2<br />

PRECISION SYRINGE EMPTY<br />

DISPOSABLE<br />

2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

PRODIGY INSULIN SYRINGE 2<br />

PRODIGY PEN NEEDLE 2<br />

SAFESNAP INSULIN SYRINGE 2<br />

SAFETYGLIDE INSULIN SYRINGE 2<br />

SAFETYGLIDE SYRINGE SYRINGE<br />

2<br />

EMPTY DISPOSABLE<br />

SINGLE USE SWAB 2<br />

SURE COMFORT 2<br />

SURE COMFORT ALCOHOL 2<br />

SURE-FINE PEN NEEDLES 2<br />

SURE-JECT INSULIN SYRINGE 2<br />

SURE-PREP ALCOHOL PREP PADS 2<br />

TERUMO INSULIN SYRINGE 2<br />

TERUMO SURGUARD 2<br />

THINPRO INSULIN SYRINGE 2<br />

TOPCARE CLICKFINE 2<br />

TOPCARE ULTRA COMFORT 2<br />

ULTICARE NEEDLE DISPOSABLE, -<br />

2<br />

SYRINGE EMPTY DISPOSABLE<br />

ULTIGUARD 30GX0.5 ML SYRINGE, -<br />

30GX1 ML SYRINGE, -SYRINGE<br />

EMPTY DISPOSABLE<br />

ULTILET ALCOHOL SWAB 2<br />

ULTILET INSULIN SYRINGE 2<br />

ULTILET PEN NEEDLE 2<br />

ULTRA COMFORT 2<br />

ULTRACOMFORT DISPOSABLE<br />

SYRINGE, -NEEDLE DISPOSABLE, -<br />

SYRINGE EMPTY DISPOSABLE<br />

2<br />

UNIFINE PENTIPS 2<br />

VANISHPOINT SYRINGE EMPTY<br />

2<br />

DISPOSABLE<br />

VERSALON ALL PURPOSE SPONGE misc supp (dress,tape,gauze) 2<br />

WEBCOL 2<br />

MUSCULOSKELETAL MEDICATIONS<br />

CNS MUSCLE RELAXANTS<br />

AMRIX cyclobenzaprine 3 [PAR]<br />

carisoprodol compound 1 [PAR]<br />

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2


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

carisoprodol compound-codeine 1 [PAR]<br />

carisoprodol tablet 1 [PAR]<br />

chlorzoxazone 1 [PAR]<br />

cyclobenzaprine hcl tablet 1 [PAR]<br />

FEXMID cyclobenzaprine 3 [PAR]<br />

FLEXERIL [G] cyclobenzaprine 3 [PAR]<br />

metaxalone 1 [PAR]<br />

methocarbamol tablet 1 [PAR]<br />

NORFLEX [INJ][G] orphenadrine 3<br />

orphenadrine citrate injection [INJ] 1<br />

orphenadrine citrate tablet sustained<br />

1 [PAR]<br />

action<br />

orphenadrine compound 1 [PAR]<br />

orphenadrine compound forte 1 [PAR]<br />

PARAFON FORTE DSC [G] chlorzoxazone 3 [PAR]<br />

RILUTEK riluzole 4<br />

ROBAXIN INJECTION [INJ] methocarbamol 3<br />

ROBAXIN TABLET [G] methocarbamol 3 [PAR]<br />

ROBAXIN-750 [G] methocarbamol 3 [PAR]<br />

SKELAXIN [G] metaxalone 3 [PAR]<br />

SOMA [G] carisoprodol 3 [PAR]<br />

DIRECT MUSCLE RELAXANTS<br />

ANECTINE [INJ] succinylcholine 3<br />

baclofen tablet 1<br />

DANTRIUM CAPSULE [G] dantrolene 3<br />

DANTRIUM INJECTION [INJ] dantrolene 3<br />

dantrolene sodium 1<br />

DYSPORT [INJ] abobotulinumtoxina 3<br />

revonto [INJ] 1<br />

tizanidine hcl 1<br />

ZANAFLEX [G] tizanidine 3<br />

DRUGS TO PREVENT AND TREAT GOUT<br />

allopurinol sodium [INJ] 1<br />

allopurinol tablet 1<br />

ALOPRIM [INJ][G] allopurinol 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

COLCRYS colchicine 2<br />

probenecid 1<br />

probenecid-colchicine 1<br />

ULORIC febuxostat 2 [ST]<br />

ZYLOPRIM [G] allopurinol 3<br />

NON-STEROIDAL ANTIINFLAMMATORY AGENTS<br />

ANAPROX [G] naproxen sodium 3 [ST]<br />

ANAPROX DS [G] naproxen sodium 3 [ST]<br />

ANSAID flurbiprofen 3 [ST]<br />

ARTHROTEC 50 diclofenac sodium/misoprostol 3 [ST]<br />

ARTHROTEC 75 diclofenac sodium/misoprostol 3 [ST]<br />

CATAFLAM [G] diclofenac potassium 3 [ST]<br />

CELEBREX celecoxib 2 [ST]<br />

CLINORIL [G] sulindac 3 [ST]<br />

DAYPRO [G] oxaprozin 3 [ST]<br />

diclofenac potassium 1<br />

diclofenac sodium tablet enteric<br />

coated, -tablet sustained release<br />

1<br />

24hr<br />

EC-NAPROSYN [G] naproxen 3 [ST]<br />

etodolac 1<br />

FELDENE [G] piroxicam 3 [ST]<br />

fenoprofen calcium 1<br />

flurbiprofen tablet 1<br />

ibuprofen 100 mg/5 ml, -100 mg/5<br />

ml sus, -100 mg/5 ml susp, -400 mg<br />

tablet, -600 mg tablet, -800 mg<br />

1<br />

tablet<br />

INDOCIN I.V. [INJ] indomethacin sodium trihydrate 3<br />

INDOCIN SR indomethacin 3 [ST]<br />

INDOCIN SUPPOSITORY RECTAL indomethacin 3<br />

INDOCIN SUSPENSION ORAL indomethacin 3 [ST]<br />

indomethacin capsule, -capsule<br />

sustained action<br />

1<br />

indomethacin injection [INJ] 4<br />

ketoprofen capsule, -capsule 24hr<br />

sustained release pellets<br />

1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ketorolac tromethamine injection<br />

[INJ]<br />

1<br />

ketorolac tromethamine tablet 1 [QLL, 20/5]<br />

meclofenamate sodium capsule 1<br />

meloxicam 15 mg tablet, -<br />

suspension oral<br />

1<br />

meloxicam 7.5 mg tablet 1 [QLL,<br />

34/34]<br />

MOBIC 15 MG TABLET, -<br />

SUSPENSION ORAL [G]<br />

meloxicam 3 [ST]<br />

MOBIC 7.5 MG TABLET [G] meloxicam 3 [QLL,<br />

34/34][ST]<br />

nabumetone 1<br />

NALFON fenoprofen 3 [ST]<br />

NAPRELAN naproxen sodium 3 [ST]<br />

NAPRELAN CR DOSE CARD naproxen 3 [ST]<br />

NAPROSYN [G] naproxen 3 [ST]<br />

naproxen 250 mg tablet, -375 mg<br />

tablet, -suspension oral, -tablet<br />

enteric coated<br />

1<br />

naproxen 500 mg tablet 1<br />

naproxen sodium 275 mg tab, -550<br />

mg tab<br />

1<br />

NEOPROFEN [INJ] ibuprofen lysine 3<br />

oxaprozin 1<br />

piroxicam capsule 1<br />

PONSTEL mefenamic acid 3 [ST]<br />

sulindac tablet 1<br />

tolmetin sodium 1<br />

TORADOL [INJ] ketorolac 3<br />

VIMOVO naproxen/esomeprazole mag 3 [ST]<br />

VOLTAREN TABLET ENTERIC<br />

COATED<br />

diclofenac sodium 3 [ST]<br />

VOLTAREN-XR [G] diclofenac sodium 3 [ST]<br />

ZIPSOR diclofenac potassium 3 [ST]<br />

OTHER DRUGS FOR ARTHRITIS<br />

CUPRIMINE penicillamine 2<br />

DEPEN penicillamine 3<br />

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Drug Generic Tier Restrictions<br />

gold sodium thiomalate [INJ] 1<br />

myochrysine [INJ] 1<br />

RIDAURA auranofin 2<br />

SYPRINE trientine 2<br />

SALICYLATES AND RELATED DRUGS<br />

aspirin ec 975 mg tablet 1<br />

choline mag trisalicylate 1<br />

diflunisal 1<br />

EASPRIN aspirin 3<br />

salsalate 1<br />

ZORPRIN aspirin 3<br />

NUTRITION,BLOOD MODIFIERS,ELECTROLYTES<br />

ANTIPLATELET DRUGS<br />

AGGRASTAT [INJ] tirofib hc m-hyd/na chlor 3<br />

AGGRENOX aspirin/dipyridamole 2<br />

cilostazol 1<br />

dipyridamole tablet 1<br />

EFFIENT prasugrel 2<br />

INTEGRILIN [INJ] eptifibatide 3<br />

PERSANTINE [G] dipyridamole 3<br />

PLAVIX clopidogrel 2<br />

PLETAL [G] cilostazol 3<br />

REOPRO [INJ] abciximab 3<br />

ticlopidine hcl 1<br />

BLOOD DETOXICANTS<br />

constulose 1<br />

enulose 1<br />

FOSRENOL lanthanum carbonate 3<br />

generlac 1<br />

KRISTALOSE lactulose 3<br />

lactulose 1<br />

RENAGEL sevelamer 3<br />

RENVELA sevelamer carbonate 2<br />

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Drug Generic Tier Restrictions<br />

ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.<br />

ALBUMINAR-25 [INJ] albumin human 3<br />

alburx [INJ] 1<br />

albutein [INJ] 1<br />

alcohol in dextrose [INJ] 1<br />

AMINOSYN [INJ] amino acids 2<br />

AMINOSYN II [INJ] amino acids 2<br />

AMINOSYN II 3.5% M-DEXTROSE<br />

5% [INJ]<br />

amino acids 2<br />

AMINOSYN II 3.5%-DEXTROSE 25%<br />

[INJ]<br />

amino acids 2<br />

AMINOSYN II 3.5%-DEXTROSE 5%<br />

[INJ]<br />

amino acids 2<br />

AMINOSYN II 4.25% M-DEXT 10%<br />

[INJ]<br />

amino acids 2<br />

AMINOSYN II 4.25%-DEXTROSE<br />

25% [INJ]<br />

amino acids 2<br />

AMINOSYN II 5% IN 25%<br />

DEXTROSE [INJ]<br />

amino acids 2<br />

AMINOSYN II IN DEXTROSE [INJ] amino acids 2<br />

AMINOSYN II WITH LYTES-CA-DW<br />

[INJ]<br />

amino acids 2<br />

AMINOSYN M [INJ] amino acids 2<br />

AMINOSYN WITH ELECTROLYTES amino acids 2<br />

[INJ]<br />

AMINOSYN-HBC [INJ] amino acids 2<br />

AMINOSYN-HF [INJ] amino acids 2<br />

AMINOSYN-PF [INJ] amino acids 2<br />

AMINOSYN-RF [INJ] amino acids 2<br />

AMMONIUM CHLORIDE INJECTION ammonium chloride 2<br />

[INJ]<br />

BRANCHAMIN [INJ] amino acids 2<br />

BUMINATE [INJ] albumin human 3<br />

calcium chloride injection [INJ] 1<br />

CLINIMIX [INJ] amino acids 2<br />

CLINIMIX E [INJ] amino acids 2<br />

CLINISOL [INJ] amino acids 2<br />

CYSTAGON [LA] cysteamine 2<br />

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Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

d5w/kcl 10 meq/l iv solution, -30<br />

meq/l iv solution [INJ]<br />

1<br />

dextrose 10%-1/4ns [INJ] 1<br />

dextrose 10%-1/4ns-kcl [INJ] 1<br />

dextrose 2.5%-lr 1/2 str sol [INJ] 1<br />

dextrose 5%-1/2ns-kcl [INJ] 1<br />

dextrose 5%-1/3ns-kcl [INJ] 1<br />

dextrose 5%-1/4ns-kcl [INJ] 1<br />

dextrose 5%-electrolyte #48 [INJ] 1<br />

dextrose 5%-electrolyte #75 [INJ] 1<br />

dextrose 5%-ns-kcl [INJ] 1<br />

dextrose in ringers injection [INJ] 1<br />

dextrose in water [INJ] 1<br />

dextrose with sodium chloride [INJ] 1<br />

FLEXBUMIN [INJ] albumin human 3<br />

FREAMINE HBC [INJ] amino acids 3<br />

FREAMINE III [INJ] amino acids 2<br />

FREAMINE III WITH ELECTROLYTES<br />

[INJ]<br />

aa 3%/electrolyte-tpn/glycerin 3<br />

HEPATAMINE [INJ] amino acids 2<br />

HEPATASOL [INJ] amino acids 2<br />

HUMAN ALBUMIN 25% IV<br />

SOLUTION [INJ]<br />

albumin human 3<br />

HYPERLYTE CR [INJ] electrolyte solutions 3<br />

IONOSOL B WITH DEXTROSE 5%<br />

[INJ]<br />

electrolyte solutions 2<br />

IONOSOL MB-DEXTROSE 5% [INJ] electrolyte solutions 2<br />

IONOSOL T-DEXTROSE 5% [INJ] electrolyte solutions 2<br />

ISOLYTE H WITH DEXTROSE [INJ] dextrose/electrolytes 2<br />

ISOLYTE M WITH DEXTROSE [INJ] dextrose/electrolytes 2<br />

ISOLYTE P WITH DEXTROSE [INJ] dextrose/electrolytes 2<br />

ISOLYTE S [INJ] electrolyte solutions 2<br />

ISOLYTE S WITH DEXTROSE [INJ] dextrose/electrolytes 2<br />

kcl 40 meq in d5w-lact ringer [INJ] 1<br />

lactated ringers injection [INJ] 1<br />

magnesium sulfate injection [INJ] 1<br />

MAGNESIUM SULFATE-D5W [INJ] magnesium sulfate/d5w 2<br />

mannitol injection [INJ] 1<br />

NEPHRAMINE [INJ] amino acids 2<br />

NEUT [INJ] sodium bicarbonate 2<br />

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Drug Generic Tier Restrictions<br />

NORMOSOL-M AND DEXTROSE<br />

[INJ]<br />

dextrose/electrolytes 2<br />

NORMOSOL-R [INJ] electrolyte solutions 2<br />

NORMOSOL-R AND DEXTROSE [INJ] electrolyte solutions 2<br />

NORMOSOL-R PH 7.4 [INJ] electrolyte solutions 2<br />

NOVAMINE [INJ] amino acids 2<br />

nutrilyte [INJ] 1<br />

nutrilyte ii [INJ] 1<br />

OSMITROL [INJ] mannitol 3<br />

PLASBUMIN-25 [INJ] albumin human 3<br />

PLASMA-LYTE 148 [INJ] electrolyte solutions 2<br />

PLASMA-LYTE 148 IN DEXTROSE<br />

[INJ]<br />

electrolyte solutions 2<br />

PLASMA-LYTE 56 [INJ] electrolyte solutions 2<br />

PLASMA-LYTE 56 IN DEXTROSE<br />

[INJ]<br />

d5w/electrolyte-56 solution 2<br />

PLASMA-LYTE A PH 7.4 [INJ] electrolyte solutions 2<br />

PLASMA-LYTE R [INJ] electrolyte solutions 2<br />

potassium chl-normal saline [INJ] 1<br />

potassium chloride-nacl [INJ] 1<br />

PREMASOL [INJ] amino acids 2<br />

PROCALAMINE [INJ] aa 3%/electrolyte-tpn/glycerin 2<br />

PROSOL [INJ] amino acids 3<br />

RENAMIN [INJ] amino acids 2<br />

RESECTISOL mannitol 3<br />

R-GENE 10 [INJ] arginine 2<br />

ringers injection [INJ] 1<br />

sodium acetate [INJ] 1<br />

sodium bicarbonate injection [INJ] 1<br />

sodium chloride 0.45% irrig, -0.9%<br />

irrig., -sterile saline 0.9% irr<br />

1<br />

sodium chloride 0.45% soln, -0.45%<br />

soln-excel con, -0.9% soln, -0.9%<br />

soln., -0.9% soln-excel cont, -0.9%<br />

solution, -3% iv soln, -4 meq/ml vl,<br />

-5% iv soln, -cl 2.5 meq/ml vial<br />

[INJ]<br />

1<br />

sodium lactate [INJ] 1<br />

sodium phosphate injection [INJ] 1<br />

TPN ELECTROLYTES [INJ][G] electrolyte solutions 3<br />

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Drug Generic Tier Restrictions<br />

TPN ELECTROLYTES II [INJ] electrolyte solutions 2<br />

TRAVASOL [INJ] amino acids 2<br />

TRAVASOL WITH DEXTROSE [INJ] amino acids 2<br />

TRAVASOL WITH ELECTROLYTES<br />

[INJ]<br />

amino acids 2<br />

TROPHAMINE [INJ] amino acids 2<br />

FLUORIDE PRODUCTS<br />

CAVIRINSE sodium fluoride 3<br />

CONTROL RX sodium fluoride 3<br />

denta 5000 plus 1<br />

dentagel 1<br />

easygel 1<br />

epiflur 1<br />

ethedent 1<br />

FLUORABON sodium fluoride 3<br />

FLUOR-A-DAY DROPS sodium fluoride 3<br />

fluor-a-day tablet chewable 1<br />

fluoridex daily defense 1<br />

FLUORIDEX SENSITIVITY RELIEF sodium fluoride/pot nitrate 3<br />

fluoritab tablet chewable 1<br />

flura 1<br />

FLURA-DROPS sodium fluoride 3<br />

GEL-KAM stannous fluoride 3<br />

lozi-flur 1<br />

ludent fluoride 1<br />

LURIDE sodium fluoride 3<br />

neutragard advanced 1<br />

perio med 1<br />

PHOS-FLUR sodium fluoride 3<br />

PREVIDENT sodium fluoride 3<br />

PREVIDENT 5000 sodium fluoride 3<br />

PREVIDENT 5000 PLUS sodium fluoride 3<br />

PREVIDENT 5000 SENSITIVE sodium fluoride/pot nitrate 3<br />

renaf 1<br />

sf 1<br />

sf 5000 plus 1<br />

sodium fluoride drops, -solution<br />

non-oral, -tablet, -tablet chewable<br />

1<br />

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Drug Generic Tier Restrictions<br />

stanimax 1<br />

stannous fluoride solution 1<br />

HEPARIN ANTAGONISTS<br />

PROTAMINE SULFATE [INJ] protamine 3<br />

INJECTABLE ANTICOAGULANTS<br />

ARIXTRA 10 MG SYRINGE, -5 MG<br />

SYRINGE, -7.5 MG SYRINGE [INJ]<br />

fondaparinux sodium 4<br />

ARIXTRA 2.5 MG SYRINGE [INJ] fondaparinux sodium 2<br />

enoxaparin 100 mg/ml syr, -30<br />

mg/0.3 ml syr, -40 mg/0.4 ml syr, -<br />

60 mg/0.6 ml syr, -80 mg/0.8 ml syr<br />

[INJ]<br />

1<br />

enoxaparin 120 mg/0.8 ml syr, -150<br />

mg/ml syr [INJ]<br />

4<br />

FRAGMIN 10,000 UNITS SYRINGE, -<br />

10,000 UNITS/ML VIAL, -12,500<br />

UNITS SYRINGE, -15,000 UNITS<br />

SYRINGE, -18,000 UNITS SYRINGE,<br />

-25,000 UNITS/ML VIAL, -7,500<br />

UNITS SYRINGE [INJ]<br />

dalteparin (porcine) 4<br />

FRAGMIN 2,500 UNITS SYRINGE, -<br />

5,000 UNITS SYRINGE [INJ]<br />

dalteparin (porcine) 3<br />

heparin sodium in 0.45% nacl [INJ] 1<br />

heparin sodium in 0.9% nacl [INJ] 1<br />

heparin sodium in 5% dextrose<br />

[INJ]<br />

1<br />

heparin sodium injection [INJ] 1<br />

INNOHEP [INJ] tinzaparin sodium, porcine 3<br />

LOVENOX 100 MG PREFILLED SYR, -<br />

120 MG PREFILLED SYR, -150 MG<br />

PREFILLED SYR, -300 MG VIAL, -60<br />

MG PREFILLED SYRN, -80 MG<br />

PREFILLED SYRN [INJ]<br />

enoxaparin 4<br />

LOVENOX 30 MG PREFILLED SYRN,<br />

-40 MG PREFILLED SYRN [INJ]<br />

enoxaparin 2<br />

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Drug Generic Tier Restrictions<br />

ORAL ANTICOAGULANTS, VITAMIN K<br />

ARGATROBAN [INJ] argatroban 3<br />

COUMADIN INJECTION [INJ] warfarin sodium 3<br />

COUMADIN TABLET [G] warfarin sodium 3<br />

jantoven 1<br />

warfarin sodium 1<br />

OTHER DRUGS AFFECTING COAGULATION<br />

ATRYN [INJ] antithrombin iii, human recomb 3<br />

REFLUDAN [INJ] lepirudin,recombinant 2<br />

THROMBATE III [INJ] antithrombin iii,human 3<br />

POTASSIUM REMOVING RESINS<br />

kalexate 1<br />

KAYEXALATE [G] sodium polystyrene sulfonate 3<br />

KIONEX POWDER [G] sodium polystyrene sulfonate 3<br />

kionex suspension oral 1<br />

marlexate 1<br />

sodium polystyrene sulfonate 1<br />

sps 1<br />

POTASSIUM SUPPLEMENTS<br />

cytra-2 1<br />

dextrose 5%-lr iv solution [INJ] 1<br />

EFFER-K 10 MEQ TABLET EFF, -20<br />

MEQ TABLET EFF<br />

potassium bicarb/ca 3<br />

effer-k 25 meq tablet eff 1<br />

epiklor 1<br />

k effervescent 1<br />

KAOCHLOR potassium chloride 3<br />

kaon-cl 10 1<br />

KAY CIEL potassium chloride 3<br />

kcl 20 meq in d5w solution, -20<br />

meq/l iv solution, -40 meq in d5w<br />

solution, -40 meq/l iv solution [INJ]<br />

1<br />

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Drug Generic Tier Restrictions<br />

kcl 20 meq in d5w-lact ringer, -40<br />

meq in d5w-lact ringer [INJ]<br />

1<br />

klor-con 10 1<br />

klor-con 20 meq packet 1<br />

KLOR-CON 25 MEQ PACKET potassium chloride 3<br />

klor-con 8 1<br />

klor-con m10 1<br />

klor-con m15 1<br />

klor-con m20 1<br />

klor-con-ef 1<br />

K-PHOS NEUTRAL phosphorus 3<br />

K-TAB potassium chloride 3<br />

liqui-dualcitra 1<br />

MICRO-K [INJ] potassium chloride 3<br />

ORACIT sodium citrate/citric acid 3<br />

phospha 250 neutral 1<br />

potassium acetate injection [INJ] 1<br />

potassium bicarbonate tablet<br />

effervescent<br />

1<br />

potassium chloride capsule<br />

sustained action, -cl 20 meq tab er,<br />

-cl er 10 meq tablet, -cl er 20 meq<br />

tablet, -cl er 8 meq tablet, -solution<br />

1<br />

potassium chloride injection [INJ] 1<br />

potassium cl 10 meq tab sa, -tablet<br />

effervescent<br />

1<br />

sodium citrate & citric acid 1<br />

vis-phos n 1<br />

THERAPEUTIC VITAMINS AND MINERALS<br />

CALCIJEX [INJ][G] calcitriol 3<br />

calcitriol capsule, -solution 1<br />

calcitriol injection [INJ] 1<br />

calcium acetate 1<br />

CARNITOR INJECTION [INJ][G] levocarnitine 3<br />

CARNITOR SF levocarnitine 3<br />

CARNITOR SOLUTION, -TABLET [G] levocarnitine 3<br />

eliphos 1<br />

HECTOROL CAPSULE doxercalciferol 3<br />

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Drug Generic Tier Restrictions<br />

HECTOROL INJECTION [INJ] doxercalciferol 3<br />

levocarnitine injection [INJ] 1<br />

levocarnitine solution, -tablet 1<br />

PHOSLO [G] calcium acetate 3<br />

ROCALTROL [G] calcitriol 3<br />

ZEMPLAR CAPSULE paricalcitol 2<br />

ZEMPLAR INJECTION [INJ] paricalcitol 2<br />

VITAMINS AND MINERALS AND RELATED PRODUCTS<br />

INTRALIPID 30% IV FAT EMUL<br />

[INJ][G]<br />

fat emulsions 2<br />

INTRALIPID 10% IV FAT EMUL, -<br />

20% IV FAT EMUL [INJ][G]<br />

fat emulsions 3<br />

LIPOSYN II [INJ] fat emulsions 2<br />

liposyn iii [INJ] 1<br />

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS<br />

ABORTIFACIENTS<br />

CERVIDIL dinoprostone 3<br />

HEMABATE [INJ] carboprost tromethamine 2<br />

PROSTIN E2 VAGINAL<br />

SUPPOSITORY<br />

dinoprostone 2<br />

ANDROGEN DRUGS<br />

ANADROL-50 oxymetholone 4 [PAR]<br />

ANDRODERM testosterone 3 [PAR]<br />

ANDROGEL testosterone 2 [PAR]<br />

ANDROID methyltestosterone 3<br />

ANDROXY fluoxymesterone 2<br />

danazol capsule 1<br />

DELATESTRYL [INJ][G] testosterone enanthate 3<br />

DEPO-TESTOSTERONE [INJ][G] testosterone cypionate 3<br />

FIRST-TESTOSTERONE testosterone propionate 3<br />

FIRST-TESTOSTERONE MC testosterone propionate 3<br />

METHITEST methyltestosterone 2<br />

OXANDRIN 10 MG TABLET [G] oxandrolone 4 [PAR]<br />

OXANDRIN 2.5 MG TABLET [G] oxandrolone 3 [PAR]<br />

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Drug Generic Tier Restrictions<br />

oxandrolone 1 [PAR]<br />

STRIANT testosterone 3 [PAR]<br />

TESTIM testosterone 2 [PAR]<br />

TESTOPEL [INJ] testosterone 2<br />

testosterone cypionate injection<br />

1<br />

[INJ]<br />

testosterone enanthate [INJ] 1<br />

TESTRED methyltestosterone 3<br />

CONTRACEPTIVES<br />

apri 1<br />

aranelle 1<br />

aviane 1<br />

azurette 1<br />

balziva 1<br />

BREVICON [G] norethindrone-ethin estradiol 3<br />

caziant 1<br />

cesia 1<br />

cryselle 1<br />

CYCLESSA [G] desogestrel-ethinyl estradiol 3<br />

DEMULEN 1-50-21 ethynodiol diace-eth estradiol 3<br />

DESOGEN [G] desogestrel-ethinyl estradiol 3<br />

enpresse 1<br />

ESTROSTEP FE [G] noreth a-et estra/fe fumarate 3<br />

FEMCON FE noreth-ethinyl estradiol/iron 3<br />

gianvi 1<br />

gildess fe 1<br />

jolessa 1<br />

junel 1<br />

junel fe 1<br />

kariva 1<br />

kelnor 1-35 1<br />

leena 1<br />

lessina 1<br />

LEVLEN 28 levonorgestrel-ethin estradiol 3<br />

levora-28 1<br />

LOESTRIN [G] norethindrone a-e estradiol 3<br />

LOESTRIN 24 FE noreth a-et estra/fe fumarate 3<br />

LOESTRIN FE [G] noreth a-et estra/fe fumarate 3<br />

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Drug Generic Tier Restrictions<br />

LO-OVRAL-28 [G] norgestrel-ethinyl estradiol 3<br />

LOSEASONIQUE l-norgest-eth estr/ethin estr 3<br />

low-ogestrel 1<br />

lutera 1<br />

LYBREL levonorgestrel-ethin estradiol 3<br />

microgestin 1<br />

microgestin fe 1<br />

MIRCETTE desog-et estra/ethin estra 3<br />

MODICON [G] norethindrone-ethin estradiol 3<br />

mononessa 1<br />

NATAZIA estradiol valerate/dienogest 3<br />

necon 1<br />

next choice 1<br />

NORDETTE-28 [G] levonorgestrel-ethin estradiol 3<br />

norgestrel-ethiny estra 1<br />

NORINYL 1+35 [G] norethindrone-ethin estradiol 3<br />

NORINYL 1+50 norethindrone-mestranol 3<br />

nortrel 1<br />

NUVARING etonogestrel/ethin estradiol 3<br />

ocella 1<br />

ogestrel 1<br />

ORTHO EVRA ethinyl estradiol/norelgest 3<br />

ORTHO TRI-CYCLEN norgestimate-ethinyl estradiol 3<br />

ORTHO TRI-CYCLEN LO norgestimate-ethinyl estradiol 3<br />

ORTHO-CEPT [G] desogestrel-ethinyl estradiol 3<br />

ORTHO-CYCLEN [G] norgestimate-ethinyl estradiol 3<br />

ORTHO-NOVUM [G] norethindrone-ethin estradiol 3<br />

OVCON-35 [G] norethindrone-ethin estradiol 3<br />

OVCON-50 norethindrone-ethin estradiol 3<br />

PLAN B [G] levonorgestrel 3<br />

PLAN B ONE-STEP levonorgestrel 3<br />

portia 1<br />

previfem 1<br />

quasense 1<br />

reclipsen 1<br />

SEASONALE [G] levonorgestrel-ethin estradiol 3<br />

SEASONIQUE l-norgest-eth estr/ethin estr 3<br />

solia 1<br />

sprintec 1<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

sronyx 1<br />

tilia fe 1<br />

tri-legest fe 1<br />

tri-lo-sprintec 1<br />

trinessa 1<br />

TRI-NORINYL [G] norethindrone-ethin estradiol 3<br />

tri-previfem 1<br />

tri-sprintec 1<br />

trivora-28 1<br />

velivet 1<br />

YASMIN 28 [G] eth estradiol/drospirenone 3<br />

YAZ [G] eth estradiol/drospirenone 3<br />

zenchent 1<br />

zovia 1-35e 1<br />

zovia 1-50e 1<br />

ESTROGEN DRUGS<br />

ALORA estradiol 3 [QLL,<br />

10/35]<br />

CENESTIN estrogen,conjug,synthetic a 3<br />

CLIMARA [G] estradiol 3 [QLL, 5/35]<br />

DELESTROGEN [INJ][G] estradiol valerate 3<br />

DEPO-ESTRADIOL [INJ] estradiol cypionate 3<br />

DIVIGEL estradiol 3 [QLL,<br />

34/34]<br />

ELESTRIN estradiol 3 [QLL, 144<br />

gm/34]<br />

ENJUVIA estrogen,conjug,synthetic b 2<br />

ESTRACE CREAM WITH<br />

estradiol 2<br />

APPLICATOR<br />

ESTRACE TABLET [G] estradiol 3<br />

ESTRADERM estradiol 2 [QLL,<br />

10/35]<br />

estradiol patch transdermal weekly 1 [QLL, 5/35]<br />

estradiol tablet 1<br />

estradiol valerate injection [INJ] 1<br />

ESTRASORB estradiol 3 [QLL,<br />

118/34]<br />

ESTRING estradiol 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

estropipate 1<br />

EVAMIST estradiol 3 [QLL, 16<br />

ml/34]<br />

FEMRING estradiol 3<br />

FEMTRACE estradiol 3<br />

GYNODIOL estradiol 3<br />

MENEST estrogens,esterified 3<br />

MENOSTAR estradiol 3 [QLL, 5/35]<br />

OGEN [G] estropipate 3<br />

ORTHO-EST estropipate 3<br />

PREMARIN CREAM WITH<br />

estrogens,conjugated 2<br />

APPLICATOR, -TABLET<br />

PREMARIN INJECTION [INJ] estrogens,conjugated 2<br />

VAGIFEM estradiol 2<br />

VIVELLE estradiol 2 [QLL,<br />

10/35]<br />

VIVELLE-DOT estradiol 2 [QLL,<br />

10/35]<br />

ESTROGEN/PROGESTIN COMBINATIONS<br />

ACTIVELLA [G] estradiol/noreth ac 3<br />

ANGELIQ estradiol/drospirenone 3<br />

CLIMARA PRO estradiol/levonorgestrel 2 [QLL, 5/35]<br />

COMBIPATCH estradiol/noreth ac 2<br />

estradiol-norethindrone acetat 1<br />

FEMHRT norethindrone a-e estradiol 3<br />

mimvey 1<br />

PREFEST estradiol/norgestimate 3<br />

PREMPHASE estrogen/medroxyprogesterone 2<br />

PREMPRO estrogen/medroxyprogesterone 2<br />

OB/GYN TOPICAL ANTIINFECTIVES<br />

ACID JELLY acetic ac/ricinoleic/oxyquinol 3<br />

AVC sulfanilamide 3<br />

CLEOCIN [G] clindamycin phosphate 3<br />

CLINDAMAX CREAM WITH<br />

APPLICATOR<br />

clindamycin phosphate 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

clindamycin phosphate cream with<br />

applicator<br />

1<br />

CLINDESSE clindamycin phosphate 3<br />

fem ph 1<br />

METROGEL-VAGINAL [G] metronidazole 3<br />

metronidazole gel with applicator 1<br />

RELAGARD acetic acid/oxyquin so4 3<br />

vandazole 1<br />

OXYTOCICS<br />

METHERGINE INJECTION [INJ] methylergonovine 2<br />

METHERGINE TABLET methylergonovine 2<br />

oxytocin injection [INJ] 1<br />

PITOCIN [INJ] oxytocin 3<br />

PRENATAL VITAMINS<br />

advanced care plus 1<br />

advanced natalcare 1<br />

cal-nate 1<br />

carenatal dha 1<br />

cavan one omega 1<br />

cavan-alpha kit 1<br />

cavan-ec sod dha 1<br />

CITRANATAL 90 DHA prenatal vit( = or > 1mg fa) 3<br />

CITRANATAL DHA prenatal vit( = or > 1mg fa) 3<br />

CITRANATAL RX prenatal vit( = or > 1mg fa) 3<br />

combi rx 1<br />

complete natal dha 1<br />

completenate 1<br />

co-natal fa 1<br />

CONCEPT DHA prenatal vit( = or > 1mg fa) 3<br />

CONCEPT OB prenatal vit( = or > 1mg fa) 3<br />

docosavit 1<br />

dualvit ob 1<br />

edge ob 1<br />

elite ob dha 1<br />

elite-ob 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

fe c plus tablet 1<br />

folbecal 1<br />

folcal dha 1<br />

folcaps omega-3 1<br />

folinatal plus b 1<br />

folivane-ec calcium dha nf 1<br />

folivane-ob 1<br />

folivane-prx dha nf 1<br />

foltabs 1<br />

foltabs 90 plus dha 1<br />

gentex ade 1<br />

GESTICARE prenatal vit( = or > 1mg fa) 3<br />

GESTICARE DHA prenatal vit( = or > 1mg fa) 3<br />

hip prenatal 1<br />

ICAR-C PLUS iron,carbonyl/vit c/vit b12/fa 3<br />

inatal advance 1<br />

inatal gt 1<br />

inatal ultra 1<br />

kolnatal dha 1<br />

LACTOCAL-F prenatal vit( = or > 1mg fa) 3<br />

maternity 1<br />

multinatal plus 1<br />

multi-nate 30 1<br />

multi-nate 30 dha 1<br />

multi-nate dha extra 1<br />

mynatal 1<br />

mynatal advance 1<br />

mynatal plus 1<br />

mynatal-z 1<br />

mynate 90 plus 1<br />

natacaps 1<br />

NATACHEW prenatal vitamins (< 1mg fa) 3<br />

NATAFORT prenatal vitamins (< 1mg fa) 3<br />

natalcare pic forte 1<br />

natalcare plus 1<br />

natatab 1<br />

NATELLE prenatal vit( = or > 1mg fa) 3<br />

NATELLE C prenatal vit( = or > 1mg fa) 3<br />

NATELLE ONE prenatal vit( = or > 1mg fa) 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

NATELLE PLUS prenatal vit( = or > 1mg fa) 3<br />

NATELLE PREFER prenatal vit( = or > 1mg fa) 3<br />

NATELLE-EZ prenatal vit( = or > 1mg fa) 3<br />

NEEVO prenatal vit( = or > 1mg fa) 3<br />

NOVANATAL prenatal vit( = or > 1mg fa) 3<br />

NOVASTART prenatal vit( = or > 1mg fa) 3<br />

nutrinate 1<br />

nutrispire 1<br />

ob + dha 1<br />

ob 90 + dha 1<br />

ob-natal one 1<br />

OBTREX prenatal vit( = or > 1mg fa) 3<br />

O-CAL FA prenatal vit( = or > 1mg fa) 3<br />

O-CAL PRENATAL prenatal vit( = or > 1mg fa) 3<br />

OPTINATE prenatal vit( = or > 1mg fa) 3<br />

pnv-dha 1<br />

pnv-iron 1<br />

pnv-omega 1<br />

pnv-select 1<br />

poly iron pn 1<br />

POLY IRON PN FORTE prenatal vitamins (< 1mg fa) 3<br />

pr natal 430 1<br />

pr natal 430 ec 1<br />

pr natal 440 ec 1<br />

PREFERA-OB prenatal vit( = or > 1mg fa) 3<br />

PREFERA-OB ONE prenatal vit( = or > 1mg fa) 3<br />

PREFERA-OB PLUS DHA prenatal vit( = or > 1mg fa) 3<br />

prenacare 1<br />

prenafirst 1<br />

prenaplus 1<br />

prenatabs fa 1<br />

prenatabs obn 1<br />

prenatabs rx 1<br />

prenatal 19 1<br />

prenatal ad 1<br />

prenatal formula tablet 1<br />

prenatal low iron 1<br />

prenatal mr 90 fe 1<br />

prenatal multivitamin w-iron 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

prenatal plus 1<br />

prenatal rx 1 1<br />

prenatal z 1<br />

prenatal-u 1<br />

PRENATE DHA prenatal vit( = or > 1mg fa) 3<br />

PRENATE ELITE prenatal vit( = or > 1mg fa) 3<br />

PRENATE ESSENTIAL prenatal vit( = or > 1mg fa) 3<br />

prenate plus 1<br />

PRENEXA prenatal vitamins (< 1mg fa) 3<br />

PREQUE 10 prenatal vitamins (< 1mg fa) 3<br />

previt+dha 1<br />

previte rx 1<br />

pruet dha 1<br />

pruet dha ec 1<br />

re-nata 29 1<br />

re-nata 29 ob 1<br />

renate 1<br />

renate dha 1<br />

renate dha extra 1<br />

rovin-nv 1<br />

rovin-nv dha 1<br />

se-care 1<br />

se-care conceive 1<br />

se-care gesture 1<br />

SELECT-OB prenatal vit( = or > 1mg fa) 3<br />

SELECT-OB + DHA prenatal vit( = or > 1mg fa) 3<br />

se-natal 19 1<br />

se-natal 90 1<br />

se-natal one 1<br />

se-plete dha 1<br />

se-tan dha 1<br />

setonet 1<br />

setonet-ec 1<br />

TANDEM DHA prenatal vit( = or > 1mg fa) 3<br />

TANDEM OB prenatal vit( = or > 1mg fa) 3<br />

taron a prenatal 1<br />

taron ec calcium 1<br />

taron-c dha 1<br />

taron-ec cal 1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

taron-prex prenatal 1<br />

tri rx 1<br />

triadvance 1<br />

TRICARE prenatal vit( = or > 1mg fa) 3<br />

TRICARE PRENATAL DHA ONE prenatal vit( = or > 1mg fa) 3<br />

trifera ob 1<br />

trimesis rx 1<br />

trinatal rx 1 1<br />

trinate 1<br />

triveen-one 1<br />

triveen-prx rnf 1<br />

triveen-u 1<br />

ultimatecare advantage 1<br />

ultimatecare one 1<br />

ultimatecare one nf 1<br />

vinacal 1<br />

vinate az 1<br />

vinate az extra 1<br />

vinate c 1<br />

vinate calcium 1<br />

vinate care 1<br />

vinate gt 1<br />

vinate ic 1<br />

vinate ii 1<br />

vinate iii 1<br />

vinate one 1<br />

vinate pn care 1<br />

vinate ultra 1<br />

vinate-m 1<br />

vitafol-ob 1<br />

VITAFOL-OB+DHA prenatal vit( = or > 1mg fa) 3<br />

vitafol-pn 1<br />

vitanatal ob + dha 1<br />

vitaphil 1<br />

vitaphil + dha 1<br />

vitaphil + dha 90 1<br />

vitaphil aide 1<br />

vitaspire 1<br />

VOL-TAB RX prenatal vit( = or > 1mg fa) 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

vynatal-fa 1<br />

zatean-pn 1<br />

zatean-pn dha 1<br />

zatean-pn plus 1<br />

PROGESTIN DRUGS<br />

AYGESTIN [G] norethindrone acetate 3<br />

camila 1<br />

CRINONE progesterone 3<br />

DEPO-PROVERA 150 MG/ML VIAL medroxyprogesterone 3 [QLL, 1<br />

[INJ][G]<br />

ml/90]<br />

DEPO-SUBQ PROVERA 104 [INJ] medroxyprogesterone 3 [QLL, 1<br />

syringe/90]<br />

errin 1<br />

FIRST-PROGESTERONE VGS 100 progesterone 2<br />

FIRST-PROGESTERONE VGS 200 progesterone 2<br />

FIRST-PROGESTERONE VGS 25 progesterone 2<br />

FIRST-PROGESTERONE VGS 400 progesterone 2<br />

FIRST-PROGESTERONE VGS 50 progesterone 2<br />

jolivette 1<br />

medroxyprogesterone acetate<br />

1 [QLL, 1<br />

injection [INJ]<br />

ml/90]<br />

medroxyprogesterone acetate tablet 1<br />

MICRONOR [G] norethindrone 3<br />

nora-be 1<br />

norethindrone acetate tablet 1<br />

NOR-Q-D [G] norethindrone 3<br />

PROCHIEVE progesterone 3<br />

progesterone in oil [INJ] 1<br />

progesterone injection [INJ] 1<br />

PROMETRIUM progesterone 2<br />

PROVERA [G] medroxyprogesterone 3<br />

SPECIALIZED OB/GYN DRUGS<br />

leuprolide acetate [INJ] 1<br />

LUPRON [INJ] leuprolide 4<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

LUPRON DEPOT 11.25 MG 3MO KIT,<br />

-22.5 MG 3MO KIT, -3.75 MG KIT, -<br />

4 MONTH KIT [INJ]<br />

leuprolide 2 [PAR]<br />

LUPRON DEPOT 7.5 MG KIT [INJ] leuprolide 4 [PAR]<br />

LUPRON DEPOT-PED [INJ] leuprolide 4 [PAR]<br />

PREPIDIL dinoprostone 3<br />

SUPPRELIN LA [INJ] histrelin ac 4<br />

SYNAREL nafarelin 4<br />

OPHTHALMIC MEDICATIONS<br />

ANTIGLAUCOMA DRUGS<br />

acetazolamide capsule sustained<br />

action, -tablet<br />

1<br />

acetazolamide sodium [INJ] 1<br />

ALPHAGAN P 0.1% DROPS brimonidine tartrate 2<br />

ALPHAGAN P 0.15% EYE DROPS [G] brimonidine tartrate 3<br />

apraclonidine hcl 1<br />

AZOPT brinzolamide 3<br />

BETAGAN [G] levobunolol 3 [ST]<br />

betaxolol hcl drops 1<br />

BETIMOL timolol 3 [ST]<br />

BETOPTIC S betaxolol 3 [ST]<br />

brimonidine 0.2% eye drop 1<br />

brimonidine tartrate 0.15% drp 1<br />

carteolol hcl 1<br />

COMBIGAN brimonidine tartrate/timolol 2 [ST]<br />

COSOPT [G] dorzolamide/timolol 3 [ST]<br />

DIAMOX SEQUELS [G] acetazolamide 3<br />

dorzolamide hcl 1<br />

dorzolamide-timolol 1<br />

IOPIDINE [G] apraclonidine 3<br />

ISOPTO CARBACHOL carbachol 3<br />

ISOPTO CARPINE pilocarpine hcl 3<br />

ISTALOL timolol 3 [ST]<br />

levobunolol hcl 1<br />

LUMIGAN bimatoprost 3<br />

methazolamide 1<br />

metipranolol 1<br />

MIOSTAT [INJ] carbachol 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

OPTIPRANOLOL [G] metipranolol 3 [ST]<br />

PHOSPHOLINE IODIDE echothiophate iodide 2<br />

pilocarpine hcl drops 1<br />

PILOPINE HS pilocarpine hcl 2<br />

PROPINE dipivefrin 3<br />

timolol maleate drops, -gel-forming<br />

1<br />

solution<br />

TIMOPTIC timolol 3 [ST]<br />

TIMOPTIC OCUDOSE timolol 3 [ST]<br />

TIMOPTIC-XE [G] timolol 3 [ST]<br />

TRAVATAN travoprost 2<br />

TRAVATAN Z travoprost 2<br />

TRUSOPT [G] dorzolamide 3<br />

XALATAN latanoprost 2<br />

OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS<br />

BLEPHAMIDE sulfacetamide/prednisolone ac 3<br />

BLEPHAMIDE S.O.P. sulfacetamide/prednisolone ac 3<br />

CORTISPORIN SUSPENSION DROPS neomycin sulfate/polymyxin/hc 3<br />

cortomycin ointment 1<br />

dexasporin 1<br />

MAXITROL [G] neomycin/polymyxin/dexameth 3<br />

methadex 1<br />

neomycin-bacitracin-poly-hc 1<br />

neomycin-polymyxin-dexameth 1<br />

neomycin-polymyxin-hc suspension<br />

1<br />

drops<br />

poly-dex 1<br />

POLY-PRED neomycin/polymyxin/prednisol 2<br />

PRED-G gentamicin/prednisolone 2<br />

sulfacetamide-prednisolone 1<br />

TOBRADEX [G] tobramycin sulfate/dexameth 3<br />

tobramycin-dexamethasone 1<br />

ZYLET tobramycin/lotepred etab 2<br />

OPHTHALMIC CORTICOSTEROID DRUGS<br />

ALREX loteprednol etabonate 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

dexamethasone sodium phosphate<br />

drops<br />

1<br />

dexasol 1<br />

DUREZOL difluprednate 3<br />

FLAREX fluorometholone 3<br />

fluorometholone 1<br />

FML [G] fluorometholone 3<br />

FML FORTE fluorometholone 3<br />

FML S.O.P. fluorometholone 2<br />

LOTEMAX loteprednol etabonate 2<br />

MAXIDEX dexamethasone 3<br />

OMNIPRED [G] prednisolone acetate 3<br />

PRED FORTE [G] prednisolone acetate 3<br />

PRED MILD prednisolone acetate 2<br />

prednisol 1<br />

prednisolone acetate suspension<br />

drops<br />

1<br />

prednisolone sodium phosphate<br />

drops<br />

1<br />

RETISERT fluocinolone acetonide 3<br />

TRIESENCE [INJ] triamcinolone acetonide 3<br />

VEXOL rimexolone 3<br />

OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS<br />

ak-poly-bac 1<br />

aktob 1<br />

AZASITE azithromycin 2<br />

bacitracin 500 unit/gm ointmnt 1<br />

bacitracin-polymyxin eye oint 1<br />

BESIVANCE besifloxacin 3<br />

BLEPH-10 [G] sulfacetamide sodium 3<br />

CILOXAN [G] ciprofloxacin 3<br />

ciprofloxacin hcl drops 1<br />

erythromycin ointment 1<br />

gentak 1<br />

gentamicin 3 mg/gm eye oint 1<br />

gentamicin sulfate drops 1<br />

gentasol 1<br />

IQUIX levofloxacin 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

neocidin 1<br />

neomycin-bacitracin-polymyxin 1<br />

neomycin-polymyxin-gramicidin 1<br />

NEOSPORIN DROPS [G] neomycin/gramicidin/polymyxin 3<br />

OCUFLOX [G] ofloxacin 3<br />

ofloxacin drops 1<br />

polycin-b 1<br />

polymyxin b sul-trimethoprim 1<br />

POLYTRIM [G] polymyxin b sulfate/tmp 3<br />

QUIXIN levofloxacin 3<br />

romycin 1<br />

sulfac 1<br />

sulfacetamide sodium drops 1<br />

sulfamide 1<br />

TERRAMYCIN WITH POLYMYXIN oxytetracycline hcl/polymyxin 3<br />

tobramycin sulfate drops 1<br />

tobrasol 1<br />

TOBREX [G] tobramycin 3<br />

VIGAMOX moxifloxacin 2<br />

ZYMAR gatifloxacin 2<br />

ZYMAXID gatifloxacin 2<br />

OPHTHALMIC TOPICAL ANTIVIRAL DRUGS<br />

trifluridine 1<br />

VIROPTIC [G] trifluridine 3<br />

OTHER OPHTHALMIC DRUGS<br />

ACULAR [G] ketorolac 3<br />

ACULAR LS [G] ketorolac 3<br />

ACULAR PF ketorolac 3<br />

ACUVAIL ketorolac 3<br />

ak-con 1<br />

ak-dilate 1<br />

akorn balanced salt 1<br />

ak-pentolate 1<br />

AKTEN lidocaine 3<br />

ALAMAST pemirolast potassium 3<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ALBALON naphazoline 3<br />

ALCAINE [G] proparacaine 3<br />

allersol 1<br />

ALOCRIL nedocromil 3<br />

ALOMIDE lodoxamide 3<br />

altafrin 1<br />

atropine care 1<br />

atropine sulfate drops, -ointment 1<br />

azelastine hcl drops 1<br />

BEPREVE bepotastine besilate 3<br />

BETADINE SOLUTION povidone-iodine 3<br />

BOTOX [INJ] botulinum toxin a 2 [PAR]<br />

BSS [INJ] sodium/calcium/mag/potassium 3<br />

BSS PLUS sodium/calcium/mag/potassium 3<br />

CROLOM cromolyn 3<br />

cromolyn sodium drops 1<br />

CYCLOGYL 0.5% EYE DROPS, -2% cyclopentolate 3<br />

EYE DROPS<br />

CYCLOGYL 1% EYE DROPS [INJ] cyclopentolate 3<br />

cyclopentolate hcl 1<br />

cylate 1<br />

diclofenac sodium drops 1<br />

ELESTAT epinastine hcl 3<br />

EMADINE emedastine difumarate 3<br />

flurbiprofen sodium 1<br />

homatropaire 1<br />

homatropine 1<br />

ISOPTO ATROPINE atropine sulfate 3<br />

ISOPTO HOMATROPINE homatropine hbr 3<br />

ISOPTO HYOSCINE scopolamine 3<br />

ketorolac tromethamine drops 1<br />

LACRISERT hydroxypropylmethylcellulose 3<br />

LUCENTIS [INJ] ranibizumab 3<br />

MYDFRIN phenylephrine hcl 3<br />

mydral 1<br />

MYDRIACYL [G] tropicamide 3<br />

naphazoline hcl drops 1<br />

NATACYN natamycin 2<br />

neofrin 1<br />

NEVANAC nepafenac 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

OCUFEN [G] flurbiprofen 3<br />

OPHTHETIC proparacaine 3<br />

OPTIVAR [G] azelastine hcl 3<br />

parcaine 1<br />

PATADAY olopatadine hcl 2<br />

PATANOL olopatadine hcl 2<br />

phenylephrine hcl drops 1<br />

proparacaine hcl 1<br />

RESTASIS cyclosporine 2 [QLL, 60<br />

vials/30]<br />

tropicacyl 1<br />

tropicamide 1<br />

VISUDYNE [INJ] verteporfin 2<br />

VITRASERT ganciclovir 3<br />

VOLTAREN DROPS [G] diclofenac sodium 3<br />

XIBROM bromfenac 3<br />

ZIRGAN ganciclovir 3<br />

RESPIRATORY MEDICATIONS<br />

ANTIHISTAMINE/DECONGESTANT COMBINATIONS<br />

ALLEGRA-D 12 HOUR [G] pse/fexofenadine 3 [QLL,<br />

68/34][ST]<br />

ALLEGRA-D 24 HOUR pse/fexofenadine 3 [QLL,<br />

34/34][ST]<br />

CLARINEX-D 12 HOUR pse/desloratadine 3 [QLL,<br />

68/34][ST]<br />

CLARINEX-D 24 HOUR pse/desloratadine 3 [QLL,<br />

34/34][ST]<br />

fexofenadine-pse er 1 [QLL,<br />

68/34]<br />

promethazine vc 1 [PAR]<br />

SEMPREX-D pse/acrivas 3<br />

ANTIHISTAMINES<br />

ALLEGRA 180 MG TABLET [G] fexofenadine 3 [QLL,<br />

34/34][ST]<br />

ALLEGRA 60 MG TABLET [G] fexofenadine 3 [QLL,<br />

68/34][ST]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

ALLEGRA ODT fexofenadine 3 [QLL,<br />

68/34][ST]<br />

ALLEGRA SUSPENSION ORAL fexofenadine 3 [ST]<br />

ben-tann 1 [PAR]<br />

carbinoxamine maleate 1<br />

cetirizine 1 mg/1 ml soln, -1 mg/ml<br />

soln, -1 mg/ml syrup, -5 mg/5 ml<br />

syrup<br />

1<br />

CLARINEX SYRUP desloratadine 3 [ST]<br />

CLARINEX TABLET, -TABLET desloratadine 3 [QLL,<br />

DISPERSIBLE LINGUAL<br />

34/34][ST]<br />

clemastine fum 2.68 mg tab, -syrup 1<br />

complete allergy medicine 1 [PAR]<br />

cyproheptadine hcl syrup, -tablet 1 [PAR]<br />

dexchlorpheniramine maleate 1 [PAR]<br />

diphenhydramine 12.5 mg/5 ml, -25<br />

1 [PAR]<br />

mg cap, -50 mg cap, -50 mg capsule<br />

diphenhydramine hcl injection [INJ] 1<br />

diphenmax 1 [PAR]<br />

DYTAN diphenhydramine tannate 3 [PAR]<br />

fexofenadine hcl 180 mg tablet 1 [QLL,<br />

34/34]<br />

fexofenadine hcl 30 mg tablet, -60<br />

1 [QLL,<br />

mg tablet<br />

68/34]<br />

palgic 1<br />

PHENERGAN [INJ][G] promethazine 3<br />

promethazine hcl injection [INJ] 1<br />

promethazine hcl syrup, -tablet 1 [PAR]<br />

tripohist 1<br />

triprolidine hcl syrup 1<br />

XYZAL SOLUTION levocetirizine dihydrochlor 2 [ST]<br />

XYZAL TABLET levocetirizine dihydrochlor 2 [QLL,<br />

34/34][ST]<br />

BETA-2 ADRENERGIC DRUGS<br />

albuterol sulfate nebs, -solution nonoral,<br />

-syrup, -tablet, -tablet<br />

sustained release 12hr, -vial<br />

nebulizer<br />

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1


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

FORADIL formoterol fumarate 2 [QLL,<br />

120/34]<br />

MAXAIR AUTOHALER pirbuterol 3 [QLL,<br />

28/34]<br />

metaproterenol sulfate syrup, -tablet 1<br />

PROAIR HFA albuterol 2 [QLL, 26<br />

gm/34]<br />

PROVENTIL HFA albuterol 3 [QLL, 20<br />

gm/34]<br />

SEREVENT DISKUS salmeterol 2 [QLL, 120<br />

doses/34]<br />

terbutaline sulfate injection [INJ] 1<br />

terbutaline sulfate tablet 1<br />

VENTOLIN HFA albuterol 2 [QLL, 54<br />

gm/34]<br />

VOSPIRE ER [G] albuterol 3<br />

XOPENEX HFA levalbuterol 3 [QLL, 45<br />

gm/34]<br />

LEUKOTRIENE MODIFIERS<br />

ACCOLATE zafirlukast 3<br />

SINGULAIR montelukast sodium 2<br />

ZYFLO zileuton 3<br />

ZYFLO CR zileuton 2<br />

METHYL XANTHINE DRUGS<br />

aminophylline injection [INJ] 1<br />

aminophylline tablet 1<br />

CAFCIT SOLUTION [INJ] caffeine citrated 3<br />

caffeine citrate solution 1<br />

dylix 1<br />

ELIXOPHYLLIN theophylline 3<br />

LUFYLLIN dyphylline 3<br />

THEO-24 theophylline 3<br />

theochron 1<br />

theophylline 1<br />

theophylline anhydrous tablet<br />

sustained release 12hr<br />

1<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

UNIPHYL theophylline 3<br />

OTHER DRUGS FOR ASTHMA<br />

ADRENACLICK [INJ] epinephrine hcl 3 [QLL, 4/2]<br />

ADRENALIN CHLORIDE INJECTION<br />

[INJ]<br />

epinephrine hcl 3<br />

ADRENALIN CHLORIDE SOLUTION<br />

NON-ORAL<br />

epinephrine hcl 3<br />

ADVAIR DISKUS salmeterol/fluticasone 2 [QLL, 120<br />

doses/34]<br />

ADVAIR HFA salmeterol/fluticasone 2 [QLL, 24<br />

gm/34]<br />

AEROBID flunisolide 3 [QLL,<br />

21/34]<br />

AEROBID-M flunisolide 3 [QLL, 21<br />

gm/34]<br />

ALVESCO 160 MCG INHALER ciclesonide 3 [QLL, 18<br />

gm/34]<br />

ALVESCO 80 MCG INHALER ciclesonide 3 [QLL, 12<br />

gm/34]<br />

ASMANEX TWISTHALER 110 MCG mometasone 2 [QLL, 60<br />

#30<br />

doses/30]<br />

ASMANEX TWISTHALER 220 MCG mometasone 2 [QLL, 14<br />

#14<br />

doses/14]<br />

ASMANEX TWISTHALER 220 MCG mometasone 2 [QLL, 60<br />

#30<br />

doses/34]<br />

ASMANEX TWISTHALER 220 MCG mometasone 2 [QLL, 120<br />

#60<br />

doses/34]<br />

ASMANEX TWISTHALR 220 MCG mometasone 2 [QLL, 240<br />

#120<br />

doses/34]<br />

ATROVENT HFA ipratropium 2 [QLL, 26<br />

gm/34]<br />

AZMACORT triamcinolone acetonide 3 [QLL,<br />

60/34]<br />

COMBIVENT albuterol sulfate/ipratropium 2 [QLL, 44<br />

gm/34]<br />

cromolyn sodium ampul for<br />

nebulization<br />

1<br />

DULERA mometasone/formoterol 3 [PAR][QLL,<br />

120/30]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

epinephrine 0.1 mg/ml syringe, -1<br />

mg/ml ampul, -1 mg/ml vial [INJ]<br />

1<br />

EPINEPHRINE 0.15 MG AUTO-<br />

INJCT, -0.3 MG AUTO-INJECT [INJ]<br />

epinephrine hcl 3 [QLL, 4/2]<br />

EPINEPHRINE 0.3 MG/0.3 ML SYR<br />

[INJ]<br />

epinephrine hcl 3<br />

EPIPEN [INJ] epinephrine hcl 2 [QLL, 4<br />

pens/2]<br />

EPIPEN JR [INJ] epinephrine hcl 2 [QLL, 4<br />

pens/2]<br />

FLOVENT 100 MCG DISKUS, -50 fluticasone propionate 2 [QLL, 120<br />

MCG DISKUS<br />

doses/34]<br />

FLOVENT 250 MCG DISKUS fluticasone propionate 2 [QLL, 300<br />

doses/34]<br />

FLOVENT HFA 110 MCG INHALER fluticasone propionate 2 [QLL, 12<br />

gm/34]<br />

FLOVENT HFA 220 MCG INHALER fluticasone propionate 2 [QLL, 36<br />

gm/34]<br />

FLOVENT HFA 44 MCG INHALER fluticasone propionate 2 [QLL, 21<br />

gm/34]<br />

GASTROCROM cromolyn 2<br />

INTAL cromolyn 2<br />

ipratropium bromide solution nonoral<br />

1<br />

PULMICORT 180 MCG FLEXHALER budesonide 3 [QLL, 3<br />

inhalers/34]<br />

PULMICORT 90 MCG FLEXHALER budesonide 3 [QLL, 2<br />

inhalers/34]<br />

QVAR beclomethasone 2 [QLL, 22<br />

gm/34]<br />

SPIRIVA tiotropium bromide 2 [QLL, 60<br />

capsules/34]<br />

SYMBICORT budesonide/formoterol fum 2 [QLL, 20<br />

gm/34]<br />

TWINJECT [INJ] epinephrine hcl 3 [QLL, 4<br />

pens/2]<br />

XOLAIR [INJ][LA] omalizumab 4 [PAR][QLL,<br />

6/28]<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

OTHER RESPIRATORY DRUGS<br />

ARALAST [INJ][LA] alpha-1-proteinase inhibitor 4 [PAR]<br />

PROLASTIN [INJ][LA] alpha-1-proteinase inhibitor 4 [PAR]<br />

ZEMAIRA [INJ][LA] alpha-1-proteinase inhibitor 4 [PAR]<br />

UROLOGICAL MEDICATIONS<br />

ANTICHOLINERGIC ANTISPASMODICS<br />

DETROL tolterodine tartrate 3 [ST]<br />

DETROL LA tolterodine tartrate 3 [ST]<br />

DITROPAN XL 10 MG TABLET, -15<br />

MG TABLET [G]<br />

oxybutynin 3 [ST]<br />

DITROPAN XL 5 MG TABLET, -5 MG oxybutynin 3 [QLL,<br />

TABLET SA [G]<br />

34/34][ST]<br />

ENABLEX darifenacin hydrobromide 2 [ST]<br />

flavoxate hcl 1<br />

GELNIQUE oxybutynin 3 [QLL,<br />

34/34][ST]<br />

oxybutynin chloride syrup, -tablet 1<br />

oxybutynin cl er 10 mg tablet, -cl er<br />

15 mg tablet<br />

1<br />

oxybutynin cl er 5 mg tablet 1 [QLL,<br />

34/34]<br />

OXYTROL oxybutynin 3 [QLL,<br />

10/35][ST]<br />

SANCTURA trospium chloride 2 [ST]<br />

SANCTURA XR trospium chloride 2 [ST]<br />

TOVIAZ fesoterodine fumarate 3 [ST]<br />

VESICARE solifenacin succinate 3 [ST]<br />

CHOLINERGIC STIMULANTS<br />

bethanechol chloride tablet 1<br />

URECHOLINE [G] bethanechol 3<br />

OTHER GENITOURINARY PRODUCTS<br />

acetic acid 0.25% irrig soln 1<br />

AVODART dutasteride 2<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

Drug Generic Tier Restrictions<br />

CYSTADANE betaine hcl 2<br />

cytra-3 1<br />

cytra-k 1<br />

ELMIRON pentosan polysulfate sodium 2<br />

finasteride 1<br />

FLOMAX [G] tamsulosin 3<br />

glycine solution 1<br />

JALYN dutasteride/tamsulosin hcl 3<br />

K-PHOS M.F. pot acid phos/sod acid phos 2<br />

K-PHOS NO.2 pot acid phos/sod acid phos 2<br />

K-PHOS ORIGINAL potassium acid phosphate 2<br />

neomycin-polymyxin b [INJ] 1<br />

NEOSPORIN G.U. IRRIGANT [INJ] neomycin sulfate/polymyxin 3<br />

potassium citrate tablet sustained<br />

1<br />

action<br />

potassium citrate-citric acid 1<br />

PROSCAR [G] finasteride 3<br />

RAPAFLO silodosin 3<br />

RENACIDIN gluconic acid/citric acid 2<br />

RIMSO-50 dimethyl sulfoxide 3<br />

tamsulosin hcl 1<br />

tricitrates 1<br />

UROXATRAL alfuzosin hcl 2<br />

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Index:<br />

2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

1ST TIER UNIFINE PENTIPS, 80<br />

8-MOP, 55<br />

aa 3%/electrolyte-tpn/glycerin, 88, 89<br />

aabp, 60<br />

a-b otic, 61<br />

abacavir sulfate, 5<br />

abacavir sulfate/lamivudine, 4<br />

abatacept/maltose, 20<br />

abciximab, 86<br />

ABELCET, 13<br />

ABILIFY DISCMELT, 23<br />

ABILIFY INJECTION, 23<br />

ABILIFY SOLUTION, 23<br />

ABILIFY TABLET, 23<br />

abobotulinumtoxina, 83<br />

ABORTIFACIENTS, 94<br />

acamprosate calcium, 37<br />

ACANYA, 52<br />

acarbose, 66, 67<br />

ACCOLATE, 111<br />

ACCUPRIL, 41<br />

ACCURETIC, 49<br />

ACCUSURE, 80<br />

ACCUTANE, 55<br />

acebutolol, 43<br />

acebutolol hcl capsule, 43<br />

ACEON, 41<br />

acetaminophen-codeine, 29<br />

acetasol hc, 61<br />

acetazolamide, 105<br />

acetazolamide capsule sustained action, -<br />

tablet, 104<br />

acetazolamide sodium, 104<br />

acetic ac/ricinoleic/oxyquinol, 98<br />

acetic acid, 61<br />

acetic acid 0.25% irrig soln, 115<br />

acetic acid solution non-oral, 61<br />

acetic acid/aluminum acetate, 61<br />

acetic acid/hydrocortisone, 61<br />

acetic acid/oxyquin so4, 98<br />

acetic acid-aluminum, 61<br />

acetic acid-hydrocortisone, 61<br />

ACID JELLY, 98<br />

ACIPHEX, 73<br />

acitretin, 55<br />

acitretin/emollient comb, 55<br />

ACLOVATE, 56<br />

ACTEMRA 200 MG/10 ML VIAL, -400 MG/20<br />

ML VIAL, 79<br />

ACTEMRA 80 MG/4 ML VIAL, 79<br />

ACTHAR H.P., 68<br />

ACTHIB, 75<br />

ACTHREL, 68<br />

acticin, 55<br />

ACTIGALL, 72<br />

ACTIMMUNE, 78<br />

ACTIQ, 27<br />

ACTIVELLA, 98<br />

ACTONEL 150 MG TABLET, 68<br />

ACTONEL 30 MG TABLET, -5 MG TABLET, 68<br />

ACTONEL 35 MG TABLET, 68<br />

ACTONEL 75 MG TABLET, 68<br />

ACTONEL WITH CALCIUM, 68<br />

ACTOPLUS MET, 66<br />

ACTOPLUS MET XR 15-1,000 MG TB, 66<br />

ACTOPLUS MET XR 30-1,000 MG TB, 66<br />

ACTOS, 66<br />

ACULAR, 108<br />

ACULAR LS, 108<br />

ACULAR PF, 108<br />

ACUVAIL, 108<br />

acyclovir, 11<br />

acyclovir capsule, -suspension oral, -tablet,<br />

10<br />

acyclovir sodium, 10<br />

ACZONE, 52<br />

ADACEL, 75<br />

ADAGEN, 60<br />

ADALAT CC, 43<br />

adalimumab, 19<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

adapalene, 52, 53<br />

adapalene/benzoyl peroxide, 53<br />

ADCIRCA, 51<br />

adcirca (tadalafil), 51<br />

ADDERALL, 30<br />

ADDERALL XR, 31<br />

adefovir dipivoxil, 10<br />

ADOXA, 16<br />

ADOXA PAK, 16<br />

ADRENACLICK, 112<br />

ADRENALIN CHLORIDE INJECTION, 112<br />

ADRENALIN CHLORIDE SOLUTION NON-<br />

ORAL, 112<br />

ADVAIR DISKUS, 112<br />

ADVAIR HFA, 112<br />

advanced care plus, 99<br />

advanced natalcare, 99<br />

ADVICOR 1,000 MG-20 MG TABLET, -1,000<br />

MG-40 MG TABLET, -750 MG-20 MG<br />

TABLET, 46<br />

ADVICOR 500 MG-20 MG TABLET, 46<br />

AEROBID, 112<br />

AEROBID-M, 112<br />

afeditab cr, 43<br />

AFINITOR, 18<br />

agalsidase, 69<br />

AGGRASTAT, 86<br />

AGGRENOX, 86<br />

AGRYLIN, 18<br />

A-HYDROCORT, 63<br />

AIMSCO ULTRA THIN II, 80<br />

ak-con, 108<br />

ak-dilate, 108<br />

AKNE-MYCIN, 52<br />

akorn balanced salt, 108<br />

ak-pentolate, 108<br />

ak-poly-bac, 107<br />

AKTEN, 108<br />

aktob, 107<br />

ALA-CORT, 56<br />

ALAMAST, 108<br />

ALA-SCALP HP, 56<br />

ALBALON, 108<br />

albendazole, 3<br />

ALBENZA, 3<br />

albumin human, 86, 87, 88<br />

ALBUMINAR-25, 86<br />

alburx, 86<br />

albutein, 86<br />

albuterol, 111<br />

albuterol sulfate nebs, -solution non-oral, -<br />

syrup, -tablet, -tablet sustained release<br />

12hr, -vial nebulizer, 111<br />

albuterol sulfate/ipratropium, 113<br />

ALCAINE, 108<br />

alclometasone, 56<br />

alclometasone dipropionate, 56<br />

alcohol in dextrose, 86<br />

ALCOHOL PREP PADS, 80<br />

ALCOHOL PREP SWABS, 80<br />

ALCOHOL SWABS, 80<br />

ALCOHOL WIPES, 80<br />

ALDACTAZIDE, 51<br />

ALDACTONE, 51<br />

ALDARA, 58<br />

aldesleukin, 79<br />

ALDURAZYME, 68<br />

alefacept, 18<br />

alemtuzumab, 18<br />

alendronate, 69<br />

alendronate sodium 10 mg tab, -40 mg tab, -<br />

5 mg tablet, 68<br />

alendronate sodium 35 mg tab, -70 mg tab,<br />

68<br />

alendronate/vitamin d3, 69<br />

ALFENTA, 27<br />

alfentanil, 27<br />

alfentanil hydrochloride, 27<br />

alfuzosin hcl, 115<br />

alglucerase, 68<br />

alglucosidase alfa, 69<br />

ALIMTA, 18<br />

ALINIA, 8<br />

aliskiren hemifumarate, 50<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

aliskiren/hydrochlorothiazid, 50<br />

aliskiren/valsartan, 50<br />

alitretinoin, 59<br />

ALLEGRA 180 MG TABLET, 110<br />

ALLEGRA 60 MG TABLET, 110<br />

ALLEGRA ODT, 110<br />

ALLEGRA SUSPENSION ORAL, 110<br />

ALLEGRA-D 12 HOUR, 109<br />

ALLEGRA-D 24 HOUR, 110<br />

allersol, 108<br />

allopurinol, 83<br />

allopurinol sodium, 83<br />

allopurinol tablet, 83<br />

almotriptan, 32<br />

ALOCRIL, 108<br />

ALOMIDE, 108<br />

ALOPRIM, 83<br />

ALORA, 97<br />

alosetron, 71<br />

ALOXI, 25<br />

alpha-1-proteinase inhibitor, 114<br />

ALPHAGAN P 0.1% DROPS, 104<br />

ALPHAGAN P 0.15% EYE DROPS, 104<br />

alprostadil, 51<br />

alprostadil injection, 50<br />

ALREX, 106<br />

ALTABAX, 16<br />

ALTACE, 41<br />

altafrin, 108<br />

ALTOPREV, 46<br />

altretamine, 19<br />

aluminum chloride hexahydrate, 58, 59<br />

ALVESCO 160 MCG INHALER, 112<br />

ALVESCO 80 MCG INHALER, 112<br />

amantadine, 10<br />

AMARYL, 66<br />

ambenonium chloride, 37<br />

AMBIEN, 38<br />

AMBIEN CR, 38<br />

AMBISOME, 13<br />

ambrisentan, 46<br />

amcinonide, 56<br />

AMEBICIDES, 3<br />

AMERGE, 31<br />

a-methapred, 63<br />

AMEVIVE, 18<br />

AMICAR SYRUP, 60<br />

AMICAR TABLET, 60<br />

amifostine, 18, 19<br />

amikacin sulfate injection, 3<br />

amiloride hcl tablet, 51<br />

amiloride hydrochloride, 51<br />

amiloride-hydrochlorothiazide, 51<br />

amino acids, 86, 87, 88, 89<br />

aminocaproic acid, 60<br />

aminocaproic acid injection, 60<br />

aminocaproic acid syrup, -tablet, 60<br />

AMINOGLYCOSIDES, 3<br />

aminolevulinic acid hcl, 59<br />

aminophylline injection, 112<br />

aminophylline tablet, 112<br />

aminosalicylic acid, 5<br />

AMINOSYN, 86<br />

AMINOSYN II, 86<br />

AMINOSYN II 3.5% M-DEXTROSE 5%, 86<br />

AMINOSYN II 3.5%-DEXTROSE 25%, 86<br />

AMINOSYN II 3.5%-DEXTROSE 5%, 86<br />

AMINOSYN II 4.25% M-DEXT 10%, 87<br />

AMINOSYN II 4.25%-DEXTROSE 25%, 87<br />

AMINOSYN II 5% IN 25% DEXTROSE, 87<br />

AMINOSYN II IN DEXTROSE, 87<br />

AMINOSYN II WITH LYTES-CA-DW, 87<br />

AMINOSYN M, 87<br />

AMINOSYN WITH ELECTROLYTES, 87<br />

AMINOSYN-HBC, 87<br />

AMINOSYN-HF, 87<br />

AMINOSYN-PF, 87<br />

AMINOSYN-RF, 87<br />

amiodarone, 41<br />

amiodarone hcl injection, 41<br />

amiodarone hcl tablet, 41<br />

AMIODARONES, 41<br />

AMITIZA, 71<br />

amitriptyline hcl tablet, 40<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

amitriptyline/chlordiazepoxide, 35<br />

amitriptyline-chlordiazepoxide, 35<br />

amlexanox, 63<br />

amlodipine, 44<br />

amlodipine bes/olmesartan med, 49<br />

amlodipine besylate, 43<br />

amlodipine besylate-benazepril, 49<br />

amlodipine/atorvast cal, 46<br />

amlodipine/valsartan, 49<br />

amlodipine/valsartan/hctz, 49<br />

ammonium chloride, 87<br />

AMMONIUM CHLORIDE INJECTION, 87<br />

ammonium lactate 12% cream, -12% lotion,<br />

58<br />

AMMONUL, 60<br />

amnesteem, 55<br />

amoclan, 13<br />

amox tr-potassium clavulanate, 13<br />

amoxapine, 37<br />

amoxicillin, 13, 14<br />

amoxicillin clavulanate, 13<br />

amoxicillin-clavulanate er, 13<br />

AMOXIL 125 MG/5 ML SUSPENSION, 13<br />

AMOXIL 400 MG/5 ML SUSPENSION, -50<br />

MG/ML PED DROPS, -CAPSULE, -250 MG/5<br />

ML SUSPENSION, 13<br />

amphetamine salt combo, 31<br />

amphetamine/dextroamphetamine, 30, 31<br />

ampho b c-s, 13<br />

AMPHOTEC 100 MG VIAL, 13<br />

AMPHOTEC 50 MG VIAL, 13<br />

amphotericin b injection, 13<br />

amphotericin b lipid complex, 13<br />

amphotericin b liposome, 13<br />

ampicillin sodium, 13, 14<br />

ampicillin sodium/sulbactam na, 14<br />

ampicillin trihydrate, 13<br />

ampicillin-sulbactam, 13<br />

AMPYRA, 60<br />

AMRIX, 82<br />

amylase/lipase/protease, 72, 73<br />

ANADROL-50, 94<br />

ANAFRANIL, 40<br />

anagrelide, 18<br />

anagrelide hcl, 18<br />

anakinra, 79<br />

ANALGESICS, 22<br />

ANAMANTLE HC CREAM WITH APPLICATOR,<br />

-KIT, 56<br />

ANAMANTLE HC FORTE, 56<br />

ANAPROX, 83<br />

ANAPROX DS, 83<br />

anastrozole, 18<br />

anastrozole tablet, 18<br />

ANCOBON, 8<br />

ANDRODERM, 94<br />

ANDROGEL, 94<br />

ANDROGEN DRUGS, 94<br />

ANDROID, 94<br />

ANDROXY, 94<br />

ANECTINE, 83<br />

ANESTACON, 2<br />

<strong>ANESTHETICS</strong>, 1<br />

ANGELIQ, 98<br />

ANGIOTENSIN CONVERTING ENZYME<br />

INHIBITORS, 41<br />

ANGIOTENSIN II RECEPTOR ANTAGONISTS,<br />

42<br />

anidulafungin, 13<br />

ANSAID, 83<br />

ANTABUSE, 37<br />

ANTARA, 47<br />

ANTHELMINTICS, 3<br />

anthralin, 54, 55<br />

ANTIACNE DRUGS, 52<br />

ANTICHOLINERGIC ANTISPASMODICS, 114<br />

ANTIDEMENTIA DRUGS, 22<br />

ANTIDIARRHEAL DRUGS, 70<br />

ANTIDYSRHYTHMIC DRUGS, 42<br />

ANTIGLAUCOMA DRUGS, 104<br />

ANTIHISTAMINE/DECONGESTANT<br />

COMBINATIONS, 109<br />

ANTIHISTAMINES, 110<br />

ANTIINFECTIVES, 3<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

ANTIINFECTIVES SPECIALIZED<br />

INDICATIONS, 3<br />

ANTIMANIA DRUGS, 23<br />

ANTINEOPLASTIC/IMMUNOSUPPRESSANT<br />

DRUGS, 18<br />

ANTIPARKINSON ANTICHOLINERGIC<br />

DRUGS, 23<br />

ANTIPLATELET DRUGS, 86<br />

ANTIPRURITIC DRUGS, 54<br />

ANTIPSORIASIS AND ANTIECZEMA DRUGS,<br />

54<br />

ANTIPSYCHOTIC DRUGS, 23<br />

antipyrine/benzocaine, 61<br />

antipyrine-benzocaine, 61<br />

ANTIRETROVIRALS AND PROTEASE INH, 4<br />

ANTISPASMODICS/DRUGS AFFECT GI<br />

MOTILITY, 70<br />

ANTI-STICK INSULIN, 80<br />

antithrombin iii, human recomb, 91<br />

antithrombin iii,human, 91<br />

ANTITHYROID DRUGS, 63<br />

ANTITUBERCULOSIS DRUGS, 5<br />

ANTIULCER DRUGS, 71<br />

ANTIVERT, 25<br />

ANTIVERTIGO AND ANTIEMETIC DRUGS, 25<br />

ANTIZOL, 60<br />

ANUSOL-HC, 72<br />

ANXIOLYTICS, 27<br />

ANZEMET INJECTION, 25<br />

ANZEMET TABLET, 25<br />

apap-caffeine-dihydrocodeine, 29<br />

APEXICON, 56<br />

APEXICON E, 56<br />

APHTHASOL, 63<br />

APIDRA, 65<br />

APIDRA SOLOSTAR, 65<br />

APLENZIN, 35<br />

APOKYN, 36<br />

apomorphine hcl, 36<br />

apraclonidine, 105<br />

apraclonidine hcl, 104<br />

aprepitant, 25, 26<br />

apri, 94<br />

APRISO, 72<br />

APTIVUS, 4<br />

ARALAST, 114<br />

ARALEN PHOSPHATE, 14<br />

aranelle, 94<br />

ARANESP 100 MCG/0.5 ML AUTOINJ, -100<br />

MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL,<br />

-150 MCG/0.3 ML AUTOINJ, -150 MCG/0.3<br />

ML SYRINGE, -150 MCG/0.75 ML VIAL, -<br />

200 MCG/0.4 ML AUTOINJ, -200 MCG/0.4<br />

ML SYRINGE, -200 MCG/ML VIAL, -300<br />

MCG/0.6 ML AUTOINJ, -300 MCG/0.6 M,<br />

75<br />

ARANESP 25 MCG/0.42 ML AUTOINJ, -25<br />

MCG/0.42 ML SYRING, -25 MCG/ML VIAL, -<br />

40 MCG/0.4 ML AUTOINJ, -40 MCG/0.4 ML<br />

SYRINGE, -40 MCG/ML VIAL, 76<br />

ARAVA, 18<br />

ARCALYST, 79<br />

AREDIA 30 MG VIAL, 68<br />

AREDIA 90 MG VIAL, 68<br />

ARESTIN, 63<br />

argatroban, 91<br />

ARGATROBAN, 91<br />

arginine, 89<br />

ARICEPT 10 MG TABLET, -5 MG TABLET, 22<br />

ARICEPT 23 MG TABLET, 22<br />

ARICEPT ODT, 22<br />

ARIMIDEX, 18<br />

aripiprazole, 23<br />

ARISTOSPAN, 63<br />

ARIXTRA 10 MG SYRINGE, -5 MG SYRINGE, -<br />

7.5 MG SYRINGE, 90<br />

ARIXTRA 2.5 MG SYRINGE, 90<br />

armodafinil, 31<br />

ARMOUR THYROID, 69<br />

AROMASIN, 18<br />

artemether/lumefantrine, 14<br />

ARTHROTEC 50, 83<br />

ARTHROTEC 75, 83<br />

ASACOL, 72<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

ASACOL HD, 72<br />

ascomp with codeine, 32<br />

asenapine, 25<br />

ASMANEX TWISTHALER 110 MCG #30, 112<br />

ASMANEX TWISTHALER 220 MCG #14, 112<br />

ASMANEX TWISTHALER 220 MCG #30, 113<br />

ASMANEX TWISTHALER 220 MCG #60, 113<br />

ASMANEX TWISTHALR 220 MCG #120, 113<br />

aspirin, 85<br />

aspirin ec 975 mg tablet, 85<br />

aspirin/dipyridamole, 86<br />

ASTELIN, 62<br />

ASTEPRO 0.15% NASAL SPRAY, 62<br />

ASTEPRO 137 MCG NASAL SPRAY, 62<br />

ASTRAMORPH-PF, 27<br />

ATACAND, 42<br />

ATACAND HCT, 49<br />

atazanavir sulfate, 4<br />

atenolol, 43<br />

atenolol tablet, 43<br />

atenolol-chlorthalidone, 49<br />

ATGAM, 76<br />

atomoxetine, 37<br />

atorvastatin calcium, 46<br />

atovaquone, 9<br />

atovaquone/proguanil hcl, 15<br />

ATRALIN, 52<br />

ATRIPLA, 4<br />

atropine care, 108<br />

atropine sulfate, 109<br />

atropine sulfate drops, -ointment, 108<br />

atropine sulfate injection, 37<br />

ATROVENT 0.03% SPRAY, 62<br />

ATROVENT 0.06% SPRAY, 62<br />

ATROVENT HFA, 113<br />

ATRYN, 91<br />

ATTENUVAX VACCINE WITH DILUENT, 76<br />

AUGMENTIN 125-31.25 SUSPEN, -TABLET<br />

CHEWABLE, 13<br />

AUGMENTIN 400-57 MG/5 ML, -250-62.5<br />

MG/5 ML, -TABLET, 13<br />

AUGMENTIN ES-600, 13<br />

AUGMENTIN XR, 13<br />

auranofin, 85<br />

aurodex, 61<br />

aurodex ear drops, 61<br />

auroguard, 61<br />

AUTO INJECTOR, 80<br />

AUTOJECT 2, 80<br />

AUTONOMIC AND CNS MEDICATIONS, 22<br />

AUTOPEN, 80<br />

AVALIDE, 49<br />

AVANDAMET, 66<br />

AVANDARYL, 66<br />

AVANDIA 2 MG TABLET, -4 MG TABLET, 66<br />

AVANDIA 8 MG TABLET, 66<br />

AVAPRO, 42<br />

AVAR, 53<br />

AVAR LS, 53<br />

AVAR-E, 53<br />

AVAR-E GREEN, 53<br />

AVAR-E LS CREAM, 53<br />

AVASTIN, 18<br />

AVC, 98<br />

AVELOX, 15<br />

AVELOX ABC PACK, 15<br />

AVELOX IV, 15<br />

aviane, 94<br />

AVIDOXY, 16<br />

AVINZA, 27<br />

AVITA, 53<br />

AVODART, 115<br />

AVONEX, 78<br />

AVONEX ADMINISTRATION PACK, 78<br />

AXERT 12.5 MG TABLET, 32<br />

AXERT 6.25 MG TABLET, 32<br />

AXID, 71<br />

AYGESTIN, 103<br />

azacitidine, 21<br />

AZACTAM 1 GM VIAL, 8<br />

AZACTAM 2 GM VIAL, 9<br />

AZACTAM-ISO-OSMOT 1 GM/50 ML, 9<br />

AZACTAM-ISO-OSMOT 2 GM/50 ML, 9<br />

AZASAN, 18<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

AZASITE, 107<br />

azathioprine, 18, 19<br />

azathioprine sodium, 18<br />

azathioprine tablet, 18<br />

azelaic acid, 53<br />

azelastine hcl, 62, 109<br />

azelastine hcl aerosol spray w/pump, 62<br />

azelastine hcl drops, 108<br />

AZELEX, 53<br />

AZILECT, 36<br />

azithromycin, 11, 12, 107<br />

azithromycin 100 mg/5 ml susp, 11<br />

azithromycin 200 mg/5 ml susp, 11<br />

azithromycin 250 mg tablet, 11<br />

azithromycin 500 mg tablet, 11<br />

azithromycin 600 mg tablet, -packet, 11<br />

azithromycin injection, 11<br />

AZMACORT, 113<br />

AZOPT, 104<br />

AZOR, 49<br />

aztreonam, 8, 9<br />

aztreonam 1 gm vial, 9<br />

aztreonam 2 gm vial, 9<br />

aztreonam/dextrose water, 9<br />

AZULFIDINE, 72<br />

azurette, 94<br />

baciim, 9<br />

bacitracin 500 unit/gm ointmnt, 107<br />

bacitracin injection, 9<br />

bacitracin-polymyxin eye oint, 107<br />

baclofen tablet, 83<br />

BACTOCILL, 13<br />

BACTRIM, 15<br />

BACTRIM DS, 15<br />

BACTROBAN, 16<br />

BACTROBAN NASAL, 16<br />

balsalazide disodium, 72<br />

balziva, 94<br />

BANZEL 200 MG TABLET, 34<br />

BANZEL 400 MG TABLET, 34<br />

BARACLUDE SOLUTION, 10<br />

BARACLUDE TABLET, 10<br />

basiliximab, 21<br />

baycadron, 63<br />

b-caine/tan ac/menth/cpyrd, 63<br />

bcg vaccine, 21, 78<br />

becaplermin, 59<br />

beclomethasone, 62, 114<br />

BECONASE AQ, 62<br />

benazepril, 41<br />

benazepril hcl, 41<br />

benazepril hcl-hctz, 49<br />

benazepril/amlodipine besylate, 50<br />

benazepril/hctz, 49<br />

benazepril-hydrochlorothiazide, 49<br />

bendroflumethiazide, 52<br />

bendroflumethiazide/nadolol, 49<br />

BENICAR, 42<br />

BENICAR HCT, 49<br />

ben-tann, 110<br />

BENTYL CAPSULE, -SYRUP, -TABLET, 70<br />

BENTYL INJECTION, 70<br />

BENZACLIN, 53<br />

BENZAMYCIN, 53<br />

BENZAMYCINPAK, 53<br />

benzene hexachloride gamma, 55<br />

BENZOTIC, 61<br />

benztropine, 23<br />

benztropine mesylate injection, 23<br />

benztropine mesylate tablet, 23<br />

benzyl alcohol, 55<br />

bepotastine besilate, 108<br />

BEPREVE, 108<br />

besifloxacin, 107<br />

BESIVANCE, 107<br />

BETA-2 ADRENERGIC DRUGS, 111<br />

BETA-ADRENERGIC ANTAGONIST DRUGS,<br />

43<br />

BETADINE SOLUTION, 108<br />

BETAGAN, 104<br />

betaine hcl, 115<br />

betamet diprop/calcipotriene, 55<br />

betameth/propylene glycol, 57<br />

betamethasone, 64<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

betamethasone acetate-sod phos, 63<br />

betamethasone dipropionate, 57<br />

betamethasone dipropionate cream, -gel, -<br />

lotion, -ointment, 56<br />

betamethasone valerate, 57<br />

betamethasone valerate cream, -lotion, -<br />

ointment, 56<br />

betamethasone/betamethasone, 63<br />

betanate, 56<br />

BETAPACE, 48<br />

BETAPACE AF, 49<br />

BETASERON, 78<br />

beta-val, 56<br />

betaxolol, 43, 104<br />

betaxolol hcl drops, 104<br />

betaxolol hcl tablet, 43<br />

bethanechol, 115<br />

bethanechol chloride tablet, 115<br />

BETIMOL, 104<br />

BETOPTIC S, 104<br />

bevacizumab, 18<br />

bexarotene, 21<br />

BIAXIN, 11<br />

BIAXIN XL, 11<br />

bicalutamide, 18<br />

BICILLIN C-R, 13<br />

BICILLIN L-A, 13<br />

BIDIL, 51<br />

BILTRICIDE, 3<br />

bimatoprost, 105<br />

bismuth/metronid/tetracyclin, 73<br />

bisoprolol, 43<br />

bisoprolol fumarate, 43<br />

bisoprolol fumarate-hctz, 49<br />

bisoprolol-hydrochlorothiazide, 49<br />

BLEPH-10, 107<br />

BLEPHAMIDE, 105<br />

BLEPHAMIDE S.O.P., 105<br />

BLOOD DETOXICANTS, 86<br />

BONIVA 150 MG TABLET, 68<br />

BONIVA 2.5 MG TABLET, 68<br />

BONIVA INJECTION, 68<br />

BOOSTRIX, 76<br />

borofair, 61<br />

bortezomib, 21<br />

bosentan, 46<br />

BOTOX, 108<br />

botulinum toxin a, 108<br />

bp 10-1, 53<br />

BRANCHAMIN, 87<br />

BREVICON, 94<br />

brimonidine 0.2% eye drop, 105<br />

brimonidine tartrate, 104<br />

brimonidine tartrate 0.15% drp, 105<br />

brimonidine tartrate/timolol, 105<br />

brinzolamide, 104<br />

bromfenac, 109<br />

bromocriptine mesylate, 36<br />

bromocriptine mesylate capsule, -tablet, 36<br />

BSS, 108<br />

BSS PLUS, 108<br />

budeprion sr, 35<br />

budeprion xl, 35<br />

budesonide, 62, 72, 113, 114<br />

budesonide/formoterol fum, 114<br />

bumetanide injection, 48<br />

bumetanide tablet, 48<br />

BUMINATE, 87<br />

BUPHENYL, 60<br />

bupivacaine, 1, 2<br />

bupivacaine hcl injection, 1<br />

bupivacaine hcl/dextrose-h2o, 1, 2<br />

bupivacaine hcl-epinephrine, 1<br />

bupivacaine hydrochloride/epi, 1, 2<br />

bupivacaine-dextrose, 1<br />

BUPRENEX, 22<br />

buprenorphine, 22, 30<br />

buprenorphine hcl tablet sublingual, 29<br />

buprenorphine injection, 22<br />

buprenorphine/naloxone, 30<br />

buproban, 40<br />

bupropion, 36, 40<br />

bupropion hbr, 35<br />

bupropion hcl, 35<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

bupropion hcl sr 100 mg tab, -100 mg tablet,<br />

-200 mg tab, 35<br />

bupropion sr 150 mg tablet, 35<br />

bupropion xl, 35<br />

BUSPAR, 27<br />

buspirone, 27<br />

buspirone hcl tablet, 27<br />

butalbital compound-codeine, 32<br />

butalbital-caff-apap-codeine, 32<br />

butenafine, 12<br />

butoconazole, 17<br />

butorphanol tartrate aerosol spray, 32<br />

butorphanol tartrate injection, 22<br />

BYETTA 10 MCG DOSE PEN INJ, 65<br />

BYETTA 5 MCG DOSE PEN INJ, 65<br />

BYSTOLIC, 43<br />

cabergoline, 68<br />

CADUET, 46<br />

CAFCIT INJECTION, 31<br />

CAFCIT SOLUTION, 112<br />

CAFERGOT, 32<br />

caffeine citrate injection, 31<br />

caffeine citrate solution, 112<br />

caffeine citrated, 31, 112<br />

CALAN, 43<br />

CALAN SR, 44<br />

CALCIJEX, 93<br />

calcipotriene, 54<br />

calcitonin, 69<br />

calcitonin-salmon, 68<br />

calcitriol, 55, 93<br />

calcitriol capsule, -solution, 93<br />

calcitriol injection, 93<br />

calcium acetate, 93<br />

CALCIUM ANTAGONISTS, 43<br />

calcium chloride injection, 87<br />

cal-nate, 99<br />

camila, 103<br />

CAMPATH, 18<br />

CAMPRAL, 37<br />

canakinumab, 79<br />

CANASA, 72<br />

CANCIDAS, 13<br />

candesartan cilexetil, 42<br />

candesartan cilexetil/hctz, 49<br />

CANTIL, 70<br />

CAPASTAT SULFATE, 5<br />

CAPEX SHAMPOO, 56<br />

CAPITAL W-CODEINE, 30<br />

CAPOTEN, 41<br />

capreomycin, 5<br />

captopril, 41<br />

captopril tablet, 41<br />

captopril-hydrochlorothiazide, 49<br />

CARAC, 58<br />

CARAFATE SUSPENSION ORAL, 72<br />

CARAFATE TABLET, 72<br />

carbachol, 105<br />

carbamazepine, 27<br />

carbamazepine suspension oral, -tablet, -<br />

tablet chewable, 27<br />

carbamazepine xr, 27<br />

CARBAMAZEPINES, 27<br />

CARBATROL, 27<br />

carbidopa, 36<br />

carbidopa/levodopa, 36<br />

carbidopa/levodopa/entacap, 36, 37<br />

carbidopa-levodopa, 36<br />

carbinoxamine maleate, 110<br />

CARBOCAINE, 1<br />

carboprost tromethamine, 94<br />

CARDIAC GLYCOSIDES, 45<br />

CARDIOVASCULAR MEDICATIONS, 41<br />

CARDIZEM, 44<br />

CARDIZEM CD, 44<br />

CARDIZEM LA, 44<br />

CARDURA 1 MG TABLET, -2 MG TABLET, -4<br />

MG TABLET, 52<br />

CARDURA 8 MG TABLET, 52<br />

CARDURA XL, 52<br />

carenatal dha, 99<br />

CARIMUNE NF NANOFILTERED, 76<br />

carisoprodol, 83<br />

carisoprodol compound, 82<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

carisoprodol compound-codeine, 82<br />

carisoprodol tablet, 82<br />

CARMOL HC, 56<br />

CARNITOR INJECTION, 93<br />

CARNITOR SF, 93<br />

CARNITOR SOLUTION, -TABLET, 93<br />

carteolol hcl, 105<br />

cartia xt, 44<br />

carvedilol, 43<br />

CASODEX, 18<br />

caspofungin acetate, 13<br />

CATAFLAM, 83<br />

CATAPRES, 45<br />

CATAPRES-TTS 1, 45<br />

CATAPRES-TTS 2, 45<br />

CATAPRES-TTS 3, 45<br />

cavan one omega, 99<br />

cavan-alpha kit, 99<br />

cavan-ec sod dha, 99<br />

CAVIRINSE, 89<br />

caziant, 95<br />

CEDAX, 5<br />

CEENU, 18<br />

cefaclor, 5, 6<br />

cefaclor er, 5<br />

cefadroxil, 6<br />

cefazolin 1 gm add-van vial, -1 gm vial, -1<br />

gm-d5w bag, -10 gm vial, -20 gm bulk vial,<br />

-500 mg vial, 6<br />

cefdinir, 6<br />

cefditoren pivoxil, 6<br />

cefepime, 6<br />

cefepime hcl, 6<br />

cefixime, 7<br />

cefotaxime, 6<br />

cefotaxime sodium, 6<br />

cefotetan, 6<br />

cefoxitin, 6<br />

cefoxitin sodium, 6<br />

cefpodoxime, 7<br />

cefpodoxime proxetil, 6<br />

cefprozil, 6<br />

ceftazidime, 6, 7<br />

ceftibuten, 5<br />

CEFTIN, 6<br />

ceftriaxone, 6<br />

cefuroxime, 7<br />

cefuroxime axetil, 6<br />

cefuroxime injection, 6<br />

cefuroxime sod 1.5 gm vial, -sod 7.5 gm vial,<br />

-sod 750 mg vial, 6<br />

cefuroxime tablet, 6<br />

CELEBREX, 83<br />

celecoxib, 83<br />

CELESTONE INJECTION, 63<br />

CELESTONE SOLUTION ORAL, 64<br />

CELEXA SOLUTION, 38<br />

CELEXA TABLET, 38<br />

CELLCEPT CAPSULE, 18<br />

CELLCEPT INJECTION, 18<br />

CELLCEPT TABLET, -SUSPENSION<br />

RECONSTITUTED ORAL, 18<br />

CELONTIN, 40<br />

CENESTIN, 97<br />

CENTANY, 16<br />

CENTRALLY ACTING ANTIHYPERTENSIVES,<br />

45<br />

cephalexin, 6<br />

CEPHALOSPORINS, 5<br />

CEREBYX, 33<br />

CEREDASE, 68<br />

CEREZYME, 68<br />

cerovel, 58<br />

certolizumab pegol, 19<br />

CERVARIX, 76<br />

CERVIDIL, 94<br />

CESAMET, 25<br />

cesia, 95<br />

cetirizine 1 mg/1 ml soln, -1 mg/ml soln, -1<br />

mg/ml syrup, -5 mg/5 ml syrup, 110<br />

cevimeline, 63<br />

CHANTIX, 40<br />

CHEMET, 60<br />

CHENODAL, 72<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

chenodiol, 72<br />

chlorambucil, 19<br />

chloramphenicol sod succinate, 7<br />

CHLORAMPHENICOLS, 7<br />

chlorhexidine gluconate mouthwash, 63<br />

chloroprocaine, 2<br />

chloroprocaine hcl, 1<br />

chloroquine phosphate, 14<br />

chloroquine phosphate tablet, 14<br />

chlorothiazide, 51, 52<br />

chlorothiazide sodium, 51, 52<br />

chloroxylenol-pramoxine hcl, 61<br />

chlorpromazine hcl injection, 23<br />

chlorpromazine hcl tablet, 23<br />

chlorthalidone, 51, 52<br />

chlorthalidone/atenolol, 50<br />

chlorzoxazone, 82<br />

cholestyramine, 47<br />

cholestyramine light, 47<br />

cholestyramine/aspartame, 47<br />

cholestyramine/sucrose, 47<br />

choline mag trisalicylate, 85<br />

CHOLINERGIC STIMULANTS, 115<br />

ciclesonide, 62, 112<br />

ciclopirox, 12<br />

ciclopirox cream, -gel, -kit, -shampoo, -<br />

suspension topical, 12<br />

ciclopirox solution non-oral, 12<br />

ciclopirox/nail lacquer remov, 12<br />

cidofovir, 11<br />

cilostazol, 86<br />

CILOXAN, 107<br />

cimetidine 200 mg tablet, -300 mg tablet, -<br />

400 mg tablet, -800 mg tablet, -solution,<br />

71<br />

cimetidine injection, 71<br />

CIMZIA, 19<br />

cinacalcet hcl, 69<br />

CIPRO, 15<br />

CIPRO HC, 61<br />

CIPRO I.V., 15<br />

CIPRO XR, 15<br />

CIPRODEX, 61<br />

ciprofloxacin, 15, 107<br />

ciprofloxacin er, 15<br />

ciprofloxacin hcl drops, 107<br />

ciprofloxacin hcl tablet, 15<br />

ciprofloxacin/dexameth, 61<br />

ciprofloxacin/hc, 61<br />

ciprofloxacin-d5w, 15<br />

citalopram, 38<br />

citalopram hbr, 38<br />

CITRANATAL 90 DHA, 99<br />

CITRANATAL DHA, 99<br />

CITRANATAL RX, 99<br />

CLAFORAN, 6<br />

claravis, 55<br />

CLARIFOAM EF, 53<br />

CLARINEX SYRUP, 110<br />

CLARINEX TABLET, -TABLET DISPERSIBLE<br />

LINGUAL, 110<br />

CLARINEX-D 12 HOUR, 110<br />

CLARINEX-D 24 HOUR, 110<br />

clarithromycin, 11<br />

clarithromycin er, 11<br />

CLASS II NARCOTICS, 27<br />

CLASS III NARCOTICS, 29<br />

clemastine fum 2.68 mg tab, -syrup, 110<br />

clenia cleanser, 53<br />

CLENIA CREAM, 53<br />

CLEOCIN, 98<br />

CLEOCIN HCL, 7<br />

CLEOCIN PALMITATE, 7<br />

CLEOCIN PHOSPHATE, 7<br />

CLEOCIN PHOSPHATE IN D5W, 7<br />

CLEOCIN T, 53<br />

CLIMARA, 97<br />

CLIMARA PRO, 98<br />

clinda-derm, 53<br />

CLINDAGEL, 53<br />

CLINDAMAX CREAM WITH APPLICATOR, 98<br />

CLINDAMAX GEL, -LOTION, 53<br />

clindamycin hcl, 7<br />

clindamycin hcl capsule, 7<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

clindamycin palmitate, 7<br />

clindamycin palmitate hcl, 7<br />

clindamycin phos/benz per, 52<br />

clindamycin phosphate, 7, 53, 98<br />

clindamycin phosphate cream with<br />

applicator, 98<br />

clindamycin phosphate foam, -gel, -lotion, -<br />

solution non-oral, -swab medicated, 53<br />

clindamycin phosphate injection, 7<br />

clindamycin/benz per/hyalur na, 53<br />

clindamycin/benzoyl prx/skn #5, 53<br />

clindamycin/tretinoin, 54<br />

clindamycin-benzoyl peroxide, 53<br />

CLINDAMYCINS, 7<br />

CLINDAREACH, 53<br />

CLINDESSE, 98<br />

CLINDETS, 53<br />

CLINIMIX, 87<br />

CLINIMIX E, 87<br />

CLINISOL, 87<br />

CLINORIL, 83<br />

clobetasol emollient, 56<br />

clobetasol propionate, 56, 58<br />

clobetasol propionate cream, -foam, -gel, -<br />

ointment, -solution non-oral, 56<br />

CLOBEX, 56<br />

clocortolone pivalate, 56<br />

CLODERM, 56<br />

clomipramine, 40<br />

clomipramine hcl capsule, 40<br />

clonidine, 45<br />

clonidine hcl injection, 45<br />

clonidine hcl tablet, 45<br />

clonidine hcl/chlorthalidone, 49<br />

clopidogrel, 86<br />

CLORPRES, 49<br />

clotrimazole 1% cream, -1% solution, -af 1%<br />

cream, 12<br />

clotrimazole troche, 8<br />

clotrimazole/betamethasone, 17<br />

clotrimazole-betamethasone, 17<br />

clozapine, 23<br />

CLOZARIL, 23<br />

CNL 8, 12<br />

CNS MUSCLE RELAXANTS, 82<br />

CNS STIMULANT DRUGS, 30<br />

COARTEM, 14<br />

codeine phosphate injection, 27<br />

codeine phosphate/apap, 30<br />

codeine sulfate, 28<br />

codeine/apap/caffeine/butalb, 32<br />

codeine/asa/caffeine/butalb, 32<br />

COGENTIN, 23<br />

co-gesic, 30<br />

COGNEX, 22<br />

COLAZAL, 72<br />

colchicine, 83<br />

COLCRYS, 83<br />

colesevelam, 47<br />

COLESTID, 47<br />

colestipol, 47<br />

colestipol hcl, 47<br />

colistimethate 150 mg vial, 9<br />

colistimethate, sodium, 9<br />

collagenase, 59<br />

collagenase clostridium hist., 60<br />

COLOCORT, 72<br />

COLY-MYCIN M PARENTERAL, 9<br />

COLY-MYCIN S, 61<br />

COLYTE, 72<br />

COLYTE WITH FLAVOR PACKETS, 72<br />

combi rx, 99<br />

COMBIGAN, 105<br />

COMBIPATCH, 98<br />

COMBIVENT, 113<br />

COMBIVIR, 4<br />

COMBUNOX, 28<br />

COMPAZINE INJECTION, 25<br />

COMPAZINE SYRUP, 25<br />

complete allergy medicine, 110<br />

complete natal dha, 99<br />

completenate, 99<br />

compro, 25<br />

COMTAN, 36<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

COMVAX, 76<br />

co-natal fa, 99<br />

CONCEPT DHA, 99<br />

CONCEPT OB, 99<br />

CONCERTA, 31<br />

CONDYLOX GEL, 55<br />

CONDYLOX SOLUTION NON-ORAL, 55<br />

constulose, 86<br />

CONTRACEPTIVES, 94<br />

CONTROL RX, 89<br />

COPAXONE, 60<br />

COPEGUS, 10<br />

CORDARONE, 41<br />

CORDRAN LOTION, -OINTMENT, 56<br />

CORDRAN SP, 56<br />

CORDRAN TAPE MEDICATED, 56<br />

COREG, 43<br />

COREG CR, 43<br />

CORGARD, 43<br />

CORLOPAM, 49<br />

cormax, 56<br />

CORTEF, 64<br />

CORTENEMA, 72<br />

corticorelin ovine triflutate, 68<br />

corticotropin, 68<br />

CORTIFOAM, 72<br />

cortisone tablet, 64<br />

CORTISPORIN CREAM, -OINTMENT, 16<br />

CORTISPORIN SUSPENSION DROPS, 105<br />

CORTISPORIN SUSPENSION DROPS, -<br />

SOLUTION NON-ORAL, 61<br />

CORTISPORIN-TC, 61<br />

cortomycin ointment, 105<br />

cortomycin solution non-oral, -suspension<br />

drops, 61<br />

CORVERT, 49<br />

CORZIDE, 49<br />

COSOPT, 105<br />

COUMADIN INJECTION, 91<br />

COUMADIN TABLET, 91<br />

COVERA-HS, 44<br />

COZAAR, 42<br />

CREON, 72<br />

CRESTOR 10 MG TABLET, -20 MG TABLET, -<br />

40 MG TABLET, 46<br />

CRESTOR 5 MG TABLET, 46<br />

CRINONE, 103<br />

CRIXIVAN, 4<br />

CROLOM, 108<br />

cromolyn, 108, 113<br />

cromolyn sodium ampul for nebulization, 113<br />

cromolyn sodium drops, 108<br />

crotamiton, 55<br />

cryselle, 95<br />

CUBICIN, 9<br />

CUPRIMINE, 85<br />

CURAD GAUZE PADS, 80<br />

CURITY ALCOHOL PREPS, 80<br />

CURITY GAUZE SPONGES, 80<br />

CUTIVATE, 56<br />

CYCLESSA, 95<br />

cyclobenzaprine, 82<br />

cyclobenzaprine hcl tablet, 82<br />

CYCLOGYL 0.5% EYE DROPS, -2% EYE<br />

DROPS, 108<br />

CYCLOGYL 1% EYE DROPS, 108<br />

cyclopentolate, 108<br />

cyclopentolate hcl, 108<br />

cyclophosphamide tablet, 19<br />

cycloserine, 5<br />

CYCLOSERINE, 5<br />

cyclosporine, 20, 109<br />

cyclosporine capsule, -solution, 19<br />

cyclosporine injection, 19<br />

cyclosporine modified, 19<br />

CYKLOKAPRON, 60<br />

cylate, 108<br />

CYMBALTA 20 MG CAPSULE, -60 MG<br />

CAPSULE, 35<br />

CYMBALTA 30 MG CAPSULE, 35<br />

cyproheptadine hcl syrup, -tablet, 110<br />

CYSTADANE, 115<br />

CYSTAGON, 87<br />

cysteamine, 87<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

CYTOMEL, 69<br />

CYTOTEC, 72<br />

CYTOVENE, 10<br />

cytra-2, 92<br />

cytra-3, 115<br />

cytra-k, 115<br />

D.H.E.45, 32<br />

d5w/electrolyte-56 solution, 88<br />

d5w/kcl 10 meq/l iv solution, -30 meq/l iv<br />

solution, 87<br />

daclizumab, 79<br />

dalfampridine, 60<br />

dalteparin (porcine), 91<br />

d-amphetamine, 31<br />

danazol capsule, 94<br />

DANTRIUM CAPSULE, 83<br />

DANTRIUM INJECTION, 83<br />

dantrolene, 83<br />

dantrolene sodium, 83<br />

dapsone, 3, 52<br />

DAPSONE, 3<br />

DAPTACEL, 76<br />

daptomycin, 9<br />

DARAPRIM, 14<br />

darbepoetin alfa, 75, 76<br />

darifenacin hydrobromide, 114<br />

darunavir ethanolate, 4<br />

dasatinib, 21<br />

DAYPRO, 84<br />

DAYTRANA, 31<br />

DAZIDOX, 28<br />

DDAVP 4 MCG/ML AMPUL, 68<br />

DDAVP 4 MCG/ML VIAL, 68<br />

DDAVP SOLUTION, -AEROSOL SPRAY<br />

W/PUMP, -TABLET, 68<br />

DEBACTEROL, 63<br />

deferasirox, 60<br />

DELATESTRYL, 94<br />

delavirdine mesylate, 4<br />

del-beta, 56<br />

DELESTROGEN, 97<br />

DEMADEX, 48<br />

demeclocycline hcl, 16<br />

DEMEROL, 28<br />

DEMSER, 45<br />

DEMULEN 1-50-21, 95<br />

DENAVIR, 10<br />

denosumab, 69<br />

denta 5000 plus, 89<br />

dentagel, 89<br />

DEPACON, 41<br />

depade, 37<br />

DEPAKENE, 41<br />

DEPAKOTE, 41<br />

DEPAKOTE ER, 41<br />

DEPAKOTE SPRINKLE, 41<br />

DEPEN, 85<br />

DEPO-ESTRADIOL, 97<br />

DEPO-MEDROL, 64<br />

DEPO-PROVERA 150 MG/ML VIAL, 103<br />

DEPO-PROVERA 400 MG/ML VIAL, 19<br />

DEPO-SUBQ PROVERA 104, 103<br />

DEPO-TESTOSTERONE, 94<br />

DERMA-SMOOTHE-FS, 56<br />

DERMATOLOGICAL MEDICATIONS, 52<br />

DERMATOP, 57<br />

DERMOTIC, 61<br />

desipramine, 38<br />

desipramine hcl, 37<br />

desloratadine, 110<br />

desmopressin acetate, 68, 69<br />

desmopressin acetate aerosol spray w/pump,<br />

-solution, -tablet, 68<br />

desmopressin acetate injection, 68<br />

DESOGEN, 95<br />

desogestrel-ethinyl estradiol, 95, 96<br />

desog-et estra/ethin estra, 95<br />

DESONATE, 57<br />

desonide, 57, 58<br />

desonide cream, -lotion, -ointment, 57<br />

desonide/emollient combo #30, 57<br />

DESOWEN, 57<br />

desoximetasone, 58<br />

desoximetasone cream, -gel, -ointment, 57<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

DESOXYN, 31<br />

desvenlafaxine succinate, 35<br />

DETROL, 114<br />

DETROL LA, 114<br />

dexamethasone, 64, 106<br />

dexamethasone elixir, -solution oral, -tablet,<br />

64<br />

dexamethasone intensol, 64<br />

dexamethasone sodium phosphate drops,<br />

106<br />

dexamethasone sodium phosphate injection,<br />

64<br />

dexasol, 106<br />

dexasporin, 105<br />

dexchlorpheniramine maleate, 110<br />

DEXEDRINE, 31<br />

DEXILANT DR 30 MG CAPSULE, 73<br />

DEXILANT DR 60 MG CAPSULE, 73<br />

dexlansoprazole, 73, 74<br />

dexmethylphenidate, 31<br />

dexmethylphenidate hcl, 31<br />

DEXPAK, 64<br />

dextroamphetamine sulfate, 31<br />

dextroamphetamine-amphetamine, 31<br />

dextrose 10%-1/4ns, 87<br />

dextrose 10%-1/4ns-kcl, 87<br />

dextrose 2.5%-lr 1/2 str sol, 87<br />

dextrose 5%-1/2ns-kcl, 87<br />

dextrose 5%-1/3ns-kcl, 87<br />

dextrose 5%-1/4ns-kcl, 87<br />

dextrose 5%-electrolyte #48, 87<br />

dextrose 5%-electrolyte #75, 87<br />

dextrose 5%-lr iv solution, 92<br />

dextrose 5%-ns-kcl, 87<br />

dextrose in ringers injection, 87<br />

dextrose in water, 87<br />

dextrose with sodium chloride, 87<br />

dextrose/electrolytes, 88<br />

DIABETA, 66<br />

DIABETIC SUPPLIES, 80<br />

DIAGNOSTIC AND MISCELLANEOUS<br />

MEDICATIONS, 60<br />

DIAGNOSTIC PRODUCTS, 60<br />

DIAMOX SEQUELS, 105<br />

diazoxide, 65<br />

DIBENZYLINE, 45<br />

diclofenac epolamine, 56<br />

diclofenac potassium, 83, 84, 85<br />

diclofenac sodium, 56, 59, 85, 109<br />

diclofenac sodium drops, 108<br />

diclofenac sodium tablet enteric coated, -<br />

tablet sustained release 24hr, 84<br />

diclofenac sodium/misoprostol, 83<br />

dicloxacillin sodium, 14<br />

dicyclomine, 70<br />

dicyclomine hcl capsule, -syrup, -tablet, 70<br />

dicyclomine hcl injection, 70<br />

didanosine, 4, 5<br />

DIDRONEL, 68<br />

difenoxin/atropine sulfate, 70<br />

DIFFERIN, 53<br />

diflorasone, 56<br />

diflorasone diacetate, 57<br />

DIFLUCAN 100 MG TABLET, -200 MG<br />

TABLET, -50 MG TABLET, 8<br />

DIFLUCAN 150 MG TABLET, 8<br />

DIFLUCAN IN DEXTROSE, 13<br />

DIFLUCAN IN SALINE, 13<br />

DIFLUCAN SUSPENSION, 8<br />

diflunisal, 85<br />

difluprednate, 106<br />

digoxin, 45<br />

digoxin injection, 45<br />

digoxin solution, -tablet, 45<br />

dihydrocodeine/apap/caffeine, 30<br />

dihydrocodeine/asa/caffeine, 30<br />

dihydroergotamine, 32<br />

dihydroergotamine mesylate injection, 32<br />

DILACOR XR, 44<br />

DILANTIN 100 MG CAPSULE, 33<br />

DILANTIN 30 MG CAPSULE, -30 MG<br />

KAPSEAL, -TABLET CHEWABLE, 33<br />

DILANTIN-125, 33<br />

DILATRATE-SR, 48<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

DILAUDID INJECTION, 28<br />

DILAUDID TABLET, 28<br />

DILAUDID-5, 28<br />

DILAUDID-HP, 28<br />

dilt-cd, 44<br />

diltia xt, 44<br />

diltiazem, 44<br />

diltiazem 24hr er, 44<br />

diltiazem er, 44<br />

diltiazem hcl injection, 44<br />

diltiazem hcl tablet, 44<br />

dilt-xr, 44<br />

diltzac er, 44<br />

dimenhydrinate injection, 25<br />

dimethyl sulfoxide, 115<br />

dinoprostone, 94, 104<br />

DIOVAN, 42<br />

DIOVAN HCT, 49<br />

DIPENTUM, 72<br />

diphenhydramine 12.5 mg/5 ml, -25 mg cap,<br />

-50 mg cap, -50 mg capsule, 110<br />

diphenhydramine hcl injection, 110<br />

diphenhydramine tannate, 110<br />

diphenmax, 110<br />

diphenoxylate/atropine sulfate, 70<br />

diphenoxylate-atropine, 70<br />

diphther,pertuss,tetanus vac, 75, 76, 77, 78<br />

DIPHTHERIA-TETANUS TOXOID, 76<br />

dipivefrin, 105<br />

DIPROLENE, 57<br />

DIPROLENE AF, 57<br />

DIPROSONE, 57<br />

dipyridamole, 86<br />

dipyridamole tablet, 86<br />

DIRECT MUSCLE RELAXANTS, 83<br />

diskets, 28<br />

disulfiram, 37<br />

DITROPAN XL 10 MG TABLET, -15 MG<br />

TABLET, 114<br />

DITROPAN XL 5 MG TABLET, -5 MG TABLET<br />

SA, 114<br />

DIURIL, 52<br />

DIURIL SODIUM, 52<br />

divalproex, 41<br />

divalproex sodium, 41<br />

divalproex sodium er, 41<br />

DIVIGEL, 97<br />

dobutamine hcl, 50<br />

dobutamine hcl in dextrose, 50<br />

docosavit, 99<br />

dofetilide, 49<br />

dolasetron mesylate, 25<br />

DOLOPHINE HCL, 28<br />

DOLOREX FORTE, 30<br />

DOMEBORO DROPS, 61<br />

donepezil, 22<br />

dopamine hcl, 50<br />

dopamine hcl in 5% dextrose, 50<br />

DORIBAX, 9<br />

doripenem, 9<br />

DORYX, 16<br />

dorzolamide, 105<br />

dorzolamide hcl, 105<br />

dorzolamide/timolol, 105<br />

dorzolamide-timolol, 105<br />

DOVONEX CREAM, 54<br />

DOVONEX SOLUTION, 54<br />

doxazosin, 52<br />

doxazosin mesylate 1 mg tab, -2 mg tab, -4<br />

mg tab, 52<br />

doxazosin mesylate 8 mg tab, 52<br />

doxepin, 59<br />

doxepin hcl capsule, -solution, 40<br />

doxercalciferol, 93<br />

doxycycline, 16<br />

doxycycline hyclate, 16, 63<br />

doxycycline hyclate 100 mg tab, -capsule, -<br />

capsule enteric coated, 16<br />

doxycycline hyclate 20 mg tab, 63<br />

doxycycline hyclate injection, 16<br />

doxycycline monohydrate, 16<br />

doxy-lemmon, 16<br />

dp (a) ped/hib conj-tet, 78<br />

dp (a) t-polio/hib conj-tet/pf, 77<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

DRITHOCREME HP, 54<br />

DRITHO-SCALP, 54<br />

dronabinol, 26<br />

dronabinol 10 mg capsule, -5 mg capsule, 25<br />

dronabinol 2.5 mg capsule, 25<br />

dronedarone, 49<br />

droperidol, 1<br />

droperidol injection, 1<br />

DROXIA, 19<br />

DRUGS AFFECTING THE EAR, 60<br />

DRUGS AFFECTING THE NOSE, 62<br />

DRUGS AFFECTING THE THROAT AND<br />

MOUTH, 63<br />

DRUGS FOR PHEOCHROMOCYTOMA, 45<br />

DRUGS TO PREVENT AND TREAT GOUT, 83<br />

DRUGS TO PREVENT AND TREAT<br />

HEADACHES, 31<br />

DRYSOL, 58<br />

DUAC CS, 53<br />

dualvit ob, 99<br />

DUETACT, 67<br />

DULERA, 113<br />

duloxetine, 35<br />

DURACLON, 45<br />

DURAGESIC, 28<br />

DURAMORPH, 28<br />

DUREZOL, 106<br />

dutasteride, 115<br />

dutasteride/tamsulosin hcl, 115<br />

DYAZIDE, 51<br />

dylix, 112<br />

DYNACIN, 16<br />

DYNACIRC CR, 44<br />

dyphylline, 112<br />

DYRENIUM, 51<br />

DYSPORT, 83<br />

DYTAN, 110<br />

E.E.S. 200, 7<br />

E.E.S. 400, 7<br />

EAR-NOSE-THROAT MEDICATIONS, 60<br />

EASPRIN, 85<br />

EASY COMFORT INSULIN SYRINGE, 80<br />

EASY TOUCH NEEDLE DISPOSABLE, -<br />

SYRINGE EMPTY DISPOSABLE, 80<br />

easygel, 89<br />

echothiophate iodide, 105<br />

EC-NAPROSYN, 84<br />

econazole nitrate cream, 12<br />

EDECRIN, 48<br />

edge ob, 99<br />

EDLUAR, 38<br />

edrophonium, 37<br />

edrophonium/atropine sulfate, 37<br />

efalizumab, 20<br />

efavirenz, 4<br />

EFFER-K 10 MEQ TABLET EFF, -20 MEQ<br />

TABLET EFF, 92<br />

effer-k 25 meq tablet eff, 92<br />

EFFEXOR, 35<br />

EFFEXOR XR 150 MG CAPSULE, -37.5 MG<br />

CAPSULE, 35<br />

EFFEXOR XR 75 MG CAPSULE, 35<br />

EFFIENT, 86<br />

EFUDEX, 58<br />

ELAPRASE, 68<br />

ELDEPRYL, 36<br />

electrolyte solution/peg's, 72, 73<br />

electrolyte solutions, 88, 89<br />

ELECTROLYTES, IRRIGATING SOLUTIONS,<br />

ETC., 86<br />

ELESTAT, 108<br />

ELESTRIN, 97<br />

eletriptan, 33<br />

ELIDEL, 58<br />

ELIGARD, 19<br />

ELIMITE, 55<br />

eliphos, 93<br />

elite ob dha, 99<br />

ELITEK, 19<br />

elite-ob, 99<br />

ELIXOPHYLLIN, 112<br />

ELMIRON, 115<br />

ELOCON, 57<br />

eltrombopag olamine, 79<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

EMADINE, 109<br />

EMBEDA, 28<br />

EMCYT, 19<br />

emedastine difumarate, 109<br />

EMEND 125 MG CAPSULE, -40 MG CAPSULE,<br />

25<br />

EMEND 80 MG CAPSULE, 26<br />

EMEND INJECTION, 26<br />

EMEND TRIFOLD PACK, 26<br />

EMGEL, 53<br />

EMLA, 2<br />

EMSAM, 33<br />

emtricitabine, 4<br />

emtricitabine/tenofovir, 5<br />

emtricitabine/tenofovir/efavir, 4<br />

EMTRIVA, 4<br />

ENABLEX, 114<br />

enalapril, 42<br />

enalapril maleate tablet, 41<br />

enalapril maleate/hctz, 50<br />

enalaprilat, 41<br />

enalapril-hydrochlorothiazide, 49<br />

ENBREL, 19<br />

endocet, 28<br />

ENDOCRINE MEDICATIONS, 63<br />

endodan, 28<br />

ENDOTHELIN RECPTR ANTAGONIST, 46<br />

ENDRATE, 60<br />

endrate disodium, 60<br />

enfuvirtide, 4<br />

ENGERIX-B, 76<br />

ENJUVIA, 97<br />

ENLON, 37<br />

ENLON-PLUS, 37<br />

enoxaparin, 91<br />

enoxaparin 100 mg/ml syr, -30 mg/0.3 ml<br />

syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr,<br />

-80 mg/0.8 ml syr, 90<br />

enoxaparin 120 mg/0.8 ml syr, -150 mg/ml<br />

syr, 90<br />

enpresse, 95<br />

entacapone, 36<br />

entecavir, 10<br />

ENTOCORT EC, 72<br />

enulose, 86<br />

ENZYMAX 500 MG TABLET, 72<br />

enzymes, digestive, 72<br />

EPIDUO, 53<br />

epiflur, 89<br />

epiklor, 92<br />

epinastine hcl, 108<br />

epinephrine 0.1 mg/ml syringe, -1 mg/ml<br />

ampul, -1 mg/ml vial, 113<br />

EPINEPHRINE 0.15 MG AUTO-INJCT, -0.3 MG<br />

AUTO-INJECT, 113<br />

EPINEPHRINE 0.3 MG/0.3 ML SYR, 113<br />

epinephrine hcl, 112, 113, 114<br />

EPIPEN, 113<br />

EPIPEN JR, 113<br />

epitol, 27<br />

EPIVIR, 4<br />

EPIVIR HBV, 10<br />

eplerenone, 51<br />

epoetin alfa, 76, 77<br />

EPOGEN 10,000 UNITS/ML VIAL, -20,000<br />

UNITS/2 ML VIAL, -20,000 UNITS/ML<br />

VIAL, -40,000 UNITS/ML VIAL, 76<br />

EPOGEN 2,000 UNITS/ML VIAL, -3,000<br />

UNITS/ML VIAL, -4,000 UNITS/ML VIAL,<br />

76<br />

epoprostenol na, 51<br />

epoprostenol sodium, 51<br />

eprosartan mesylate, 42<br />

eprosartan mesylate/hctz, 50<br />

eptifibatide, 86<br />

EPZICOM, 4<br />

EQUETRO, 27<br />

ERAXIS (ALCOHOL DILUENT), 13<br />

ERAXIS (WATER DILUENT), 13<br />

ergoloid mesylates tablet, 60<br />

ERGOMAR, 32<br />

ergotamine, 32<br />

ergotamine tartrate/caffeine, 32<br />

ergotamine-caffeine, 32<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

erlotinib hcl, 21<br />

errin, 103<br />

ERTACZO, 12<br />

ertapenem sodium, 9<br />

ery, 53<br />

ERYPED 200, 7<br />

ERYPED 400, 7<br />

ERY-TAB, 7<br />

ERYTHROCIN LACTOBIONATE, 7<br />

erythrocin stearate, 7<br />

erythromycin base, 7, 52, 53<br />

erythromycin base/benz per, 53<br />

erythromycin capsule enteric coated, -tablet,<br />

7<br />

erythromycin ethylsuccinate, 7<br />

erythromycin ethylsuccinate tablet, 7<br />

erythromycin gel, -solution non-oral, 53<br />

erythromycin lactobionate, 7<br />

erythromycin ointment, 107<br />

erythromycin-benzoyl peroxide, 53<br />

ERYTHROMYCINS, 7<br />

erythromycin-sulfisoxazole, 15<br />

escitalopram oxalate, 39<br />

ESKALITH, 23<br />

esomeprazole mag trihyd, 74<br />

ESTRACE CREAM WITH APPLICATOR, 97<br />

ESTRACE TABLET, 97<br />

ESTRADERM, 97<br />

estradiol, 97, 98<br />

estradiol cypionate, 97<br />

estradiol patch transdermal weekly, 97<br />

estradiol tablet, 97<br />

estradiol valerate, 97<br />

estradiol valerate injection, 97<br />

estradiol valerate/dienogest, 95<br />

estradiol/drospirenone, 98<br />

estradiol/levonorgestrel, 98<br />

estradiol/noreth ac, 98<br />

estradiol/norgestimate, 98<br />

estradiol-norethindrone acetat, 98<br />

estramustine phosphate sodium, 19<br />

ESTRASORB, 97<br />

ESTRING, 97<br />

ESTROGEN DRUGS, 97<br />

estrogen,conjug,synthetic a, 97<br />

estrogen,conjug,synthetic b, 97<br />

estrogen/medroxyprogesterone, 98<br />

ESTROGEN/PROGESTIN COMBINATIONS, 98<br />

estrogens,conjugated, 97<br />

estrogens,esterified, 97<br />

estropipate, 97<br />

ESTROSTEP FE, 95<br />

eszopiclone, 38<br />

etanercept, 19<br />

eth estradiol/drospirenone, 96<br />

ethacrynate sodium, 48<br />

ethacrynic acid, 48<br />

ethambutol, 5<br />

ethambutol hcl tablet, 5<br />

ethedent, 89<br />

ethinyl estradiol/norelgest, 96<br />

ethionamide, 5<br />

ethosuximide, 40<br />

ethotoin, 33<br />

eth-oxydose, 28<br />

ethynodiol diace-eth estradiol, 95<br />

ETHYOL, 19<br />

etidronate, 68<br />

etidronate disodium, 68<br />

etodolac, 84<br />

etonogestrel/ethin estradiol, 96<br />

etravirine, 4<br />

EURAX, 55<br />

EVAMIST, 97<br />

everolimus, 18, 21<br />

EVISTA, 69<br />

EVOCLIN, 53<br />

EVOXAC, 63<br />

EXALGO, 28<br />

EXEL INSULIN SYRINGE, 80<br />

EXELDERM, 12<br />

EXELON, 22<br />

exemestane, 18<br />

exenatide, 65<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

EXFORGE, 49<br />

EXFORGE HCT, 49<br />

EXJADE, 60<br />

EXTAVIA, 78<br />

EXTINA, 12<br />

ezetimibe, 47<br />

ezetimibe/simvastatin, 47<br />

FABRAZYME, 69<br />

FACTIVE, 15<br />

famciclovir, 10<br />

famciclovir 125 mg tablet, 10<br />

famciclovir 250 mg tablet, 10<br />

famciclovir 500 mg tablet, 10<br />

famotidine, 71<br />

famotidine 20 mg tablet, -40 mg tablet, -<br />

suspension oral, 71<br />

famotidine injection, 71<br />

FAMVIR 125 MG TABLET, 10<br />

FAMVIR 250 MG TABLET, 10<br />

FAMVIR 500 MG TABLET, 10<br />

FANAPT 1 MG TABLET, -10 MG TABLET, -12<br />

MG TABLET, -2 MG TABLET, -4 MG<br />

TABLET, -6 MG TABLET, -8 MG TABLET, 23<br />

FANAPT TITRATION PACK, 23<br />

FANSIDAR, 14<br />

FARESTON, 19<br />

FASLODEX, 19<br />

fat emulsions, 93<br />

FAZACLO, 23<br />

fe c plus tablet, 99<br />

febuxostat, 83<br />

felbamate, 34<br />

FELBATOL, 34<br />

FELDENE, 84<br />

felodipine er, 44<br />

fem ph, 98<br />

FEMARA, 19<br />

FEMCON FE, 95<br />

FEMHRT, 98<br />

FEMRING, 97<br />

FEMTRACE, 97<br />

fenofibrate, 47<br />

fenofibric acid, 47<br />

FENOFIBRIC ACID, 47<br />

FENOGLIDE, 47<br />

fenoldopam mesylate, 49<br />

fenoprofen, 84<br />

fenoprofen calcium, 84<br />

fentanyl, 28<br />

fentanyl citrate, 27, 28, 29<br />

fentanyl citrate injection, 28<br />

fentanyl citrate loz, 28<br />

FENTORA, 28<br />

fesoterodine fumarate, 115<br />

FEXMID, 82<br />

fexofenadine, 110<br />

fexofenadine hcl 180 mg tablet, 110<br />

fexofenadine hcl 30 mg tablet, -60 mg tablet,<br />

110<br />

fexofenadine-pse er, 110<br />

FIBRICOR, 47<br />

filgrastim, 79<br />

FINACEA, 53<br />

finasteride, 115<br />

FIORICET WITH CODEINE, 32<br />

FIORINAL WITH CODEINE #3, 32<br />

FIRST-HYDROCORTISONE, 57<br />

FIRST-MOUTHWASH BLM, 63<br />

FIRST-PROGESTERONE VGS 100, 103<br />

FIRST-PROGESTERONE VGS 200, 103<br />

FIRST-PROGESTERONE VGS 25, 103<br />

FIRST-PROGESTERONE VGS 400, 103<br />

FIRST-PROGESTERONE VGS 50, 103<br />

FIRST-TESTOSTERONE, 94<br />

FIRST-TESTOSTERONE MC, 94<br />

FLAGYL, 4<br />

FLAGYL ER, 4<br />

FLAREX, 106<br />

flavoxate hcl, 114<br />

flecainide, 42<br />

flecainide acetate, 42<br />

FLECTOR, 56<br />

FLEXBUMIN, 87<br />

FLEXERIL, 82<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

FLOLAN, 51<br />

FLOMAX, 115<br />

FLONASE, 62<br />

FLOVENT 100 MCG DISKUS, -50 MCG<br />

DISKUS, 113<br />

FLOVENT 250 MCG DISKUS, 113<br />

FLOVENT HFA 110 MCG INHALER, 113<br />

FLOVENT HFA 220 MCG INHALER, 113<br />

FLOVENT HFA 44 MCG INHALER, 113<br />

FLOXIN, 61<br />

FLOXIN I.V., 15<br />

floxuridine, 19<br />

fluconazole, 8<br />

fluconazole 100 mg tablet, -200 mg tablet, -<br />

50 mg tablet, 8<br />

fluconazole 150 mg tablet, 8<br />

fluconazole in dextrose, 13<br />

fluconazole in saline, 13<br />

fluconazole suspension, 8<br />

fluconazole/dextrose-water, 13<br />

fluconazole/sodium chloride, 13<br />

flucytosine, 8<br />

fludrocortisone acetate tablet, 66<br />

FLUMADINE, 10<br />

flumazenil, 37<br />

flunisolide, 62, 112<br />

flunisolide 0.025% spray, 62<br />

flunisolide 29 mcg-0.025% spr, 62<br />

fluocinolone acetonide, 56, 61, 106<br />

fluocinolone acetonide cream, -ointment, -<br />

solution non-oral, 57<br />

fluocinonide, 58<br />

fluocinonide cream, -gel, -ointment, -solution<br />

non-oral, 57<br />

fluocinonide emollient, 57<br />

fluocinonide-e, 57<br />

FLUORABON, 89<br />

FLUOR-A-DAY DROPS, 89<br />

fluor-a-day tablet chewable, 90<br />

FLUORIDE PRODUCTS, 89<br />

fluoridex daily defense, 90<br />

FLUORIDEX SENSITIVITY RELIEF, 90<br />

fluoritab tablet chewable, 90<br />

fluorometholone, 106<br />

FLUOROPLEX, 58<br />

fluorouracil, 58<br />

fluorouracil cream, -solution non-oral, 58<br />

fluoxetine, 39, 40<br />

fluoxetine dr, 38<br />

fluoxetine hcl 10 mg capsule, -10 mg tablet,<br />

38<br />

fluoxetine hcl 20 mg capsule, -20 mg tablet,<br />

-solution, 39<br />

fluoxetine hcl 40 mg capsule, 39<br />

fluoxymesterone, 94<br />

fluphenazine decanoate, 23<br />

fluphenazine hcl elixir, -solution, -tablet, 23<br />

fluphenazine hcl injection, 23<br />

flura, 90<br />

FLURA-DROPS, 90<br />

flurandrenolide, 56<br />

flurbiprofen, 83, 109<br />

flurbiprofen sodium, 109<br />

flurbiprofen tablet, 84<br />

flutamide, 19<br />

fluticasone furoate, 63<br />

fluticasone propionate, 56, 62, 113<br />

fluticasone propionate cream, -ointment, 57<br />

fluticasone propionate nasal inhaled steroids,<br />

62<br />

fluvastatin, 46<br />

fluvoxamine, 39<br />

fluvoxamine maleate 100 mg tab, 39<br />

fluvoxamine maleate 25 mg tab, 39<br />

fluvoxamine maleate 50 mg tab, 39<br />

FML, 106<br />

FML FORTE, 106<br />

FML S.O.P., 106<br />

FOCALIN, 31<br />

FOCALIN XR, 31<br />

folbecal, 99<br />

folcal dha, 99<br />

folcaps omega-3, 99<br />

folinatal plus b, 99<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

folivane-ec calcium dha nf, 99<br />

folivane-ob, 99<br />

folivane-prx dha nf, 99<br />

foltabs, 99<br />

foltabs 90 plus dha, 99<br />

fomepizole, 60<br />

fondaparinux sodium, 90<br />

FORADIL, 111<br />

formoterol fumarate, 111<br />

FORTAMET, 67<br />

FORTAZ 1 GM ADD-VANTAGE VIAL, -1 GM<br />

VIAL, -2 GM VIAL, -6 GM VIAL, 6<br />

FORTAZ 2 GM ADD-VANTAGE VIAL, 6<br />

FORTAZ 500 MG VIAL, 6<br />

FORTAZ IN ISO-OSMOTIC DEXTROSE, 6<br />

FORTEO, 69<br />

fortical, 69<br />

FOSAMAX 10 MG TABLET, -40 MG TABLET, -<br />

5 MG TABLET, 69<br />

FOSAMAX 35 MG TABLET, -70 MG TABLET,<br />

69<br />

FOSAMAX PLUS D, 69<br />

FOSAMAX SOLUTION, 69<br />

fosamprenavir calcium, 4<br />

foscarnet, 10<br />

foscarnet sodium, 10<br />

FOSCAVIR, 10<br />

fosfomycin tromethamine, 17<br />

fosinopril, 42<br />

fosinopril sodium, 41<br />

fosinopril-hydrochlorothiazide, 49<br />

fosphenytoin, 33<br />

fosphenytoin sodium, 33<br />

FOSRENOL, 86<br />

FRAGMIN 10,000 UNITS SYRINGE, -10,000<br />

UNITS/ML VIAL, -12,500 UNITS SYRINGE,<br />

-15,000 UNITS SYRINGE, -18,000 UNITS<br />

SYRINGE, -25,000 UNITS/ML VIAL, -7,500<br />

UNITS SYRINGE, 91<br />

FRAGMIN 2,500 UNITS SYRINGE, -5,000<br />

UNITS SYRINGE, 91<br />

FREAMINE HBC, 87<br />

FREAMINE III, 88<br />

FREAMINE III WITH ELECTROLYTES, 88<br />

FROVA, 32<br />

frovatriptan, 32<br />

fudr, 19<br />

fulvestrant, 19<br />

FURADANTIN, 17<br />

furosemide, 48<br />

furosemide injection, 48<br />

furosemide solution, -tablet, 48<br />

FUZEON, 4<br />

gabapentin, 34<br />

gabapentin capsule, -tablet, 34<br />

GABITRIL, 34<br />

galantamine, 22, 23<br />

galantamine hbr, 22<br />

galantamine hydrobromide, 22<br />

galsulfase, 69<br />

GAMASTAN S-D, 76<br />

GAMMAGARD LIQUID, 76<br />

GAMMAGARD S-D, 76<br />

GAMUNEX, 76<br />

ganciclovir, 10, 109<br />

ganciclovir sodium, 10<br />

GANTRISIN, 15<br />

GARDASIL, 76<br />

GASTROCROM, 113<br />

GASTROINTESTINAL MEDICATIONS, 70<br />

gatifloxacin, 107<br />

gavilyte-c, 72<br />

gavilyte-g, 72<br />

gavilyte-n, 72<br />

gefitinib, 19<br />

GEL-KAM, 90<br />

GELNIQUE, 114<br />

gemfibrozil, 47<br />

gemifloxacin, 15<br />

generlac, 86<br />

gengraf, 19<br />

GENOTROPIN 12 MG CARTRIDGE, -5 MG<br />

CARTRIDGE, 75<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

GENOTROPIN MINIQUICK 0.2 MG, -<br />

MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, -<br />

MINIQUICK 0.8 MG, -MINIQUICK 1 MG, -<br />

MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, -<br />

MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, -<br />

MINIQUICK 2 MG, 75<br />

gentak, 107<br />

gentamicin 0.1% ointment, -cream, 16<br />

gentamicin 100 mg/ns 100 ml, -60 mg/ns 50<br />

ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50<br />

ml pb, -90 mg/ns 100 ml pb, -gentamicin<br />

100 mg/100 ml, -gentamicin 60 mg/50 ml,<br />

-gentamicin 80 mg/50 ml, 3<br />

gentamicin 3 mg/gm eye oint, 107<br />

GENTAMICIN 60 MG/NS 100 ML PB, -80<br />

MG/NS 100 ML PB, -GENTAMICIN 100<br />

MG/50 ML, -GENTAMICIN 60 MG/100 ML, -<br />

GENTAMICIN 80 MG/100 ML, 3<br />

gentamicin sulfate drops, 107<br />

gentamicin sulfate injection, 3<br />

gentamicin/prednisolone, 106<br />

gentamicin/sodium chloride, 3<br />

gentasol, 107<br />

gentex ade, 99<br />

GEODON CAPSULE, 24<br />

GEODON INJECTION, 24<br />

GESTICARE, 99<br />

GESTICARE DHA, 99<br />

gianvi, 95<br />

gildess fe, 95<br />

glatiramer acetate, 60<br />

GLEEVEC, 19<br />

glimepiride, 66, 67<br />

glipizide, 67<br />

glipizide er, 67<br />

glipizide tablet, 67<br />

glipizide xl, 67<br />

glipizide/metformin hcl, 67<br />

glipizide-metformin, 67<br />

GLUCAGEN, 65<br />

GLUCAGON EMERGENCY KIT, 65<br />

glucagon, human recombinant, 65<br />

GLUCOCORTICOID DRUGS, 63<br />

gluconic acid/citric acid, 115<br />

GLUCOPHAGE, 67<br />

GLUCOPHAGE XR, 67<br />

GLUCOPRO SYRINGE EMPTY DISPOSABLE,<br />

80<br />

GLUCOSE ELEVATING DRUGS, 65<br />

GLUCOTROL, 67<br />

GLUCOTROL XL, 67<br />

GLUCOVANCE, 67<br />

GLUMETZA, 67<br />

glyburide, 66, 67<br />

glyburide micronized, 67<br />

glyburide/metformin hcl, 67<br />

glyburide-metformin hcl, 67<br />

glycerin liquid, 71<br />

glycine solution, 115<br />

glycopyrrolate, 71<br />

glycopyrrolate injection, 70<br />

glycopyrrolate tablet, 70<br />

glycron, 67<br />

GLYNASE, 67<br />

GLYSET, 67<br />

gold sodium thiomalate, 85<br />

golimumab, 21<br />

GOLYTELY, 72<br />

GORDO-UREA, 58<br />

goserelin acetate, 21<br />

granisetron, 26<br />

granisetron hcl injection, 26<br />

granisetron hcl tablet, 26<br />

granisol, 26<br />

GRIFULVIN V SUSPENSION ORAL, 8<br />

GRIFULVIN V TABLET, 8<br />

griseofulvin microsize, 8<br />

griseofulvin suspension oral, 8<br />

griseofulvin ultramicrosize, 8<br />

GRIS-PEG, 8<br />

GROWTH HORMONES AND RELATED<br />

DRUGS, 75<br />

guanabenz acetate, 45<br />

guanfacine, 37, 45<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

guanfacine hcl, 45<br />

guanidine hcl, 37<br />

GYNAZOLE-1, 17<br />

GYNODIOL, 97<br />

haemophilus b vaccine, 76, 77<br />

haemophilus b-tet toxoid, 75, 76<br />

halcinonide, 57<br />

HALDOL, 24<br />

HALDOL DECANOATE 100, 24<br />

HALDOL DECANOATE 50, 24<br />

HALFAN, 14<br />

HALFLYTELY-BISACODYL, 72<br />

halobetasol prop/amonium lac, 57, 58<br />

halobetasol propionate, 57, 58<br />

halofantrine, 14<br />

HALOG, 57<br />

HALONATE, 57<br />

halonate pac, 57<br />

haloperidol, 24<br />

haloperidol decanoate, 24<br />

haloperidol lactate injection, 24<br />

haloperidol lactate solution, 24<br />

haloperidol tablet, 24<br />

HAVRIX, 76<br />

hc acetate/lidocaine hcl, 56, 57, 58<br />

hctz/bisoprolol fumarate, 50<br />

hctz/metoprolol, 49<br />

hctz/triamterene, 51<br />

hctz/valsartan, 49<br />

HECTOROL CAPSULE, 93<br />

HECTOROL INJECTION, 93<br />

HELIDAC, 73<br />

HEMABATE, 94<br />

hemin, 60<br />

hep b vaccine/dp (a) t-polio, 77<br />

hep b vir recomb/hep a vir, 78<br />

hep.b immune glob/maltose, 76<br />

HEPAGAM B, 76<br />

HEPARIN ANTAGONISTS, 90<br />

heparin sodium in 0.45% nacl, 91<br />

heparin sodium in 0.9% nacl, 91<br />

heparin sodium in 5% dextrose, 91<br />

heparin sodium injection, 91<br />

HEPATAMINE, 88<br />

HEPATASOL, 88<br />

hepatatis a virus vaccine, 76, 78<br />

hepatitis b immune globulin, 76<br />

hepatitis b virus vaccine, 76, 77<br />

hepatitis b/haemophilus b vacc, 76<br />

HEPSERA, 10<br />

HESPAN, 60<br />

hetastarch in ns, 60<br />

hetastarch/e-lytes,lactate, 60<br />

hetastarch/na chlor 0.9%, 60<br />

hexachlorophene, 17<br />

HEXALEN, 19<br />

HEXTEND LACTATED ELECTROLYTE, 60<br />

HIBERIX, 76<br />

HIBTITER, 76<br />

hip prenatal, 99<br />

HIPREX, 17<br />

histrelin ac, 21, 104<br />

HIZENTRA 1 GRAM/5 ML VIAL, 76<br />

HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20<br />

ML VIAL, 76<br />

HMG-COA REDUCTASE INHIBITORS, 46<br />

homatropaire, 109<br />

homatropine, 109<br />

homatropine hbr, 109<br />

HUMALOG, 65<br />

HUMALOG MIX 50-50, 65<br />

HUMALOG MIX 75-25, 65<br />

HUMAN ALBUMIN 25% IV SOLUTION, 88<br />

human papillomav vacc bival/pf, 76<br />

human papillomavirus vacc, 76<br />

HUMAPEN LUXURA HD, 80<br />

HUMAPEN MEMOIR, 80<br />

HUMATROPE, 75<br />

HUMIRA 20 MG/0.4 ML SYRINGE, -40 MG/0.8<br />

ML SYRINGE, 19<br />

HUMIRA 40 MG/0.8 ML PEN, -CROHN'S<br />

STARTER PACK, -PSORIASIS STARTER<br />

PACK, 19<br />

HUMULIN 50-50, 65<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

HUMULIN 70-30, 65<br />

HUMULIN N, 65<br />

HUMULIN R, 65<br />

HYCET, 30<br />

HYDANTOINS, 33<br />

hydralazine hcl injection, 52<br />

hydralazine hcl tablet, 52<br />

hydra-zide, 49<br />

HYDREA, 19<br />

HYDRO 35, 59<br />

HYDRO 40, 59<br />

hydrochlorothiazide, 52<br />

hydrochlorothiazide capsule, -tablet, 52<br />

hydrocodone bitartrate/apap, 30<br />

hydrocodone bitartrate/ibuprof, 30<br />

hydrocodone bit-ibuprofen, 30<br />

hydrocodone-acetaminophen, 30<br />

hydrocortisone, 56, 57, 58, 64, 72, 73<br />

hydrocortisone 1% absorbase, -1% cream, -<br />

1% lotion, -1% oin, -1% oint, -1%<br />

ointment, -2.5% cream, -2.5% lotion, -<br />

2.5% ointment, -aloe 1% cream, -plus 1%<br />

cream, 57<br />

hydrocortisone acetate, 72<br />

hydrocortisone acetate/urea, 56, 58<br />

hydrocortisone buteprate, 58<br />

hydrocortisone butyrate, 57<br />

hydrocortisone enema, 73<br />

hydrocortisone sod succinate, 63, 64<br />

hydrocortisone tablet, 64<br />

hydrocortisone valerate, 57, 58<br />

hydrocortisone/emol no.45, 58<br />

hydrogesic, 30<br />

hydromorphone, 28<br />

hydromorphone hcl injection, 28<br />

hydromorphone hcl suppository rectal, -<br />

tablet, 28<br />

hydroxychloroquine, 15<br />

hydroxychloroquine sulfate tablet, 14<br />

hydroxypropylmethylcellulose, 109<br />

hydroxyurea, 19<br />

hydroxyurea capsule, 19<br />

hydroxyzine hcl injection, 54<br />

hydroxyzine hcl syrup, -tablet, 54<br />

hydroxyzine pamoate, 54<br />

hydroxyzine pamoate capsule, 54<br />

hypercare, 59<br />

HYPERHEP B S-D, 76<br />

HYPERLYTE CR, 88<br />

HYPERRAB S-D, 76<br />

HYPERRHO S-D, 76<br />

HYPERTET S-D, 76<br />

HYPOGLYCEMIC DRUGS, 65<br />

HYPOLIPOPROTEINEMICS, 47<br />

HYZAAR, 49<br />

ibandronate, 68<br />

IBUDONE, 30<br />

ibuprofen 100 mg/5 ml, -100 mg/5 ml sus, -<br />

100 mg/5 ml susp, -400 mg tablet, -600<br />

mg tablet, -800 mg tablet, 84<br />

ibuprofen lysine, 85<br />

ibutilide fumarate, 49<br />

ICAR-C PLUS, 99<br />

idursulfase, 68<br />

ILARIS, 79<br />

iloperidone, 23<br />

imatinib mesylate, 19<br />

IMDUR, 48<br />

imiglucerase, 68<br />

imipenem/cilastatin sodium, 9<br />

imipramine hcl, 41<br />

imipramine hcl tablet, 40<br />

imipramine pamoate, 40, 41<br />

imiquimod, 58, 59<br />

IMITREX 20 MG NASAL SPRAY, 32<br />

IMITREX 4 MG/0.5 ML SYRNG KIT, -6 MG/0.5<br />

ML SYRNG KIT, 32<br />

IMITREX 5 MG NASAL SPRAY, 32<br />

IMITREX 6 MG/0.5 ML VIAL, -4 MG/0.5 ML<br />

KIT REFILL, -6 MG/0.5 ML KIT REFILL, 32<br />

IMITREX TABLET, 32<br />

immune globulin - im, 76<br />

immune globulin - iv, 76, 77<br />

immune globulin- sq, 76, 78<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

IMMUNOLOGICALS AND VACCINES, 75<br />

IMOGAM RABIES-HT, 76<br />

IMOVAX RABIES VACCINE, 77<br />

IMURAN, 19<br />

IN CONTROL PEN NEEDLE, 80<br />

INAPSINE, 1<br />

inatal advance, 99<br />

inatal gt, 99<br />

inatal ultra, 100<br />

INCRELEX, 78<br />

indapamide, 52<br />

INDERAL LA, 43<br />

indinavir, 4<br />

INDOCIN I.V., 84<br />

INDOCIN SR, 84<br />

INDOCIN SUPPOSITORY RECTAL, 84<br />

INDOCIN SUSPENSION ORAL, 84<br />

indomethacin, 84<br />

indomethacin capsule, -capsule sustained<br />

action, 84<br />

indomethacin injection, 84<br />

indomethacin sodium trihydrate, 84<br />

INFANRIX, 77<br />

INFERGEN, 78<br />

infliximab, 20<br />

INFUMORPH, 28<br />

INJECTABLE ANTICOAGULANTS, 90<br />

INJECT-EASE, 80<br />

INNOHEP, 91<br />

INNOPRAN XL, 43<br />

INSPRA, 51<br />

INSULIN, 65<br />

INSULIN LIKE GROWTH FACTORS-1, 78<br />

INSULIN PEN NEEDLE, 80<br />

INSULIN SYRINGE, 80<br />

INSUMED, 80<br />

INSUPEN, 80<br />

INTAL, 113<br />

INTEGRA SYRINGE SYRINGE EMPTY<br />

DISPOSABLE, 80<br />

INTEGRILIN, 86<br />

INTELENCE, 4<br />

interferon alfa-2b , recomb., 78<br />

interferon alfacon-1, 78<br />

interferon beta-1a, 78<br />

interferon beta-1a/albumin, 79<br />

interferon beta-1b, 78<br />

interferon gamma-1b,recomb., 78<br />

INTERFERONS, 78<br />

INTERLEUKIN RECPTR ANTAGONIST, 79<br />

INTERLEUKINS, 79<br />

INTRALIPID 10% IV FAT EMUL, -20% IV FAT<br />

EMUL, 93<br />

INTRALIPID 30% IV FAT EMUL, 93<br />

INTRON A 10 MILLION UNIT PEN, -10<br />

MILLION UNIT/ML, -18 MILLION UNITS<br />

VIAL, -5 MILLION UNIT/ML PEN, -50<br />

MILLION UNITS VIAL, -6 MILLION<br />

UNIT/ML VL, 78<br />

INTRON A 10 MILLION UNITS VIAL, -3<br />

MILLION UNIT/ML PEN, 78<br />

INTUNIV, 37<br />

INVANZ 1 GM ADD-VANTAGE VIAL, 9<br />

INVANZ 1 GM VIAL, 9<br />

INVEGA ER 1.5 MG TABLET, -ER 3 MG<br />

TABLET, -ER 9 MG TABLET, 24<br />

INVEGA ER 6 MG TABLET, 24<br />

INVEGA SUSTENNA 117 MG PREF SY, -156<br />

MG PREF SY, -234 MG PREF SY, 24<br />

INVEGA SUSTENNA 39 MG PREF SYR, -78<br />

MG PREF SYR, 24<br />

INVIRASE, 4<br />

IONOSOL B WITH DEXTROSE 5%, 88<br />

IONOSOL MB-DEXTROSE 5%, 88<br />

IONOSOL T-DEXTROSE 5%, 88<br />

IOPIDINE, 105<br />

IPOL, 77<br />

ipratropium, 62, 113<br />

ipratropium 0.03% spray, 62<br />

ipratropium 0.06% spray, 62<br />

ipratropium bromide solution non-oral, 113<br />

IQUIX, 107<br />

irbesartan, 42<br />

irbesartan/hctz, 49<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

IRESSA, 19<br />

iron,carbonyl/vit c/vit b12/fa, 99<br />

IRRITABLE BOWEL DRUGS, 71<br />

ISENTRESS, 4<br />

ISMO, 48<br />

ISO GENTAMICIN 120 MG/100 ML, -<br />

GENTAMICIN 120 MG/50 ML, -<br />

GENTAMICIN 40 MG/100 ML, -<br />

GENTAMICIN 40 MG/50 ML, 3<br />

isocarboxazid, 34<br />

ISOCHRON, 48<br />

ISOLYTE H WITH DEXTROSE, 88<br />

ISOLYTE M WITH DEXTROSE, 88<br />

ISOLYTE P WITH DEXTROSE, 88<br />

ISOLYTE S, 88<br />

ISOLYTE S WITH DEXTROSE, 88<br />

isonarif, 5<br />

isoniazid injection, 5<br />

isoniazid syrup, -tablet, 5<br />

isoproterenol hcl, 50<br />

ISOPTIN SR, 44<br />

ISOPTO ATROPINE, 109<br />

ISOPTO CARBACHOL, 105<br />

ISOPTO CARPINE, 105<br />

ISOPTO HOMATROPINE, 109<br />

ISOPTO HYOSCINE, 109<br />

ISORDIL, 48<br />

ISORDIL TITRADOSE, 48<br />

isosorb dinit/hydralazine hcl, 51<br />

isosorbide dinitrate, 48<br />

isosorbide mononitrate, 48<br />

isotretinoin, 55<br />

isradipine, 44<br />

ISTALOL, 105<br />

ISUPREL, 50<br />

itraconazole, 8<br />

itraconazole capsule, 8<br />

ivermectin, 3<br />

IXIARO, 77<br />

JALYN, 115<br />

jantoven, 91<br />

JANUMET, 67<br />

JANUVIA, 67<br />

japanese encephalitis vaccine, 77<br />

JE-VAX, 77<br />

jolessa, 95<br />

jolivette, 103<br />

junel, 95<br />

junel fe, 95<br />

k effervescent, 92<br />

KADIAN, 28<br />

KALETRA 100-25 MG TABLET, 4<br />

KALETRA 200-50 MG TABLET, -SOLUTION, 4<br />

kalexate, 91<br />

kanamycin sulfate, 3<br />

KAOCHLOR, 92<br />

kaon-cl 10, 92<br />

KAPIDEX DR 30 MG CAPSULE, 74<br />

KAPIDEX DR 60 MG CAPSULE, 74<br />

kariva, 95<br />

KAY CIEL, 92<br />

KAYEXALATE, 91<br />

kcl 20 meq in d5w solution, -20 meq/l iv<br />

solution, -40 meq in d5w solution, -40<br />

meq/l iv solution, 92<br />

kcl 20 meq in d5w-lact ringer, -40 meq in<br />

d5w-lact ringer, 92<br />

kcl 40 meq in d5w-lact ringer, 88<br />

KEFLEX, 6<br />

kelnor 1-35, 95<br />

KENALOG, 57<br />

KENALOG-10, 64<br />

KENALOG-40, 64<br />

KEPIVANCE, 77<br />

KEPPRA INJECTION, 34<br />

KEPPRA SOLUTION, -TABLET, 34<br />

KEPPRA XR, 34<br />

KERAFOAM, 59<br />

keratol 40, 59<br />

keratol plus, 59<br />

KERATOLYTIC DRUGS, 55<br />

KERLONE, 43<br />

KETEK, 8<br />

ketoconazole, 12<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

ketoconazole cream, -shampoo, 12<br />

ketoconazole tablet, 8<br />

KETOLIDES, 8<br />

ketoprofen capsule, -capsule 24hr sustained<br />

release pellets, 84<br />

ketorolac, 85, 108<br />

ketorolac tromethamine drops, 109<br />

ketorolac tromethamine injection, 84<br />

ketorolac tromethamine tablet, 84<br />

KINERET, 79<br />

KIONEX POWDER, 91<br />

kionex suspension oral, 92<br />

KLARON, 54<br />

klor-con 10, 92<br />

klor-con 20 meq packet, 92<br />

KLOR-CON 25 MEQ PACKET, 92<br />

klor-con 8, 92<br />

klor-con m10, 92<br />

klor-con m15, 92<br />

klor-con m20, 92<br />

klor-con-ef, 92<br />

kolnatal dha, 100<br />

K-PHOS M.F., 115<br />

K-PHOS NEUTRAL, 92<br />

K-PHOS NO.2, 115<br />

K-PHOS ORIGINAL, 115<br />

KRISTALOSE, 86<br />

K-TAB, 92<br />

KURIC, 12<br />

KUVAN, 69<br />

KYTRIL INJECTION, 26<br />

KYTRIL TABLET, 26<br />

labetalol, 43<br />

labetalol hcl injection, 43<br />

labetalol hcl tablet, 43<br />

LAC-HYDRIN, 59<br />

LACLOTION, 59<br />

lacosamide, 34, 35<br />

LACRISERT, 109<br />

lactate, ammonium, 59<br />

lactated ringers injection, 88<br />

LACTOCAL-F, 100<br />

lactulose, 86<br />

LAMICTAL, 34<br />

LAMICTAL (BLUE), 34<br />

LAMICTAL (GREEN), 34<br />

LAMICTAL (ORANGE), 34<br />

LAMICTAL ODT, 34<br />

LAMICTAL ODT (BLUE), 34<br />

LAMICTAL ODT (GREEN), 34<br />

LAMICTAL ODT (ORANGE), 34<br />

LAMICTAL XR, 34<br />

LAMICTAL XR (BLUE), 34<br />

LAMICTAL XR (GREEN), 34<br />

LAMICTAL XR (ORANGE), 34<br />

LAMISIL PKT, 8<br />

LAMISIL SOLUTION, 12<br />

LAMISIL TABLET, 8<br />

lamivudine, 4, 10<br />

lamivudine/zidovudine, 4<br />

lamotrigine, 34<br />

LANOXIN INJECTION, 45<br />

LANOXIN PEDIATRIC, 45<br />

LANOXIN TABLET, 45<br />

lanreotide acetate, 21<br />

lansoprazole, 74<br />

lansoprazole dr 15 mg capsule, 74<br />

lansoprazole dr 30 mg capsule, 74<br />

lansoprazole/amox tr/clarith, 73<br />

lanthanum carbonate, 86<br />

LANTUS, 65<br />

LANTUS SOLOSTAR, 65<br />

lapatinib ditosylate, 21<br />

laronidase, 68<br />

LASIX, 48<br />

latanoprost, 105<br />

LAXATIVES AND CATHARTICS, 71<br />

leena, 95<br />

leflunomide, 18, 19<br />

lenalidomide, 20<br />

lepirudin,recombinant, 91<br />

LESCOL 20 MG CAPSULE, 46<br />

LESCOL 40 MG CAPSULE, 46<br />

LESCOL XL, 46<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

lessina, 95<br />

LETAIRIS, 46<br />

letrozole, 19<br />

leucovorin calcium injection, 19<br />

leucovorin calcium tablet, 19<br />

LEUKERAN, 19<br />

LEUKINE, 79<br />

LEUKOTRIENE MODIFIERS, 111<br />

leuprolide, 19, 104<br />

leuprolide acetate, 104<br />

levalbuterol, 111<br />

LEVAQUIN INJECTION, 15<br />

LEVAQUIN SOLUTION, -TABLET, 15<br />

LEVATOL, 43<br />

LEVEMIR, 65<br />

levetiracetam, 34<br />

levetiracetam injection, 34<br />

levetiracetam solution, -tablet, 34<br />

LEVLEN 28, 95<br />

levobunolol, 104<br />

levobunolol hcl, 105<br />

levocarnitine, 93<br />

levocarnitine injection, 93<br />

levocarnitine solution, -tablet, 93<br />

levocetirizine dihydrochlor, 111<br />

levofloxacin, 15, 107<br />

levonorgestrel, 96<br />

levonorgestrel-ethin estradiol, 95, 96<br />

levora-28, 95<br />

levorphanol tartrate tablet, 28<br />

levothroid, 69<br />

levothyroxine, 70<br />

levothyroxine sodium injection, 69<br />

levothyroxine sodium tablet, 69<br />

levoxyl, 69<br />

LEVULAN, 59<br />

LEXAPRO SOLUTION, 39<br />

LEXAPRO TABLET, 39<br />

LEXIVA SUSPENSION ORAL, 4<br />

LEXIVA TABLET, 4<br />

LIALDA, 73<br />

LIDAMANTLE, 2<br />

LIDAMANTLE HC, 57<br />

lidazone hc, 57<br />

lidocaine, 2, 63, 108<br />

lidocaine hcl 0.5% vial, -1% abboject, -1%<br />

ampul, -1% syringe, -1% vial, -1.5%<br />

ampul, -2% abboject, -2% ampul, -2%<br />

luer-jet, -2% min-i-jet, -2% syringe, -2%<br />

vial, -20% vial, -4% ampul, 1<br />

lidocaine hcl 10% vial, 49<br />

lidocaine hcl cream, -jelly with prefilled<br />

applicator, -lotion, -ointment, -solution<br />

non-oral, 2<br />

lidocaine hcl in 7.5% dextrose, 1<br />

lidocaine hcl viscous, 2<br />

lidocaine hcl-epinephrine, 1<br />

lidocaine hydrochloride/epi, 2<br />

lidocaine/prilocaine, 2<br />

lidocaine/tetracaine, 2<br />

lidocaine-hc, 57<br />

lidocaine-hydrocortisone cream, -cream with<br />

applicator, -kit, -lotion, 57<br />

lidocaine-prilocaine, 2<br />

LIDODERM, 2<br />

LIMBITROL, 35<br />

LINCOCIN, 9<br />

lincoject, 9<br />

lincomycin, 9<br />

LINDANE, 55<br />

linezolid, 10<br />

liothyronine, 69, 70<br />

liothyronine sodium injection, 70<br />

liothyronine sodium tablet, 70<br />

liotrix, 70<br />

LIPITOR, 46<br />

LIPOFEN, 47<br />

LIPOSYN II, 93<br />

liposyn iii, 93<br />

liquadd, 31<br />

liqui-dualcitra, 92<br />

liraglutide, 65<br />

LISCO SPONGES, 80<br />

lisdexamfetamine dimesylate, 31<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

lisinopril, 42<br />

lisinopril tablet, 41<br />

lisinopril/hctz, 50<br />

lisinopril-hctz, 49<br />

lisinopril-hydrochlorothiazide, 49<br />

LITE TOUCH INSULIN PEN NEEDLES, 80<br />

LITE TOUCH SYRINGE EMPTY DISPOSABLE,<br />

80<br />

lithium, 23<br />

lithium carbonate, 23<br />

lithium carbonate capsule, -tablet, -tablet<br />

sustained action, 23<br />

lithium citrate, 23<br />

LITHOBID, 23<br />

LIVALO, 46<br />

l-norgest-eth estr/ethin estr, 95, 96<br />

<strong>LOCAL</strong> <strong>ANESTHETICS</strong>, 1<br />

LOCOID, 57<br />

LOCOID LIPOCREAM, 57<br />

LODOSYN, 36<br />

lodoxamide, 108<br />

LOESTRIN, 95<br />

LOESTRIN 24 FE, 95<br />

LOESTRIN FE, 95<br />

LOFIBRA, 47<br />

LOKARA, 57<br />

LOMOTIL, 70<br />

lomustine, 18<br />

lonox, 70<br />

LOOP DIURETICS, 48<br />

LO-OVRAL-28, 95<br />

loperamide capsule, 70<br />

LOPID, 47<br />

LOPRESSOR HCT, 49<br />

LOPRESSOR INJECTION, 43<br />

LOPRESSOR TABLET, 43<br />

LOPROX, 12<br />

LORCET 10-650, 30<br />

LORCET PLUS, 30<br />

LORTAB, 30<br />

losartan, 42<br />

losartan /hctz, 49<br />

losartan potassium, 42<br />

losartan-hydrochlorothiazide, 49<br />

LOSEASONIQUE, 95<br />

LOTEMAX, 106<br />

LOTENSIN, 41<br />

LOTENSIN HCT, 49<br />

loteprednol etabonate, 106<br />

LOTREL, 50<br />

LOTRISONE, 17<br />

LOTRONEX, 71<br />

lovastatin, 46<br />

lovastatin 10 mg tablet, 46<br />

lovastatin 20 mg tablet, -40 mg tablet, 46<br />

lovastatin/niacin, 46<br />

LOVAZA, 47<br />

LOVENOX 100 MG PREFILLED SYR, -120 MG<br />

PREFILLED SYR, -150 MG PREFILLED SYR,<br />

-300 MG VIAL, -60 MG PREFILLED SYRN, -<br />

80 MG PREFILLED SYRN, 91<br />

LOVENOX 30 MG PREFILLED SYRN, -40 MG<br />

PREFILLED SYRN, 91<br />

low-ogestrel, 95<br />

loxapine, 24<br />

loxapine succinate, 24<br />

LOXITANE, 24<br />

lozi-flur, 90<br />

lubiprostone, 71<br />

LUCENTIS, 109<br />

ludent fluoride, 90<br />

LUER-LOK SYRINGE SYRINGE EMPTY<br />

DISPOSABLE, 80<br />

LUFYLLIN, 112<br />

LUMIGAN, 105<br />

LUMIZYME, 69<br />

LUNESTA, 38<br />

LUPRON, 104<br />

LUPRON DEPOT 11.25 MG 3MO KIT, -22.5<br />

MG 3MO KIT, -3.75 MG KIT, -4 MONTH<br />

KIT, 104<br />

LUPRON DEPOT 7.5 MG KIT, 104<br />

LUPRON DEPOT-PED, 104<br />

LURIDE, 90<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

lutera, 95<br />

LUVOX CR, 39<br />

LUXIQ, 57<br />

LYBREL, 95<br />

lymphocyte immune globulin, 76, 78<br />

LYRICA, 34<br />

LYSODREN, 19<br />

LYSTEDA, 60<br />

MACROBID, 17<br />

MACRODANTIN, 17<br />

mafenide acetate, 17<br />

mag hydrox/alh/smc/dpha/lido, 63<br />

MAGNACET, 28<br />

magnesium sulfate injection, 88<br />

magnesium sulfate/d5w, 88<br />

MAGNESIUM SULFATE-D5W, 88<br />

MALARONE, 15<br />

malathion, 55<br />

mannitol, 88, 89<br />

mannitol injection, 88<br />

MAO INHIBITORS, 33<br />

maprotiline hcl, 35<br />

maraviroc, 4<br />

MARCAINE, 1<br />

MARCAINE SPINAL, 1<br />

MARCAINE WITH EPINEPHRINE, 1<br />

MARCAINE-EPINEPHRINE, 1<br />

margesic h, 30<br />

MARINOL 10 MG CAPSULE, -5 MG CAPSULE,<br />

26<br />

MARINOL 2.5 MG CAPSULE, 26<br />

marlexate, 92<br />

MARPLAN, 34<br />

maternity, 100<br />

MATULANE, 19<br />

MAVIK, 42<br />

MAXAIR AUTOHALER, 111<br />

MAXALT, 32<br />

MAXALT MLT, 32<br />

MAXIDEX, 106<br />

MAXIDONE, 30<br />

MAXIPIME 1 GM ADD-VANTAGE VL, -2 GM<br />

ADD-VANTAGE VL, -1 GRAM VIAL, -2<br />

GRAM VIAL, 6<br />

MAXIPIME 500 MG VIAL, 6<br />

MAXITROL, 105<br />

MAXZIDE, 51<br />

MAXZIDE-25 MG, 51<br />

measles vaccine,atten, 76<br />

measles,mumps&rubella vaccine, 77<br />

measles,mumps,rub,varicella, 77<br />

mebendazole tablet chewable, 3<br />

mecasermin, 78<br />

mechlorethamine, 20<br />

meclizine 12.5 mg tablet, -25 mg tablet, 26<br />

meclizine hcl, 25<br />

meclofenamate sodium capsule, 84<br />

MEDICAL (MISCELLANEOUS) SUPPLIES, 80<br />

MEDI-JECTOR NEEDLE-FREE SYR A, 81<br />

MEDI-JECTOR NEEDLE-FREE SYR B, 81<br />

MEDI-JECTOR NEEDLE-FREE SYR C, 81<br />

MEDI-JECTOR VISION, 81<br />

MEDROL, 64<br />

medroxyprogesterone, 19, 103, 104<br />

medroxyprogesterone acetate injection, 104<br />

medroxyprogesterone acetate tablet, 104<br />

mefenamic acid, 85<br />

mefloquine hcl, 15<br />

MEFOXIN, 6<br />

MEGACE, 19<br />

MEGACE ES, 19<br />

megestrol, 19<br />

megestrol acetate suspension oral, -tablet,<br />

20<br />

meloxicam, 84<br />

meloxicam 15 mg tablet, -suspension oral, 84<br />

meloxicam 7.5 mg tablet, 84<br />

memantine hcl, 22<br />

MENACTRA, 77<br />

MENEST, 97<br />

mening vac a,c,y,w-135 dip, 77<br />

meningococcal vac a,c,y,w-135, 77<br />

MENOMUNE-A-C-Y-W-135, 77<br />

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2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

MENOSTAR, 97<br />

MENTAX, 12<br />

MENVEO A-C-Y-W-135-DIP, 77<br />

mepenzolate, 70<br />

meperidine, 28<br />

meperidine hcl injection, 28<br />

mepivacaine, 1, 2<br />

meprobamate, 27<br />

meprolone unipak, 64<br />

MEPRON, 9<br />

mercaptopurine, 20<br />

mercaptopurine tablet, 20<br />

meropenem, 9<br />

MERREM IV 1 GM VIAL, 9<br />

MERREM IV 500 MG VIAL, 9<br />

MERUVAX II VACCINE W-DILUENT, 77<br />

mesalamine, 72, 73<br />

mesna, 20<br />

MESNEX TABLET, 20<br />

MESTINON SYRUP, -TABLET SUSTAINED<br />

ACTION, 37<br />

MESTINON TABLET, 37<br />

METADATE CD, 31<br />

METADATE ER 10 MG TABLET SA, 31<br />

metadate er 20 mg tablet, 31<br />

METAGLIP, 67<br />

metaproterenol sulfate syrup, -tablet, 111<br />

metaxalone, 82, 83<br />

metformin, 67<br />

metformin hcl, 67<br />

metformin hcl er, 67<br />

methadex, 106<br />

methadone, 28<br />

methadone hcl injection, 28<br />

methadone hcl solution, -tablet, -tablet<br />

soluble, 28<br />

methadone intensol, 28<br />

methadose, 28<br />

methamphetamine, 31<br />

methamphetamine hcl, 31<br />

methazolamide, 105<br />

methenamine hippurate, 17<br />

methenamine mandelate, 17<br />

METHERGINE INJECTION, 98<br />

METHERGINE TABLET, 98<br />

methimazole, 63<br />

methimazole tablet, 63<br />

METHITEST, 94<br />

methocarbamol, 83<br />

methocarbamol tablet, 82<br />

methotrexate, 20<br />

methotrexate injection, 20<br />

methotrexate sodium, 21<br />

methotrexate tablet, 20<br />

methoxsalen, 55, 59<br />

methscopolamine, 71<br />

methscopolamine bromide, 70<br />

methsuximide, 40<br />

methyclothiazide tablet, 52<br />

methyl aminolevulinate hcl, 59<br />

METHYL XANTHINE DRUGS, 112<br />

methyldopa, 45<br />

methyldopa-hydrochlorothiazide, 50<br />

methyldopate hcl, 45<br />

methylergonovine, 98<br />

METHYLIN 10 MG CHEWABLE TABLET, -2.5<br />

MG CHEWABLE TAB, -5 MG CHEWABLE<br />

TABLET, -SOLUTION, 31<br />

methylin 10 mg tablet, -20 mg tablet, -5 mg<br />

tablet, 31<br />

methylin er, 31<br />

methylnaltrexone bromide, 73<br />

methylphenidate, 31<br />

methylphenidate er, 31<br />

methylphenidate hcl solution, -tablet, 31<br />

methylphenidate sr, 31<br />

methylprednisolone, 64<br />

methylprednisolone acetate, 64<br />

methylprednisolone acetate injection, 64<br />

methylprednisolone sod succ, 64<br />

methylprednisolone tablet, -tablet dose pack,<br />

64<br />

methyltestosterone, 94<br />

metipranolol, 105<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

metoclopramide, 71<br />

metoclopramide hcl injection, 70<br />

metoclopramide hcl solution oral, -tablet, 70<br />

metolazone, 52<br />

metoprolol succinate, 43<br />

metoprolol tartrate, 43<br />

metoprolol tartrate injection, 43<br />

metoprolol tartrate tablet, 43<br />

metoprolol-hydrochlorothiazide, 50<br />

METOZOLV ODT, 71<br />

metro iv, 4<br />

METROCREAM, 53<br />

METROGEL, 53<br />

METROGEL-VAGINAL, 98<br />

METROLOTION, 53<br />

metronidazole, 4, 53, 98<br />

metronidazole capsule, -tablet, 4<br />

metronidazole cream, -gel, -lotion, 53<br />

metronidazole gel with applicator, 98<br />

metronidazole injection, 4<br />

metryl, 4<br />

METVIXIA, 59<br />

metyrosine, 45<br />

MEVACOR, 46<br />

mexiletine hcl capsule, 42<br />

MIACALCIN AEROSOL SPRAY W/PUMP, 69<br />

MIACALCIN INJECTION, 69<br />

micafungin sodium, 13<br />

MICARDIS, 42<br />

MICARDIS HCT, 50<br />

miconazole, 8<br />

miconazole 3 200 mg vag supp, 17<br />

miconazole nitrate/zinc oxide, 12<br />

MICRHOGAM, 77<br />

MICRHOGAM PLUS, 77<br />

microgestin, 95<br />

microgestin fe, 95<br />

MICRO-K, 92<br />

MICRONOR, 104<br />

MICROZIDE, 52<br />

MIDAMOR, 51<br />

midodrine, 51<br />

midodrine hcl, 50<br />

migergot, 32<br />

miglitol, 67<br />

miglustat, 69<br />

MIGRANAL, 32<br />

MILLIPRED, 64<br />

MILLIPRED DP, 64<br />

milnacipran hcl, 35, 36<br />

milrinone in 5% dextrose, 45<br />

milrinone lactate, 45<br />

mimvey, 98<br />

MINERALOCORTICOID DRUGS, 66<br />

MINIPRESS, 52<br />

MINITRAN, 48<br />

MINOCIN COMBINATION PACKAGE, -KIT, -<br />

CAPSULE, 16<br />

MINOCIN INJECTION, 16<br />

minocycline, 16, 63<br />

minocycline hcl capsule, -tablet, -tablet<br />

sustained release 24hr, 16<br />

minoxidil tablet, 52<br />

MIOSTAT, 105<br />

MIRAPEX, 36<br />

MIRAPEX ER, 36<br />

MIRCETTE, 95<br />

mirtazapine, 35<br />

misc supp (dress,tape,gauze), 80, 82<br />

MISCELLANEOUS DRUGS, 60<br />

misoprostol, 72<br />

mitotane, 19<br />

mitoxantrone, 20<br />

mitoxantrone hcl injection, 20<br />

M-M-R II VACCINE, 77<br />

MOBAN, 24<br />

MOBIC 15 MG TABLET, -SUSPENSION ORAL,<br />

84<br />

MOBIC 7.5 MG TABLET, 84<br />

modafinil, 31<br />

MODICON, 95<br />

moexipril, 42<br />

moexipril hcl, 42<br />

moexipril/hctz, 50<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

moexipril-hydrochlorothiazide, 50<br />

molindone, 24<br />

mometasone, 57, 62, 112, 113<br />

mometasone furoat/ammonium l, 58<br />

mometasone furoate, 58<br />

mometasone/formoterol, 113<br />

MOMEXIN, 58<br />

MONODOX, 16<br />

MONOJECT 0.5 ML SYRN 28GX1/2, 81<br />

MONOJECT INSULIN SAFETY SYRNG, 81<br />

MONOJECT INSULIN SYRINGE, 81<br />

MONOKET, 48<br />

mononessa, 95<br />

MONOPRIL, 42<br />

montelukast sodium, 111<br />

MONUROL, 17<br />

morphine, 27, 28, 29<br />

morphine sulfate in dextrose, 28<br />

morphine sulfate injection, 28<br />

morphine sulfate solution, -suppository<br />

rectal, -tablet, 29<br />

morphine sulfate tablet sustained action, 29<br />

morphine sulfate/naltrexone, 28<br />

MOTOFEN, 70<br />

MOVIPREP, 73<br />

MOXATAG, 14<br />

moxifloxacin, 15, 107<br />

MOZOBIL, 77<br />

MS CONTIN, 29<br />

MULTAQ, 49<br />

multinatal plus, 100<br />

multi-nate 30, 100<br />

multi-nate 30 dha, 100<br />

multi-nate dha extra, 100<br />

mumps vaccine,live, 77<br />

MUMPSVAX VACCINE W-DILUENT, 77<br />

mupirocin, 16<br />

mupirocin calcium, 16<br />

mupirocin ointment, 16<br />

muronab-cd3, 20<br />

MUSCULOSKELETAL MEDICATIONS, 82<br />

MUSTARGEN, 20<br />

MYAMBUTOL, 5<br />

MYCAMINE, 13<br />

MYCOBUTIN, 5<br />

mycophenolate mofetil, 18<br />

mycophenolate mofetil capsule, 20<br />

mycophenolate mofetil tablet, 20<br />

mycophenolate sodium, 20<br />

MYCOSTATIN, 8<br />

MYDFRIN, 109<br />

mydral, 109<br />

MYDRIACYL, 109<br />

MYELOID STIMULANTS, 79<br />

MYFORTIC, 20<br />

mynatal, 100<br />

mynatal advance, 100<br />

mynatal plus, 100<br />

mynatal-z, 100<br />

mynate 90 plus, 100<br />

myochrysine, 85<br />

MYOZYME, 69<br />

MYSOLINE, 34<br />

MYTELASE, 37<br />

nabilone, 25<br />

nabumetone, 84<br />

nadolol, 43<br />

nadolol-bendroflumethiazide, 50<br />

nafarelin, 104<br />

NAFCILL IN DEXTROSE, 14<br />

nafcillin, 14<br />

nafcillin sodium, 14<br />

naftifine, 12<br />

NAFTIN, 12<br />

NAGLAZYME, 69<br />

nalbuphine hcl, 22<br />

NALFON, 84<br />

NALLPEN, 14<br />

NALLPEN IN DEXTROSE, 14<br />

NALLPEN-ISO-OSMOTIC DEXTROSE, 14<br />

naloxone hcl injection, 37<br />

naltrexone, 37<br />

naltrexone hcl tablet, 37<br />

naltrexone microspheres, 37<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

NAMENDA, 22<br />

NANO PEN NEEDLE, 81<br />

naphazoline, 108<br />

naphazoline hcl drops, 109<br />

NAPRELAN, 84<br />

NAPRELAN CR DOSE CARD, 84<br />

NAPROSYN, 84<br />

naproxen, 84<br />

naproxen 250 mg tablet, -375 mg tablet, -<br />

suspension oral, -tablet enteric coated, 85<br />

naproxen 500 mg tablet, 85<br />

naproxen sodium, 83, 84<br />

naproxen sodium 275 mg tab, -550 mg tab,<br />

85<br />

naproxen/esomeprazole mag, 85<br />

naratriptan, 31<br />

naratriptan hcl, 32<br />

NARDIL, 34<br />

NAROPIN, 2<br />

NASACORT AQ, 62<br />

NASAREL, 62<br />

NASONEX, 62<br />

natacaps, 100<br />

NATACHEW, 100<br />

NATACYN, 109<br />

NATAFORT, 100<br />

natalcare pic forte, 100<br />

natalcare plus, 100<br />

natalizumab, 21<br />

natamycin, 109<br />

natatab, 100<br />

NATAZIA, 95<br />

nateglinide, 67<br />

NATELLE, 100<br />

NATELLE C, 100<br />

NATELLE ONE, 100<br />

NATELLE PLUS, 100<br />

NATELLE PREFER, 100<br />

NATELLE-EZ, 100<br />

NATRECOR, 51<br />

nature-throid, 70<br />

NATURETIN-5, 52<br />

NAVANE, 24<br />

NEBCIN IN DEXTROSE, 3<br />

nebivolol hcl, 43<br />

necon, 95<br />

nedocromil, 108<br />

NEEVO, 100<br />

nefazodone hcl, 35<br />

nelfinavir mesylate, 5<br />

neocidin, 107<br />

NEO-FRADIN, 3<br />

neofrin, 109<br />

neomycin, 3<br />

neomycin suf/polymy/buffers/hc, 61<br />

neomycin sulfate tablet, 3<br />

neomycin sulfate/colist sul/hc, 61<br />

neomycin sulfate/polymyxin, 115<br />

neomycin sulfate/polymyxin/hc, 61, 105<br />

neomycin/bacitracin/poly/hc, 16<br />

neomycin/colist sul/hc/thonz, 61<br />

neomycin/gramicidin/polymyxin, 107<br />

neomycin/polymyxin/dexameth, 105<br />

neomycin/polymyxin/prednisol, 106<br />

neomycin-bacitracin-poly-hc, 106<br />

neomycin-bacitracin-polymyxin, 107<br />

neomycin-polymyxin b, 115<br />

neomycin-polymyxin-dexameth, 106<br />

neomycin-polymyxin-gramicidin, 107<br />

neomycin-polymyxin-hc solution, -solution<br />

non-oral, -suspension drops, 61<br />

neomycin-polymyxin-hc suspension drops,<br />

106<br />

NEOPROFEN, 85<br />

NEORAL, 20<br />

NEOSPORIN DROPS, 107<br />

NEOSPORIN G.U. IRRIGANT, 115<br />

neostigmine bromide, 37<br />

neostigmine methylsulfate, 37<br />

nepafenac, 109<br />

NEPHRAMINE, 88<br />

NESACAINE, 2<br />

NESACAINE-MPF, 2<br />

nesiritide, 51<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

NEULASTA, 79<br />

NEUMEGA, 79<br />

NEUPOGEN, 79<br />

NEURONTIN CAPSULE, -TABLET, 34<br />

NEURONTIN SOLUTION, 34<br />

NEUT, 88<br />

neutragard advanced, 90<br />

NEVANAC, 109<br />

nevirapine, 5<br />

NEXAVAR, 20<br />

NEXIUM 10 MG PACKET, -20 MG CAPSULE, -<br />

20 MG PACKET, 74<br />

NEXIUM 40 MG CAPSULE, -40 MG PACKET,<br />

74<br />

NEXIUM I.V., 74<br />

next choice, 95<br />

niacin, 47<br />

niacin/simvastatin, 47<br />

NIACOR, 47<br />

NIASPAN, 47<br />

nicardipine hcl capsule, 44<br />

nicardipine hcl injection, 44<br />

nicotine inhaler, 40<br />

nicotine ns, 40<br />

NICOTROL, 40<br />

NICOTROL NS, 40<br />

nifediac cc, 44<br />

nifedical xl, 44<br />

nifedipine, 43, 44<br />

nifedipine capsule, 44<br />

nifedipine er, 44<br />

NILANDRON, 20<br />

nilotinib hydrochloride, 21<br />

nilutamide, 20<br />

nimodipine, 44<br />

NIMOTOP, 44<br />

nisoldipine, 44<br />

NISOLDIPINE ER 17 MG TABLET, -ER 25.5<br />

MG TABLET, -ER 34 MG TABLET, -ER 8.5<br />

MG TABLET, 44<br />

nisoldipine er 20 mg tablet, -er 30 mg tablet,<br />

-er 40 mg tablet, 44<br />

nitazoxanide, 8<br />

nitisinone, 60<br />

NITRATES, 48<br />

nitro-bid, 48<br />

NITRO-DUR, 48<br />

nitrofurantoin, 17<br />

nitrofurantoin capsule, 17<br />

nitrofurantoin macrocrystal, 17<br />

nitrofurantoin mono-macro, 17<br />

nitrofurantoin/nitrofuran mac, 17<br />

nitroglycerin, 48<br />

nitroglycerin in d5w, 48<br />

nitroglycerin injection, 48<br />

nitroglycerin patch, 48<br />

nitroglycerin tablet sublingual, 48<br />

NITROLINGUAL, 48<br />

NITROMIST, 48<br />

nitroquick, 48<br />

NITROSTAT, 48<br />

nizatidine, 71<br />

NIZORAL, 12<br />

NON-STEROIDAL ANTIINFLAMMATORY<br />

AGENTS, 83<br />

nora-be, 104<br />

NORCO, 30<br />

NORDETTE-28, 95<br />

NORDIPEN 15, 81<br />

NORDIPEN 5, 81<br />

NORDITROPIN, 75<br />

NORDITROPIN FLEXPRO, 75<br />

NORDITROPIN NORDIFLEX, 75<br />

norepinephrine bitartrate, 50<br />

noreth a-et estra/fe fumarate, 95<br />

noreth-ethinyl estradiol/iron, 95<br />

norethindrone, 104<br />

norethindrone acetate, 103<br />

norethindrone acetate tablet, 104<br />

norethindrone a-e estradiol, 95, 98<br />

norethindrone-ethin estradiol, 94, 95, 96<br />

norethindrone-mestranol, 95<br />

NORFLEX, 82<br />

norfloxacin, 15<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

norgestimate-ethinyl estradiol, 96<br />

norgestrel-ethiny estra, 95<br />

norgestrel-ethinyl estradiol, 95<br />

NORINYL 1+35, 95<br />

NORINYL 1+50, 95<br />

NORITATE, 53<br />

NORMOSOL-M AND DEXTROSE, 88<br />

NORMOSOL-R, 88<br />

NORMOSOL-R AND DEXTROSE, 88<br />

NORMOSOL-R PH 7.4, 88<br />

NOROXIN, 15<br />

NORPRAMIN, 38<br />

NOR-Q-D, 104<br />

northyx, 63<br />

nortrel, 96<br />

nortriptyline, 38<br />

nortriptyline hcl capsule, -solution, 38<br />

NORVASC, 44<br />

NORVIR CAPSULE, -TABLET, 4<br />

NORVIR SOLUTION, 4<br />

NOVAMINE, 88<br />

NOVANATAL, 100<br />

NOVANTRONE, 20<br />

NOVASTART, 100<br />

NOVOCAIN, 2<br />

NOVOFINE 32, 81<br />

NOVOFINE AUTOCOVER, 81<br />

NOVOLIN 70-30 100 UNIT/ML VIAL, -U100<br />

CARTRIDGE, 65<br />

NOVOLIN 70-30 INNOLET, 66<br />

NOVOLIN N 100 UNIT/ML INNOLET, -100<br />

UNITS/ML CARTRDG, -100 UNITS/ML<br />

VIAL, 66<br />

NOVOLIN R 100 UNIT/ML CARTRIDG, -100<br />

UNIT/ML INNOLET, -100 UNITS/ML VIAL,<br />

66<br />

NOVOLOG, 66<br />

NOVOLOG MIX 70-30, 66<br />

NOVOPEN 3, 81<br />

NOVOPEN JR, 81<br />

NOXAFIL, 8<br />

NUCYNTA, 29<br />

NULYTELY WITH FLAVOR PACKS, 73<br />

NUMORPHAN, 29<br />

nutrilyte, 88<br />

nutrilyte ii, 88<br />

nutrinate, 100<br />

nutrispire, 100<br />

NUTRITION,BLOOD<br />

MODIFIERS,ELECTROLYTES, 86<br />

NUTROPIN, 75<br />

NUTROPIN AQ, 75<br />

NUTROPIN AQ NUSPIN, 75<br />

NUVARING, 96<br />

NUVIGIL, 31<br />

nyamyc, 12<br />

nystatin, 8<br />

nystatin 100,000 unit/gm powd, -cream, -<br />

ointment, 12<br />

nystatin 150,000,000 units pwd, -50,000,000<br />

units pwd, -500,000,000 units pwd, -<br />

suspension oral, -tablet, 8<br />

nystatin tablet, 17<br />

nystatin-triamcinolone, 17<br />

nystop, 12<br />

ob + dha, 100<br />

ob 90 + dha, 100<br />

OB/GYN TOPICAL ANTIINFECTIVES, 98<br />

ob-natal one, 100<br />

OBSTETRICAL AND GYNECOLOGICAL<br />

MEDICATIONS, 94<br />

OBTREX, 100<br />

O-CAL FA, 100<br />

O-CAL PRENATAL, 100<br />

ocella, 96<br />

OCL, 73<br />

OCTAGAM, 77<br />

octreotide, 20, 21<br />

octreotide 1,000 mcg/ml vial, -acet 100<br />

mcg/ml amp, -acet 100 mcg/ml vl, -acet<br />

200 mcg/ml vl, -acet 500 mcg/ml amp, -<br />

acet 500 mcg/ml vl, 20<br />

octreotide acet 50 mcg/ml amp, -acet 50<br />

mcg/ml vial, 20<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

OCUFEN, 109<br />

OCUFLOX, 107<br />

ofloxacin, 15, 61, 107<br />

ofloxacin drops, 61, 107<br />

ofloxacin tablet, 15<br />

OGEN, 97<br />

ogestrel, 96<br />

olanzapine, 25<br />

olanzapine pamoate, 25<br />

olanzapine/fluoxetine hcl, 25<br />

OLEPTRO ER, 35<br />

olmesartan med/amlodipine/hct, 50<br />

olmesartan medoxomil, 42<br />

olmesartan medoxomil/hctz, 49<br />

olopatadine hcl, 62, 109<br />

olsalazine, 72<br />

OLUX, 58<br />

OLUX-E, 58<br />

OLUX-OLUX-E, 58<br />

omalizumab, 114<br />

omega-3 acid ethyl esters, 47<br />

omeprazole, 74<br />

omeprazole dr 10 mg capsule, 74<br />

omeprazole dr 20 mg capsule, -dr 40 mg<br />

capsule, 74<br />

omeprazole magnesium-legend, 74<br />

omeprazole/sodium bicarbonat, 74<br />

omeprazole-bicarb 20-1,100 cap, 74<br />

omeprazole-bicarb 40-1,100 cap, 74<br />

OMNARIS, 62<br />

OMNICEF, 6<br />

OMNIPRED, 106<br />

OMNITROPE, 75<br />

ondansetron, 27<br />

ondansetron hcl 24 mg tablet, 26<br />

ondansetron hcl 4 mg tablet, -8 mg tablet,<br />

26<br />

ondansetron hcl in dextrose, 26<br />

ondansetron hcl injection, 26<br />

ondansetron hcl solution, 26<br />

ondansetron odt, 26<br />

ONGLYZA, 67<br />

ONSOLIS, 29<br />

OPANA, 29<br />

OPANA ER, 29<br />

OPHTHALMIC<br />

ANTIINFECTIVE/CORTICOSTEROIDS, 105<br />

OPHTHALMIC CORTICOSTEROID DRUGS,<br />

106<br />

OPHTHALMIC MEDICATIONS, 104<br />

OPHTHALMIC TOPICAL ANTIBACTERIAL<br />

DRUGS, 107<br />

OPHTHALMIC TOPICAL ANTIVIRAL DRUGS,<br />

108<br />

OPHTHETIC, 109<br />

opium, 29<br />

OPIUM, 29<br />

oprelvekin, 79<br />

OPTINATE, 100<br />

OPTIPRANOLOL, 105<br />

OPTIVAR, 109<br />

ORACEA, 16<br />

ORACIT, 92<br />

ORAL ANTICOAGULANTS, VITAMIN K, 91<br />

ORAL ANTIFUNGAL DRUGS, 8<br />

ORAL DERMATOLOGICAL DRUGS, 55<br />

ORAL HYPOGLYCEMICS AND COMBOS, 66<br />

ORALONE, 63<br />

ORAMORPH SR, 29<br />

ORAP, 24<br />

ORAPRED, 64<br />

ORAPRED ODT, 64<br />

ORASEP, 63<br />

ORAVIG, 8<br />

oraxyl, 63<br />

ORENCIA, 20<br />

ORFADIN, 60<br />

orphenadrine, 82<br />

orphenadrine citrate injection, 82<br />

orphenadrine citrate tablet sustained action,<br />

82<br />

orphenadrine compound, 82<br />

orphenadrine compound forte, 82<br />

ORSINI INSULIN SYRINGE, 81<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

ORTHO EVRA, 96<br />

ORTHO TRI-CYCLEN, 96<br />

ORTHO TRI-CYCLEN LO, 96<br />

ORTHO-CEPT, 96<br />

ORTHOCLONE OKT-3, 20<br />

ORTHO-CYCLEN, 96<br />

ORTHO-EST, 97<br />

ORTHO-NOVUM, 96<br />

oseltamivir phosphate, 11<br />

OSMITROL, 88<br />

OSMOPREP, 72<br />

OTHER ANTIARRHYTHMICS, 48<br />

OTHER ANTICONVULSANTS, 34<br />

OTHER ANTIDEPRESSANTS, 35<br />

OTHER ANTIHYPERTENSIVES, 49<br />

OTHER ANTIINFECTIVE DRUGS, 8<br />

OTHER ANTIPARKINSON DRUGS, 36<br />

OTHER ANTIULCER DRUGS, 72<br />

OTHER ANTIVIRAL DRUGS, 10<br />

OTHER CARDIOVASCULAR DRUGS, 50<br />

OTHER CNS/AUTONOMIC DRUGS, 37<br />

OTHER DRUGS AFFECTING COAGULATION,<br />

91<br />

OTHER DRUGS FOR ARTHRITIS, 85<br />

OTHER DRUGS FOR ASTHMA, 112<br />

OTHER ENDOCRINE DRUGS, 68<br />

OTHER GENITOURINARY PRODUCTS, 115<br />

OTHER GI DRUGS, 72<br />

OTHER MACROLIDES, 11<br />

OTHER OPHTHALMIC DRUGS, 108<br />

OTHER RESPIRATORY DRUGS, 114<br />

OTHER TOPICAL ANTIFUNGALS, 12<br />

OTHER VASODILATING DRUGS, 51<br />

otic edge, 61<br />

oticin hc ear solution, -suspension drops, 61<br />

otocidin, 61<br />

otomycet-hc, 61<br />

OVCON-35, 96<br />

OVCON-50, 96<br />

OVIDE, 55<br />

oxacillin, 13, 14<br />

oxacillin 1 gm add-vantage vl, -10 gm vial, -2<br />

gm add-vantage vl, -2 gm vial, 14<br />

oxacillin 1 gm vial, 14<br />

OXANDRIN 10 MG TABLET, 94<br />

OXANDRIN 2.5 MG TABLET, 94<br />

oxandrolone, 94<br />

oxaprozin, 84, 85<br />

oxcarbazepine, 27<br />

oxiconazole, 12<br />

OXISTAT, 12<br />

OXSORALEN, 59<br />

OXSORALEN-ULTRA, 55<br />

oxybutynin, 114<br />

oxybutynin chloride syrup, -tablet, 114<br />

oxybutynin cl er 10 mg tablet, -cl er 15 mg<br />

tablet, 114<br />

oxybutynin cl er 5 mg tablet, 114<br />

oxycodone, 28, 29<br />

oxycodone hcl, 29<br />

oxycodone hcl-acetaminophen, 29<br />

oxycodone hcl-ibuprofen, 29<br />

oxycodone/acetaminophen, 28, 29<br />

oxycodone/aspirin, 29<br />

oxycodone/ibuprofen, 28<br />

oxycodone-acetaminophen, 29<br />

oxycodone-aspirin, 29<br />

OXYCONTIN, 29<br />

oxymetholone, 94<br />

oxymorphone, 29<br />

oxytetracycline, 16<br />

oxytetracycline hcl/polymyxin, 107<br />

OXYTOCICS, 98<br />

oxytocin, 98<br />

oxytocin injection, 98<br />

OXYTROL, 114<br />

PACERONE 100 MG TABLET, -400 MG<br />

TABLET, 41<br />

pacerone 200 mg tablet, 41<br />

palgic, 111<br />

palifermin, 77<br />

paliperidone, 24<br />

palivizumab, 77<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

palonosetron hcl, 25<br />

PAMELOR, 38<br />

pamidronate disodium, 68, 69<br />

PAMINE, 71<br />

PAMINE FORTE, 71<br />

PANCREAZE, 73<br />

PANCRELIPASE 5,000, 73<br />

PANDEL, 58<br />

PANHEMATIN, 60<br />

PANLOR DC, 30<br />

PANLOR SS, 30<br />

PANRETIN, 59<br />

pantoprazole, 74<br />

pantoprazole sod dr 20 mg tab, 74<br />

pantoprazole sod dr 40 mg tab, 74<br />

PARAFON FORTE DSC, 82<br />

parcaine, 109<br />

PARCOPA, 36<br />

paregoric, 70<br />

PARENTERAL ANTIFUNGALS, 13<br />

paricalcitol, 93<br />

PARLODEL, 36<br />

PARNATE, 34<br />

paromomycin sulfate, 3<br />

paroxetine, 39<br />

paroxetine hcl 10 mg tablet, -40 mg tablet,<br />

39<br />

paroxetine hcl 20 mg tablet, -30 mg tablet, -<br />

tablet sustained release 24hr, 39<br />

paroxetine hcl suspension oral, 39<br />

paroxetine mesylate, 39<br />

PASER, 5<br />

PATADAY, 109<br />

PATANASE, 62<br />

PATANOL, 109<br />

PAXIL 10 MG TABLET, -40 MG TABLET, 39<br />

PAXIL 20 MG TABLET, -30 MG TABLET, 39<br />

PAXIL CR, 39<br />

PAXIL SUSPENSION ORAL, 39<br />

pazopanib, 21<br />

PCE, 7<br />

PEDIADERM HC, 58<br />

PEDIAPRED, 64<br />

PEDIARIX, 77<br />

pedi-dri, 12<br />

PEDIOTIC, 61<br />

PEDVAXHIB, 77<br />

peg 3350-electrolyte, 73<br />

peg-3350 and electrolytes, 73<br />

peg-3350 with flavor packs, 73<br />

pegademase bovine, 60<br />

PEGANONE, 33<br />

PEGASYS 180 MCG/0.5 ML CONV.PK, 78<br />

PEGASYS 180 MCG/ML VIAL, 79<br />

pegfilgrastim, 79<br />

peginterferon alfa-2a, 78, 79<br />

peginterferon alfa-2b, 79<br />

PEGINTRON 120 MCG KIT, -150 MCG KIT, -<br />

80 MCG KIT, 79<br />

PEGINTRON 50 MCG KIT, 79<br />

PEGINTRON REDIPEN, 79<br />

pegvisomant, 69<br />

pemetrexed disodium, 18<br />

pemirolast potassium, 108<br />

PEN 12MM 29G NEEDLES, -31GX3/16, -<br />

31GX5/16, -6MM 31G, -8MM 31G<br />

NEEDLES, -AURORA 6MM 31G, -AURORA S<br />

12MM 29G, -AURORA S 8MM 31G, -BD<br />

29GX1/2, -BD 29GX3/16, -BD 29GX5/16, -<br />

BD MINI 31GX3/16, -BD ORIG 29GX1/2, -<br />

BD SHORT 31GX5/16, -LIVE BETTER 6MM<br />

31G, -LIVE B, 81<br />

pen g pot/dextrose-water, 14<br />

pen g procaine/pen g benz, 13<br />

PEN NEEDLES, 81<br />

penbutolol, 43<br />

penciclovir, 10<br />

penicillamine, 85<br />

penicillin g benzathine, 13<br />

penicillin g potassium, 14<br />

PENICILLIN G POTASSIUM IN D5W, 14<br />

penicillin g procaine, 14<br />

penicillin g sodium, 14<br />

PENICILLIN GK-ISO-OSM DEXTROSE, 14<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

penicillin v potassium, 14<br />

PENICILLINS, 13<br />

PENLAC, 12<br />

PENNSAID, 56<br />

PENTACEL, 77<br />

PENTAM 300, 9<br />

pentamidine, 9<br />

pentamidine isethionate, 9<br />

PENTASA, 73<br />

pentazocine, 22<br />

pentopak, 50<br />

pentosan polysulfate sodium, 115<br />

pentoxifylline, 51<br />

pentoxifylline tablet sustained action, 50<br />

pentoxil, 50<br />

PEPCID INJECTION, 71<br />

PEPCID SUSPENSION ORAL, -TABLET, 71<br />

PERANEX HC PADS MEDICATED, 58<br />

PERCOCET, 29<br />

PERCODAN, 29<br />

perindopril erbumine, 41, 42<br />

perio med, 90<br />

periogard, 63<br />

PERIOSTAT, 63<br />

perisol, 63<br />

permethrin, 55<br />

permethrin cream, 55<br />

perphenazine, 24<br />

perphenazine-amitriptyline, 35<br />

PERSANTINE, 86<br />

PEXEVA 10 MG TABLET, -40 MG TABLET, 39<br />

PEXEVA 20 MG TABLET, -30 MG TABLET, 39<br />

PFIZERPEN, 14<br />

phenadoz, 26<br />

phenelzine, 34<br />

PHENERGAN, 111<br />

phenoxybenzamine, 45<br />

phentolamine, 46<br />

PHENTOLAMINE MESYLATE INJECTION, 46<br />

phenylephrine hcl, 109<br />

phenylephrine hcl drops, 109<br />

PHENYTEK, 33<br />

phenytoin, 33<br />

phenytoin sodium, 33<br />

phenytoin sodium extended, 33<br />

phenytoin sodium injection, 33<br />

phenytoin suspension oral, 33<br />

PHISOHEX, 17<br />

PHOS-FLUR, 90<br />

PHOSLO, 93<br />

phospha 250 neutral, 92<br />

PHOSPHOLINE IODIDE, 105<br />

phosphorus, 92<br />

physostigmine salicylate injection, 37<br />

pilocarpine hcl, 63, 105<br />

pilocarpine hcl drops, 105<br />

pilocarpine hcl tablet, 63<br />

PILOPINE HS, 105<br />

pimecrolimus, 58<br />

pimozide, 24<br />

pindolol, 43<br />

pioglitazone hcl, 66<br />

pioglitazone hcl/metformin hc, 66<br />

pioglitazone/glimepiride, 67<br />

piperacillin, 14<br />

piperacillin/tazobactam sodium, 14<br />

piperacillin-tazobactam, 14<br />

PIPRACIL IN DEXTROSE, 14<br />

pirbuterol, 111<br />

piroxicam, 84<br />

piroxicam capsule, 85<br />

pitavastatin calcium, 46<br />

PITOCIN, 98<br />

PLAN B, 96<br />

PLAN B ONE-STEP, 96<br />

PLAQUENIL, 15<br />

PLASBUMIN-25, 88<br />

PLASMA-LYTE 148, 88<br />

PLASMA-LYTE 148 IN DEXTROSE, 88<br />

PLASMA-LYTE 56, 88<br />

PLASMA-LYTE 56 IN DEXTROSE, 88<br />

PLASMA-LYTE A PH 7.4, 88<br />

PLASMA-LYTE R, 89<br />

PLASMODICIDES, 14<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

PLAVIX, 86<br />

plerixafor, 77<br />

PLETAL, 86<br />

PLEXION, 53<br />

pnv-dha, 100<br />

pnv-iron, 100<br />

pnv-omega, 100<br />

pnv-select, 101<br />

podofilox, 55<br />

poliomyelitis vac,killed, 77<br />

POLOCAINE, 2<br />

poly iron pn, 101<br />

POLY IRON PN FORTE, 101<br />

polycin-b, 107<br />

poly-dex, 106<br />

polyethylene glycol 3350, -pkt, -powd, 72<br />

polymyxin b, 9<br />

polymyxin b sulfate injection, 9<br />

POLYMYXIN B SULFATE POWDER, 9<br />

polymyxin b sulfate/tmp, 107<br />

polymyxin b sul-trimethoprim, 107<br />

POLY-PRED, 106<br />

POLYTRIM, 107<br />

PONSTEL, 85<br />

portia, 96<br />

posaconazole, 8<br />

pot acid phos/sod acid phos, 115<br />

potassium acetate injection, 92<br />

potassium acid phosphate, 115<br />

potassium bicarb/ca, 92<br />

potassium bicarbonate tablet effervescent,<br />

92<br />

potassium chl-normal saline, 89<br />

potassium chloride, 92<br />

potassium chloride capsule sustained action,<br />

-cl 20 meq tab er, -cl er 10 meq tablet, -cl<br />

er 20 meq tablet, -cl er 8 meq tablet, -<br />

solution, 93<br />

potassium chloride injection, 93<br />

potassium chloride-nacl, 89<br />

potassium citrate tablet sustained action, 115<br />

potassium citrate-citric acid, 115<br />

potassium cl 10 meq tab sa, -tablet<br />

effervescent, 93<br />

POTASSIUM REMOVING RESINS, 91<br />

POTASSIUM SPARING DIURETICS, 51<br />

POTASSIUM SUPPLEMENTS, 92<br />

povidone-iodine, 108<br />

pr natal 430, 101<br />

pr natal 430 ec, 101<br />

pr natal 440 ec, 101<br />

pr otic solution, 61<br />

pralidoxime chloride, 60<br />

pramipexole, 36<br />

pramipexole dihydrochloride, 36<br />

pramlintide acetate, 65<br />

PRAMOTIC, 61<br />

pramoxine hcl/chloroxylenol, 61<br />

PRANDIMET, 67<br />

PRANDIN, 67<br />

prascion, 53<br />

prascion fc, 54<br />

prascion ts, 54<br />

prasugrel, 86<br />

PRAVACHOL, 46<br />

pravastatin, 46<br />

pravastatin sodium, 47<br />

praziquantel, 3<br />

prazosin, 52<br />

prazosin hcl, 52<br />

PRECISION SYRINGE EMPTY DISPOSABLE,<br />

81<br />

PRECOSE, 67<br />

PRED FORTE, 106<br />

PRED MILD, 106<br />

PRED-G, 106<br />

prednicarbate, 57, 58<br />

prednisol, 106<br />

prednisolone, 64<br />

prednisolone acetate, 106<br />

prednisolone acetate suspension drops, 106<br />

prednisolone sod phosphate, 64<br />

prednisolone sodium phosphate drops, 106<br />

prednisolone sodium phosphate solution, 64<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

prednisolone solution oral, 64<br />

prednisone, 64<br />

prednisone intensol, 64<br />

prednisone solution, -tablet, -tablet dose<br />

pack, 64<br />

PREFERA-OB, 101<br />

PREFERA-OB ONE, 101<br />

PREFERA-OB PLUS DHA, 101<br />

PREFEST, 98<br />

pregabalin, 34<br />

PRELONE, 64<br />

PREMARIN CREAM WITH APPLICATOR, -<br />

TABLET, 97<br />

PREMARIN INJECTION, 97<br />

PREMASOL, 89<br />

PREMPHASE, 98<br />

PREMPRO, 98<br />

prenacare, 101<br />

prenafirst, 101<br />

prenaplus, 101<br />

prenatabs fa, 101<br />

prenatabs obn, 101<br />

prenatabs rx, 101<br />

prenatal 19, 101<br />

prenatal ad, 101<br />

prenatal formula tablet, 101<br />

prenatal low iron, 101<br />

prenatal mr 90 fe, 101<br />

prenatal multivitamin w-iron, 101<br />

prenatal plus, 101<br />

prenatal rx 1, 101<br />

prenatal vit( = or > 1mg fa), 99, 100, 101,<br />

102, 103<br />

PRENATAL VITAMINS, 99<br />

prenatal vitamins (< 1mg fa), 100, 101<br />

prenatal z, 101<br />

prenatal-u, 101<br />

PRENATE DHA, 101<br />

PRENATE ELITE, 101<br />

PRENATE ESSENTIAL, 101<br />

prenate plus, 101<br />

PRENEXA, 101<br />

PREPIDIL, 104<br />

PREQUE 10, 101<br />

PREVACID 30 MG CAPSULE DR, -30 MG<br />

SOLUTAB, -DR 30 MG CAPSULE, 74<br />

PREVACID DR 15 MG CAPSULE, -15 MG<br />

SOLUTAB, 74<br />

prevalite, 47<br />

PREVIDENT, 90<br />

PREVIDENT 5000, 90<br />

PREVIDENT 5000 PLUS, 90<br />

PREVIDENT 5000 SENSITIVE, 90<br />

previfem, 96<br />

previt+dha, 101<br />

previte rx, 101<br />

PREVPAC, 73<br />

PREZISTA 150 MG TABLET, -300 MG<br />

TABLET, -75 MG TABLET, 4<br />

PREZISTA 400 MG TABLET, -600 MG<br />

TABLET, 4<br />

PRIALT, 22<br />

PRIFTIN, 5<br />

PRILOSEC DR 10 MG CAPSULE, -DR 20 MG<br />

CAPSULE, 74<br />

PRILOSEC DR 40 MG CAPSULE, -PKT, 74<br />

PRIMALEV, 29<br />

primaquine, 15<br />

PRIMAQUINE, 15<br />

PRIMAXIN 250 MG VIAL, 9<br />

PRIMAXIN 500 MG VIAL, 9<br />

PRIMAXIN I.M., 9<br />

primidone, 34<br />

PRIMLEV, 29<br />

PRIMSOL, 17<br />

PRINIVIL, 42<br />

PRINZIDE, 50<br />

PRISTIQ, 35<br />

PRIVIGEN, 77<br />

PROAIR HFA, 111<br />

PROAMATINE, 51<br />

probenecid, 83<br />

probenecid-colchicine, 83<br />

procainamide, 42<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

procainamide hcl injection, 42<br />

procaine, 2<br />

PROCALAMINE, 89<br />

procarbazine, 19<br />

PROCARDIA, 44<br />

PROCARDIA XL, 44<br />

PROCENTRA, 31<br />

PROCHIEVE, 104<br />

prochlorperazine edisylate, 25, 26<br />

prochlorperazine maleate suppository rectal,<br />

-tablet, 26<br />

PROCRIT 10,000 UNITS/ML VIAL, -2,000<br />

UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -<br />

4,000 UNITS/ML VIAL, 77<br />

PROCRIT 20,000 UNITS/ML VIAL, -40,000<br />

UNITS/ML VIAL, 77<br />

PROCTOCORT, 73<br />

PROCTOCREAM-HC, 73<br />

procto-pak, 73<br />

proctosol-hc, 73<br />

proctozone-hc, 73<br />

PRODIGY INSULIN SYRINGE, 81<br />

PRODIGY PEN NEEDLE, 81<br />

progesterone, 103, 104<br />

progesterone in oil, 104<br />

progesterone injection, 104<br />

PROGESTIN DRUGS, 103<br />

PROGLYCEM, 65<br />

PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE,<br />

20<br />

PROGRAF 5 MG CAPSULE, 20<br />

PROGRAF INJECTION, 20<br />

PROLASTIN, 114<br />

PROLEUKIN, 79<br />

PROLIA, 69<br />

PROMACTA, 79<br />

promethazine, 111<br />

promethazine hcl injection, 111<br />

promethazine hcl suppository rectal, 26<br />

promethazine hcl syrup, -tablet, 111<br />

promethazine vc, 110<br />

promethegan, 26<br />

PROMETRIUM, 104<br />

PRONESTYL, 42<br />

propafenone, 42<br />

propafenone hcl, 42<br />

propantheline bromide, 71<br />

proparacaine, 108, 109<br />

proparacaine hcl, 109<br />

PROPINE, 105<br />

propranolol, 43<br />

propranolol hcl cap sa, -solution, -tablet, 43<br />

propranolol hcl injection, 43<br />

propranolol-hydrochlorothiazid, 50<br />

propylthiouracil, 63<br />

PROQUAD, 77<br />

PROQUIN XR, 15<br />

PROSCAR, 115<br />

PROSOL, 89<br />

PROSTIGMIN, 37<br />

PROSTIN E2 VAGINAL SUPPOSITORY, 94<br />

PROSTIN VR PEDIATRIC, 51<br />

protamine, 90<br />

PROTAMINE SULFATE, 90<br />

PROTON PUMP INHIBITORS, 73<br />

PROTONIX DR 20 MG TABLET, 74<br />

PROTONIX DR 40 MG TABLET, -PKT, 74<br />

PROTONIX IV, 74<br />

PROTOPAM CHLORIDE, 60<br />

PROTOPIC, 59<br />

protriptyline, 38<br />

protriptyline hcl, 38<br />

PROVENTIL HFA, 111<br />

PROVERA, 104<br />

PROVIGIL, 31<br />

PROZAC 10 MG PULVULE, 39<br />

PROZAC 20 MG PULVULE, -SOLUTION, 39<br />

PROZAC 40 MG PULVULE, 39<br />

PROZAC WEEKLY, 39<br />

PRUDOXIN, 59<br />

pruet dha, 101<br />

pruet dha ec, 101<br />

pse/acrivas, 110<br />

pse/desloratadine, 110<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

pse/fexofenadine, 109, 110<br />

PULMICORT 180 MCG FLEXHALER, 113<br />

PULMICORT 90 MCG FLEXHALER, 114<br />

PURINETHOL, 20<br />

PYLERA, 73<br />

pyrazinamide, 5<br />

pyridostigmine, 37<br />

pyridostigmine bromide, 37<br />

pyrimethamine, 14<br />

pyrimethamine/sulfadoxine, 14<br />

QUALAQUIN, 15<br />

quasense, 96<br />

QUESTRAN, 47<br />

QUESTRAN LIGHT, 47<br />

quetiapine fumarate, 25<br />

quinapril, 41<br />

quinapril hcl, 42<br />

quinapril/hctz, 49<br />

quinapril-hydrochlorothiazide, 50<br />

quinaretic, 50<br />

quinidine gluconate injection, 42<br />

quinidine gluconate tablet sustained action,<br />

42<br />

quinidine sulfate tablet, -tablet sustained<br />

action, 42<br />

quinine sulfate, 15<br />

QUINOLONES, 15<br />

quinupristin/dalfopristin, 9<br />

QUIXIN, 107<br />

QVAR, 114<br />

RABAVERT, 77<br />

rabeprazole sodium, 73<br />

rabies immune globulin, 76<br />

rabies vac,pf chick-emb cell, 77<br />

rabies vaccine,human diploid, 77<br />

raloxifene, 69<br />

raltegravir potassium, 4<br />

ramelteon, 38<br />

ramipril, 41, 42<br />

RANEXA, 51<br />

ranibizumab, 109<br />

RANICLOR, 6<br />

ranitidine, 71<br />

ranitidine 150 mg tablet, -300 mg tablet, -<br />

capsule, -syrup, 71<br />

ranitidine hcl injection, 71<br />

ranolazine, 51<br />

RAPAFLO, 115<br />

RAPAMUNE, 20<br />

rapiflux 20 mg tablet, 39<br />

RAPTIVA, 20<br />

rasagiline mesylate, 36<br />

rasburicase, 19<br />

RAZADYNE, 22<br />

RAZADYNE ER, 23<br />

REBETOL SOLUTION, -CAPSULE, 10<br />

REBIF 22 MCG/0.5 ML SYRINGE, -44<br />

MCG/0.5 ML SYRINGE, 79<br />

REBIF TITRATION PACK, 79<br />

RECLAST, 69<br />

reclipsen, 96<br />

RECOMBIVAX HB, 77<br />

REFLUDAN, 91<br />

REGLAN INJECTION, 71<br />

REGLAN TABLET, 71<br />

REGONOL, 37<br />

REGRANEX, 59<br />

RELAGARD, 98<br />

RELENZA, 10<br />

RELION NOVOLIN 70-30 VIAL, -RELION<br />

VIAL, 66<br />

RELION NOVOLIN N 100 UNITS/ML, -RELION<br />

100 UNITS/ML, 66<br />

RELION NOVOLIN R 100 UNITS/ML, 66<br />

RELISTOR, 73<br />

RELPAX, 33<br />

REMERON, 35<br />

remeven, 59<br />

REMICADE, 20<br />

remifentanil, 22<br />

REMODULIN, 51<br />

RENACIDIN, 115<br />

renaf, 90<br />

RENAGEL, 86<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

RENAMIN, 89<br />

re-nata 29, 101<br />

re-nata 29 ob, 101<br />

renate, 101<br />

renate dha, 101<br />

renate dha extra, 101<br />

RENVELA, 86<br />

REOPRO, 86<br />

repaglinide, 67<br />

repaglinide/metformin hcl, 67<br />

reprexain, 30<br />

REQUIP, 36<br />

REQUIP XL, 36<br />

RESCRIPTOR, 4<br />

RESECTISOL, 89<br />

reserpine, 50<br />

RESPIRATORY MEDICATIONS, 109<br />

RESTASIS, 109<br />

retapamulin, 16<br />

RETIN-A, 54<br />

RETIN-A MICRO, 54<br />

RETIN-A MICRO PUMP, 54<br />

RETISERT, 106<br />

RETROVIR CAPSULE, -SYRUP, -TABLET, 4<br />

RETROVIR INJECTION, 4<br />

re-u40, 59<br />

revatio (sildenafil citrate), 51<br />

REVATIO INJECTION, 51<br />

REVATIO TABLET, 51<br />

REVIA, 37<br />

REVLIMID, 20<br />

revonto, 83<br />

REYATAZ, 4<br />

R-GENE 10, 89<br />

RHEUMATREX, 20<br />

RHINOCORT AQUA, 62<br />

rho(d) immune globulin, 76, 77, 78<br />

RHOGAM, 77<br />

RHOGAM PLUS, 77<br />

RHOPHYLAC, 77<br />

ribapak, 10<br />

ribasphere 200 mg tablet, 10<br />

ribasphere 400 mg tablet, -600 mg tablet, -<br />

capsule, 10<br />

RIBATAB, 11<br />

ribavirin, 10, 11<br />

ribavirin 200 mg tablet, 11<br />

ribavirin 400 mg tablet, -600 mg tablet, -<br />

capsule, 11<br />

RIDAURA, 85<br />

rifabutin, 5<br />

RIFADIN CAPSULE, 5<br />

RIFADIN INJECTION, 5<br />

RIFAMATE, 5<br />

rifampin, 5<br />

rifampin capsule, 5<br />

rifampin injection, 5<br />

rifampin/inh/pyrazinamide, 5<br />

rifampin/isoniazid, 5<br />

rifapentine, 5<br />

RIFATER, 5<br />

rifaximin, 10<br />

rilonacept, 79<br />

RILUTEK, 83<br />

riluzole, 83<br />

rimantadine, 10<br />

rimantadine hcl, 11<br />

rimexolone, 106<br />

RIMSO-50, 115<br />

ringers injection, 89<br />

RIOMET, 67<br />

risedron sod/calcium carbona, 68<br />

risedronate, 68<br />

RISPERDAL CONSTA 12.5 MG SYR, -25 MG<br />

SYR, 24<br />

RISPERDAL CONSTA 37.5 MG SYR, -50 MG<br />

SYR, 24<br />

RISPERDAL M-TAB, 24<br />

RISPERDAL SOLUTION, 24<br />

RISPERDAL TABLET, 24<br />

risperidone, 24<br />

risperidone m-tab, 24<br />

risperidone odt, 24<br />

risperidone solution, 24<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

risperidone tablet, 25<br />

RITALIN, 31<br />

RITALIN LA, 31<br />

RITALIN-SR, 31<br />

ritonavir, 4<br />

ritonavir/lopinavir, 4<br />

RITUXAN, 20<br />

rituximab, 20<br />

rivastigmine, 23<br />

rivastigmine tartrate, 22<br />

rizatriptan benzoate, 32<br />

ROBAXIN INJECTION, 83<br />

ROBAXIN TABLET, 83<br />

ROBAXIN-750, 83<br />

ROBINUL FORTE, 71<br />

ROBINUL INJECTION, 71<br />

ROBINUL TABLET, 71<br />

ROCALTROL, 93<br />

ROCEPHIN, 6<br />

ROMAZICON, 37<br />

romycin, 107<br />

ropinirole, 36<br />

ropinirole hcl, 36<br />

ropivacaine, 2<br />

rosaderm cleanser, 54<br />

rosiglitazone maleate, 66<br />

rosiglitazone maleate/glimepir, 66<br />

rosiglitazone/metformin hcl, 66<br />

rosuvastatin calcium, 46<br />

ROTARIX, 77<br />

ROTATEQ, 77<br />

rotavirus vac, live att, 89-12, 77<br />

rotavirus vac, live pentav, 77<br />

rovin-nv, 102<br />

rovin-nv dha, 102<br />

ROWASA, 73<br />

ROXICET SOLUTION, 29<br />

roxicet tablet, 29<br />

ROXICODONE, 29<br />

ROXICODONE INTENSOL, 29<br />

ROZEREM, 38<br />

rubella vaccine, 77<br />

rufinamide, 34<br />

RYBIX ODT, 22<br />

RYTHMOL, 42<br />

RYTHMOL SR, 42<br />

RYZOLT, 22<br />

SABRIL, 34<br />

SAFESNAP INSULIN SYRINGE, 81<br />

SAFETYGLIDE INSULIN SYRINGE, 81<br />

SAFETYGLIDE SYRINGE SYRINGE EMPTY<br />

DISPOSABLE, 81<br />

SAIZEN, 75<br />

SALAGEN, 63<br />

SALICYLATES AND RELATED DRUGS, 85<br />

salmeterol, 111<br />

salmeterol/fluticasone, 112<br />

salsalate, 85<br />

SAMSCA, 69<br />

SANCTURA, 114<br />

SANCTURA XR, 114<br />

SANCUSO, 26<br />

SANDIMMUNE CAPSULE, -SOLUTION, 20<br />

SANDIMMUNE INJECTION, 20<br />

SANDOSTATIN, 20<br />

SANDOSTATIN LAR 10 MG KIT, -30 MG KIT,<br />

20<br />

SANDOSTATIN LAR 20 MG KIT, 21<br />

SANTYL, 59<br />

SAPHRIS, 25<br />

sapropterin dihydrochloride, 69<br />

saquinavir mesylate, 4<br />

SARAFEM 10 MG TABLET, 39<br />

SARAFEM 15 MG TABLET, 40<br />

SARAFEM 20 MG TABLET, 40<br />

sargramostim, 79<br />

SAVELLA 100 MG TABLET, -12.5 MG TABLET,<br />

-25 MG TABLET, -50 MG TABLET, 35<br />

SAVELLA TITRATION PACK, 36<br />

saxagliptin hydrochloride, 67<br />

SCABICIDES, 55<br />

SCALACORT, 58<br />

scopolamine, 26, 71, 109<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

SCOPOLAMINE HYDROBROMIDE INJECTION,<br />

71<br />

SEASONALE, 96<br />

SEASONIQUE, 96<br />

seb-prev 10% cream, -10% gel, 54<br />

se-care, 102<br />

se-care conceive, 102<br />

se-care gesture, 102<br />

SECONDARY AMINES, 37<br />

SECTRAL, 43<br />

SEDATIVE/HYPNOTIC DRUGS, 38<br />

SELECTIVE SEROTONIN REUPTAKE<br />

INHIBITORS, 38<br />

SELECT-OB, 102<br />

SELECT-OB + DHA, 102<br />

selegiline, 33, 36, 37<br />

selegiline hcl capsule, -tablet, 36<br />

selenium sulfide, 54, 55<br />

selenium sulfide 2.25% shampoo, -2.5%<br />

lotion, -sulf 2.5% shampoo, 54<br />

selenos, 54<br />

selfemra 10 mg capsule, 40<br />

selfemra 20 mg capsule, 40<br />

SELSEB, 54<br />

SELZENTRY, 4<br />

SEMPREX-D, 110<br />

se-natal 19, 102<br />

se-natal 90, 102<br />

se-natal one, 102<br />

SENSIPAR, 69<br />

SENSORCAINE, 2<br />

SENSORCAINE WITH DEXTROSE, 2<br />

SENSORCAINE WITH EPINEPHRINE, 2<br />

SENSORCAINE-MPF, 2<br />

SENSORCAINE-MPF EPINEPHRINE, 2<br />

se-plete dha, 102<br />

SEPTRA, 15<br />

SEPTRA DS, 15<br />

SEREVENT DISKUS, 111<br />

SEROMYCIN, 5<br />

SEROQUEL 100 MG TABLET, -200 MG<br />

TABLET, -25 MG TABLET, -50 MG TABLET,<br />

25<br />

SEROQUEL 300 MG TABLET, -400 MG<br />

TABLET, 25<br />

SEROQUEL XR 150 MG TABLET, -200 MG<br />

TABLET, 25<br />

SEROQUEL XR 300 MG TABLET, -400 MG<br />

TABLET, -50 MG TABLET, 25<br />

SEROSTIM, 75<br />

sertaconazole nitrate, 12<br />

sertraline, 40<br />

sertraline hcl 100 mg tablet, -50 mg tablet,<br />

40<br />

sertraline hcl 25 mg tablet, 40<br />

sertraline hcl solution, 40<br />

se-tan dha, 102<br />

setonet, 102<br />

setonet-ec, 102<br />

sevelamer, 86<br />

sevelamer carbonate, 86<br />

sf, 90<br />

sf 5000 plus, 90<br />

SFROWASA, 73<br />

silodosin, 115<br />

SILVADENE, 17<br />

silver sulfadiazine, 17<br />

SIMCOR 1,000-20 MG TABLET, -750-20 MG<br />

TABLET, 47<br />

SIMCOR 500-20 MG TABLET, 47<br />

SIMPONI, 21<br />

SIMULECT, 21<br />

simvastatin, 47<br />

simvastatin tablet, 47<br />

sinecatechins, 59<br />

SINEMET 10-100, 36<br />

SINEMET 25-100, 36<br />

SINEMET 25-250, 36<br />

SINEMET CR, 36<br />

SINGLE USE SWAB, 81<br />

SINGULAIR, 111<br />

sirolimus, 20<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

sitagliptin phos/metformin hcl, 67<br />

sitagliptin phosphate, 67<br />

SKELAXIN, 83<br />

SKELID, 69<br />

SMOKING CESSATION PRODUCTS, 40<br />

sodium acetate, 89<br />

sodium benzoate/na ph-acetate, 60<br />

sodium bicarbonate, 88<br />

sodium bicarbonate injection, 89<br />

sodium chloride 0.45% irrig, -0.9% irrig., -<br />

sterile saline 0.9% irr, 89<br />

sodium chloride 0.45% soln, -0.45% solnexcel<br />

con, -0.9% soln, -0.9% soln., -0.9%<br />

soln-excel cont, -0.9% solution, -3% iv<br />

soln, -4 meq/ml vl, -5% iv soln, -cl 2.5<br />

meq/ml vial, 89<br />

sodium citrate & citric acid, 93<br />

sodium citrate/citric acid, 92<br />

SODIUM EDECRIN, 48<br />

sodium fluoride, 89, 90<br />

sodium fluoride drops, -solution non-oral, -<br />

tablet, -tablet chewable, 90<br />

sodium fluoride/pot nitrate, 90<br />

sodium lactate, 89<br />

sodium oxybate, 37<br />

sodium phenylbutyrate, 60<br />

sodium phosphate injection, 89<br />

sodium phosphate/na biphos, 72<br />

sodium polystyrene sulfonate, 91, 92<br />

sodium sulfacetamide-sulfur cleanser, -foam,<br />

-pads medicated, -sulfacetamide-sulfur<br />

lotn, -sulf-sulfur wash, -suspensions, (not<br />

oral), 54<br />

sodium tetradecyl sulfate, 60<br />

sodium/calcium/mag/potassium, 108<br />

SOLARAZE, 59<br />

solia, 96<br />

solifenacin succinate, 115<br />

SOLODYN, 16<br />

SOLU-CORTEF, 64<br />

SOLU-CORTEF (PF), 64<br />

SOLU-MEDROL, 64<br />

SOLU-MEDROL (PF), 64<br />

SOMA, 83<br />

somatropin, 75<br />

SOMATULINE DEPOT, 21<br />

SOMAVERT, 69<br />

SONATA 10 MG CAPSULE, 38<br />

SONATA 5 MG CAPSULE, 38<br />

sorafenib tosylate, 20<br />

SORIATANE, 55<br />

SORIATANE CK 10 MG KIT, 55<br />

SORIATANE CK 25 MG KIT, 55<br />

sorine, 49<br />

sotalol, 48, 49<br />

sotalol af, 49<br />

SOTALOL HCL, 49<br />

SOTRADECOL, 60<br />

sotret, 55<br />

SPECIALIZED OB/GYN DRUGS, 104<br />

SPECTRACEF, 6<br />

SPIRIVA, 114<br />

spironolactone, 51<br />

spironolactone tablet, 51<br />

spironolactone/hctz, 51<br />

spironolactone-hctz, 51<br />

SPORANOX CAPSULE, 8<br />

SPORANOX SOLUTION, 8<br />

sprintec, 96<br />

SPRYCEL, 21<br />

sps, 92<br />

sronyx, 96<br />

ssd, 17<br />

ssd af, 17<br />

stagesic, 30<br />

STALEVO 100, 36<br />

STALEVO 125, 36<br />

STALEVO 150, 36<br />

STALEVO 200, 37<br />

STALEVO 50, 37<br />

STALEVO 75, 37<br />

stanimax, 90<br />

stannous fluoride, 90<br />

stannous fluoride solution, 90<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

STARLIX, 67<br />

stavudine, 4, 5<br />

STAVZOR, 41<br />

STELARA, 21<br />

STERAPRED, 64<br />

STERAPRED DS, 64<br />

STIMATE, 69<br />

STRATTERA, 37<br />

streptomycin, 5<br />

STREPTOMYCIN SULFATE INJECTION, 5<br />

STRIANT, 94<br />

STROMECTOL, 3<br />

sublimaze, 29<br />

SUBOXONE, 30<br />

SUBUTEX, 30<br />

succimer, 60<br />

SUCCINIMIDES, 40<br />

succinylcholine, 83<br />

sucralfate, 72<br />

sucralfate suspension oral, -tablet, 72<br />

sufenta, 22<br />

sufentanil citrate injection, 22<br />

SULAR, 44<br />

sulconazole nitrate, 12<br />

sulfac, 107<br />

sulfacetamide sodium, 54, 107<br />

sulfacetamide sodium drops, 107<br />

sulfacetamide sodium lotion, -suspension<br />

topical, 55<br />

sulfacetamide/prednisolone ac, 105<br />

sulfacetamide/sulfur, 53, 54<br />

sulfacetamide-prednisolone, 106<br />

sulfadiazine tablet, 15<br />

sulfamethoxazole/trimethoprim, 15<br />

sulfamethoxazole-trimethoprim injection, 15<br />

sulfamethoxazole-trimethoprim suspension<br />

oral, -tablet, 15<br />

sulfamide, 107<br />

SULFAMYLON, 17<br />

sulfanilamide, 98<br />

sulfasalazine, 72<br />

sulfasalazine dr, 73<br />

sulfasalazine tablet, 73<br />

sulfatol c, 54<br />

sulfatrim, 15<br />

sulfazine, 73<br />

sulfazine ec, 73<br />

sulfisoxazole acetyl, 15<br />

SULFONAMIDES, 15<br />

sulfuric acid/sulf phenol, 63<br />

sulindac, 83<br />

sulindac tablet, 85<br />

sulzee, 54<br />

sumatriptan, 32, 33<br />

SUMATRIPTAN 20 MG NASAL SPRAY, 33<br />

sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml<br />

refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml kit,<br />

-6 mg/0.5 ml refill, -6 mg/0.5 ml syrng, 33<br />

sumatriptan 4 mg/0.5 ml vial, -6 mg/0.5 ml<br />

vial, 33<br />

SUMATRIPTAN 5 MG NASAL SPRAY, 33<br />

sumatriptan suc/naproxen sod, 33<br />

sumatriptan succinate tablet, 33<br />

SUMAXIN, 54<br />

sunitinib malate, 21<br />

SUPPRELIN LA, 104<br />

SUPRAX, 7<br />

SURE COMFORT, 81<br />

SURE COMFORT ALCOHOL, 81<br />

SURE-FINE PEN NEEDLES, 81<br />

SURE-JECT INSULIN SYRINGE, 81<br />

SURE-PREP ALCOHOL PREP PADS, 81<br />

SURMONTIL, 40<br />

SUSTIVA, 4<br />

SUTENT, 21<br />

SYMBICORT, 114<br />

SYMBYAX, 25<br />

SYMLIN, 65<br />

SYMLINPEN 120, 65<br />

SYMLINPEN 60, 65<br />

SYNAGIS, 77<br />

SYNALGOS-DC, 30<br />

SYNAREL, 104<br />

SYNERA, 2<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

SYNERCID, 9<br />

SYNTHROID, 70<br />

SYPRINE, 85<br />

TACLONEX, 55<br />

TACLONEX SCALP, 55<br />

tacrine, 22<br />

tacrolimus, 20, 59<br />

tacrolimus 0.5 mg capsule, -1 mg capsule, 21<br />

tacrolimus 5 mg capsule, 21<br />

TALWIN INJECTION, 22<br />

TAMBOCOR, 42<br />

TAMIFLU 30 MG GELCAP, 11<br />

TAMIFLU 45 MG GELCAP, -75 MG GELCAP,<br />

11<br />

TAMIFLU SUSPENSION, 11<br />

tamoxifen citrate tablet, 21<br />

tamsulosin, 115<br />

tamsulosin hcl, 115<br />

TANDEM DHA, 102<br />

TANDEM OB, 102<br />

TAPAZOLE, 63<br />

tapentadol hcl, 29<br />

TARCEVA, 21<br />

TARGRETIN, 21<br />

TARKA, 50<br />

taron a prenatal, 102<br />

taron ec calcium, 102<br />

taron-c dha, 102<br />

taron-ec cal, 102<br />

taron-prex prenatal, 102<br />

TASIGNA, 21<br />

TASMAR, 37<br />

tazarotene, 55<br />

TAZICEF, 7<br />

TAZORAC, 55<br />

taztia xt, 44<br />

TEGRETOL, 27<br />

TEGRETOL XR 100 MG TABLET, 27<br />

TEGRETOL XR 200 MG TABLET, -400 MG<br />

TABLET, 27<br />

TEKTURNA, 50<br />

TEKTURNA HCT, 50<br />

telavancin, 9<br />

telbivudine, 11<br />

telithromycin, 8<br />

telmisartan, 42<br />

telmisartan/amlodipine, 50<br />

telmisartan/hctz, 50<br />

TEMOVATE, 58<br />

TEMOVATE EMOLLIENT, 58<br />

TENEX, 45<br />

tenofovir disproxil fumarate, 5<br />

TENORETIC 100, 50<br />

TENORETIC 50, 50<br />

TENORMIN, 43<br />

TERAZOL 3 80 MG SUPPOSITORY, 17<br />

TERAZOL 3 CREAM, 18<br />

TERAZOL 7, 18<br />

terazosin 1 mg capsule, -2 mg capsule, -5<br />

mg capsule, 52<br />

terazosin 10 mg capsule, 52<br />

terbinafine, 8, 12<br />

terbinafine hcl, 8<br />

terbinafine/hydroxy chitosan, 8<br />

TERBINEX, 8<br />

terbutaline sulfate injection, 111<br />

terbutaline sulfate tablet, 111<br />

terconazole, 17, 18<br />

terconazole 0.4% cream, 18<br />

terconazole 0.8% cream, 18<br />

terconazole 80 mg suppository, 18<br />

teriparatide, 69<br />

TERRAMYCIN, 16<br />

TERRAMYCIN IM, 16<br />

TERRAMYCIN WITH POLYMYXIN, 107<br />

TERSI FOAM, 55<br />

TERTIARY AMINES, 40<br />

TERUMO INSULIN SYRINGE, 81<br />

TERUMO SURGUARD, 81<br />

TESTIM, 94<br />

TESTOPEL, 94<br />

testosterone, 94<br />

testosterone cypionate, 94<br />

testosterone cypionate injection, 94<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

testosterone enanthate, 94<br />

testosterone propionate, 94<br />

TESTRED, 94<br />

TETANUS DIPHTHERIA TOXOIDS, 77<br />

tetanus immune globulin, 76<br />

tetanus toxoid adsorbed, 77<br />

tetanus,diphtheria toxoid, 76, 77, 78<br />

TETANUS-DIPHTERIA-DECAVAC, 78<br />

tetrabenazine, 37<br />

tetracyc hcl/bis ss/metronid, 73<br />

tetracycline hcl capsule, 16<br />

TETRACYCLINES, 16<br />

tetrahydrozoline, 62<br />

TEVETEN, 42<br />

TEVETEN HCT, 50<br />

TEV-TROPIN, 75<br />

TEXACORT, 58<br />

thalidomide, 60<br />

THALITONE, 52<br />

THALOMID, 60<br />

THEO-24, 112<br />

theochron, 112<br />

theophylline, 112<br />

theophylline anhydrous tablet sustained<br />

release 12hr, 112<br />

THERACYS, 21<br />

THERAPEUTIC VITAMINS AND MINERALS, 93<br />

thermazene, 17<br />

THIAZIDE AND RELATED DRUGS, 51<br />

THINPRO INSULIN SYRINGE, 82<br />

thioguanine, 21<br />

THIOGUANINE, 21<br />

thioridazine hcl, 25<br />

thiothixene, 24, 25<br />

THROMBATE III, 91<br />

THROMBOPOIETIC AGENTS, 79<br />

THYMOGLOBULIN, 78<br />

thyroid, 69<br />

THYROID SUPPLEMENTS, 69<br />

thyroid tablet, 70<br />

THYROLAR-1, 70<br />

THYROLAR-1/2, 70<br />

THYROLAR-1/4, 70<br />

THYROLAR-2, 70<br />

THYROLAR-3, 70<br />

tiagabine, 34<br />

TIAZAC, 44<br />

ticarcillin/k clavulanate, 14<br />

TICE BCG, 78<br />

ticlopidine hcl, 86<br />

TIGAN CAPSULE, 26<br />

TIGAN INJECTION, 26<br />

tigecycline, 9<br />

TIKOSYN, 49<br />

tilia fe, 96<br />

tiludronate, 69<br />

TIMENTIN, 14<br />

timolol, 104, 105<br />

timolol maleate drops, -gel-forming solution,<br />

105<br />

timolol maleate tablet, 43<br />

TIMOPTIC, 105<br />

TIMOPTIC OCUDOSE, 105<br />

TIMOPTIC-XE, 105<br />

tinzaparin sodium, porcine, 91<br />

tiotropium bromide, 114<br />

tipranavir/vitamin e tpgs, 4<br />

tirofib hc m-hyd/na chlor, 86<br />

TIROSINT, 70<br />

tizanidine, 83<br />

tizanidine hcl, 83<br />

TOBRADEX, 106<br />

tobramycin, 3, 107<br />

tobramycin sulfate drops, 107<br />

tobramycin sulfate in ns, 3<br />

tobramycin sulfate injection, 3<br />

tobramycin sulfate/dexameth, 106<br />

tobramycin/lotepred etab, 106<br />

tobramycin-dexamethasone, 106<br />

tobrasol, 107<br />

TOBREX, 107<br />

tocilizumab, 79<br />

TOFRANIL, 41<br />

TOFRANIL-PM, 41<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

tolazamide, 67<br />

tolbutamide, 67<br />

tolcapone, 37<br />

tolmetin sodium, 85<br />

tolterodine tartrate, 114<br />

tolvaptan, 69<br />

TOPAMAX, 34<br />

TOPCARE CLICKFINE, 82<br />

TOPCARE ULTRA COMFORT, 82<br />

TOPICAL <strong>ANESTHETICS</strong>, 2<br />

TOPICAL ANTIBACTERIAL DRUGS, 16<br />

TOPICAL ANTIFUNGAL-CORTICOSTEROID<br />

COMB., 17<br />

TOPICAL ANTI-INFLAMMATORY DRUGS, 56<br />

TOPICAL CORTICOSTEROID DRUGS, 56<br />

TOPICAL DERMATOLOGICAL DRUGS, 58<br />

TOPICORT, 58<br />

TOPICORT LP, 58<br />

topiragen, 34<br />

topiramate, 34<br />

topiramate capsule sprinkle, -tablet, 34<br />

topisulf, 54<br />

TOPROL XL, 43<br />

TORADOL, 85<br />

toremifene, 19<br />

torsemide, 48<br />

torsemide injection, 48<br />

torsemide tablet, 48<br />

TOTACILLIN-N, 14<br />

TOVIAZ, 115<br />

TPN ELECTROLYTES, 89<br />

TPN ELECTROLYTES II, 89<br />

TRACLEER, 46<br />

tramadol, 22<br />

tramadol hcl tablet, 22<br />

tramadol hcl tablet sustained release 24hr,<br />

22<br />

tramadol hcl-acetaminophen, 22<br />

tramadol/apap, 22<br />

TRANDATE, 43<br />

trandolapril, 42<br />

trandolapril/verapamil, 50<br />

trandolapril-verapamil, 50<br />

tranexamic acid, 60<br />

TRANSDERM-SCOP, 26<br />

tranylcypromine, 34<br />

tranylcypromine sulfate, 34<br />

TRAVASOL, 89<br />

TRAVASOL WITH DEXTROSE, 89<br />

TRAVASOL WITH ELECTROLYTES, 89<br />

TRAVATAN, 105<br />

TRAVATAN Z, 105<br />

travoprost, 105<br />

trazodone, 35<br />

trazodone hcl tablet, 36<br />

treagan otic, 61<br />

TRECATOR, 5<br />

TRELSTAR 11.25 MG SYRINGE, -3.75 MG<br />

SYRINGE, 21<br />

TRELSTAR 22.5 MG SYRINGE, -22.5 MG<br />

VIAL, 21<br />

TRELSTAR DEPOT, 21<br />

TRELSTAR LA, 21<br />

TRENTAL, 51<br />

treprostinil sodium, 51<br />

tretinoin, 21, 52, 53, 54<br />

tretinoin 0.025% cream, -0.05% cream, -<br />

0.1% cream, -gel, 54<br />

tretinoin capsule, 21<br />

tretinoin/emol cmb9/skin cln1, 54<br />

TRETIN-X, 54<br />

TREXALL, 21<br />

TREXIMET, 33<br />

trezix, 30<br />

tri rx, 102<br />

triadvance, 102<br />

triamcinolone acetonide, 57, 62, 63, 64, 106,<br />

113<br />

triamcinolone acetonide cream, -lotion, -<br />

ointment, 58<br />

triamcinolone acetonide injection, 64<br />

triamcinolone acetonide paste, 63<br />

triamcinolone hexacetonide, 63<br />

triamterene, 51<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

triamterene-hctz, 51<br />

TRIBENZOR, 50<br />

TRICARE, 102<br />

TRICARE PRENATAL DHA ONE, 102<br />

tricitrates, 115<br />

TRICOR, 47<br />

triderm, 58<br />

TRIDESILON, 58<br />

trientine, 85<br />

TRIESENCE, 106<br />

trifera ob, 102<br />

trifluoperazine hcl, 25<br />

trifluridine, 108<br />

TRIGLIDE, 47<br />

trihexyphenidyl hcl, 23<br />

TRIHIBIT, 78<br />

tri-legest fe, 96<br />

TRILEPTAL, 27<br />

TRILIPIX, 47<br />

tri-lo-sprintec, 96<br />

trilyte with flavor packets, 73<br />

trimesis rx, 102<br />

trimethobenzamide, 26<br />

trimethobenzamide hcl capsule, 26<br />

trimethobenzamide hcl injection, 26<br />

trimethoprim, 17<br />

trimethoprim tablet, 17<br />

trimipramine, 40<br />

trimipramine maleate, 41<br />

trinatal rx 1, 102<br />

trinate, 102<br />

trinessa, 96<br />

TRI-NORINYL, 96<br />

TRIOSTAT, 70<br />

TRIPEDIA, 78<br />

tripohist, 111<br />

tri-previfem, 96<br />

triprolidine hcl syrup, 111<br />

triptorelin pamoate, 21<br />

tri-sprintec, 96<br />

triveen-one, 102<br />

triveen-prx rnf, 102<br />

triveen-u, 102<br />

trivora-28, 96<br />

TRIZIVIR, 5<br />

TROPHAMINE, 89<br />

tropicacyl, 109<br />

tropicamide, 109<br />

trospium chloride, 114<br />

TRUSOPT, 105<br />

TRUVADA, 5<br />

TWINJECT, 114<br />

TWINRIX, 78<br />

TWYNSTA, 50<br />

TYGACIL, 9<br />

TYKERB, 21<br />

TYLENOL-CODEINE NO.3, 30<br />

TYLENOL-CODEINE NO.4, 30<br />

TYLOX, 29<br />

TYPHIM VI, 78<br />

typhoid vaccine, 78<br />

TYSABRI, 21<br />

TYZEKA, 11<br />

TYZINE, 62<br />

U-CORT, 58<br />

u-kera e urea emollient, 59<br />

ULESFIA, 55<br />

ULORIC, 83<br />

ULTICARE NEEDLE DISPOSABLE, -SYRINGE<br />

EMPTY DISPOSABLE, 82<br />

ULTIGUARD 30GX0.5 ML SYRINGE, -30GX1<br />

ML SYRINGE, -SYRINGE EMPTY<br />

DISPOSABLE, 82<br />

ULTILET ALCOHOL SWAB, 82<br />

ULTILET INSULIN SYRINGE, 82<br />

ULTILET PEN NEEDLE, 82<br />

ultimatecare advantage, 102<br />

ultimatecare one, 102<br />

ultimatecare one nf, 102<br />

ULTIVA, 22<br />

ULTRA COMFORT, 82<br />

ULTRACET, 22<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

ULTRACOMFORT DISPOSABLE SYRINGE, -<br />

NEEDLE DISPOSABLE, -SYRINGE EMPTY<br />

DISPOSABLE, 82<br />

ULTRAM, 22<br />

ULTRAM ER, 22<br />

ULTRAVATE, 58<br />

ULTRAVATE PAC, 58<br />

UMECTA, 59<br />

UMECTA PD, 59<br />

UNASYN, 14<br />

UNIFINE PENTIPS, 82<br />

UNIPHYL, 112<br />

UNIRETIC, 50<br />

unithroid, 70<br />

UNIVASC, 42<br />

URAMAXIN, 59<br />

urea, 58, 59<br />

urea 40, 59<br />

urea 40% cream, -40% nail film susp, -45%<br />

cream, -50% cream, -50% nail stick, -50%<br />

nailstik, -foam, -gel, -kit, -lotion, -<br />

ointment, -towelette, 59<br />

urealac cream, -gel, -lotion, -soln, top, 59<br />

URECHOLINE, 115<br />

URINARY ANTIINFECTIVES, 17<br />

UROLOGICAL MEDICATIONS, 114<br />

UROQID-ACID NO.2, 17<br />

UROXATRAL, 115<br />

URSO, 73<br />

URSO FORTE, 73<br />

ursodiol, 72, 73<br />

ursodiol capsule, -tablet, 73<br />

ustekinumab, 21<br />

utac, 17<br />

VAGIFEM, 97<br />

VAGINAL ANTIFUNGALS, 17<br />

valacyclovir, 11<br />

VALCYTE, 11<br />

valganciclovir, 11<br />

valproate sodium, 41<br />

valproate sodium injection, 41<br />

valproic acid, 41<br />

VALPROIC ACID AND DERIVATIVES, 41<br />

valproic acid capsule, -syrup, 41<br />

valsartan, 42<br />

VALTREX, 11<br />

VALTURNA, 50<br />

VANCOCIN HCL, 9<br />

vancomycin, 9<br />

vancomycin 1 gm add-van vial, -1 gm vial, -<br />

10 gm vial, -5 gm vial, -500 mg a/v vial, -<br />

500 mg vial, -750 mg vial, 9<br />

VANCOMYCIN HCL 1G/200 ML BAG, 9<br />

VANCOMYCIN-D5W, 9<br />

vandazole, 98<br />

VANISHPOINT SYRINGE EMPTY<br />

DISPOSABLE, 82<br />

VANOS, 58<br />

VANTAS, 21<br />

VANTIN, 7<br />

VAQTA, 78<br />

varenicline tartrate, 40<br />

varicella vacc/pf, 78<br />

varicella virus vaccine live, 78<br />

VARIVAX VACCINE, 78<br />

VASERETIC, 50<br />

VASODILATOR ANTIHYPERTENSIVES, 52<br />

VASOTEC, 42<br />

VECTICAL, 55<br />

velaglucerase alfa, 69<br />

VELCADE, 21<br />

velivet, 96<br />

venlafaxine, 35, 36<br />

venlafaxine hcl, 36<br />

venlafaxine hcl er capsule sustained release<br />

24 hr, 36<br />

VENLAFAXINE HCL ER TAB SA, 36<br />

VENTOLIN HFA, 111<br />

VERAMYST, 63<br />

verapamil, 43, 44, 45<br />

verapamil 360 mg cap pellet, 44<br />

verapamil er, 44<br />

verapamil hcl capsule 24hr sustained release<br />

pellets, -er 120 mg capsule, -er 180 mg<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

capsule, -er 240 mg capsule, -tablet, -<br />

tablet sustained action, 45<br />

verapamil hcl injection, 45<br />

VERDESO, 58<br />

VEREGEN, 59<br />

VERELAN, 45<br />

VERELAN PM, 45<br />

veripred 20, 64<br />

VERSALON ALL PURPOSE SPONGE, 82<br />

verteporfin, 109<br />

VESANOID, 21<br />

VESICARE, 115<br />

VEXOL, 106<br />

VFEND, 8<br />

VFEND IV, 13<br />

VIBATIV, 9<br />

VIBRAMYCIN 50 MG CAPSULE, 16<br />

VIBRAMYCIN SUSPENSION, -SYRUP, -100<br />

MG CAPSULE, 16<br />

VIBRA-TABS, 16<br />

VICODIN, 30<br />

VICODIN ES, 30<br />

VICODIN HP, 30<br />

VICOPROFEN, 30<br />

VICTOZA 2-PAK, 65<br />

VICTOZA 3-PAK, 65<br />

VIDAZA, 21<br />

VIDEX, 5<br />

VIDEX EC, 5<br />

vigabatrin, 34<br />

VIGAMOX, 107<br />

VIMOVO, 85<br />

VIMPAT INJECTION, 34<br />

VIMPAT SOLUTION, -TABLET, 35<br />

vinacal, 102<br />

vinate az, 102<br />

vinate az extra, 102<br />

vinate c, 102<br />

vinate calcium, 102<br />

vinate care, 103<br />

vinate gt, 103<br />

vinate ic, 103<br />

vinate ii, 103<br />

vinate iii, 103<br />

vinate one, 103<br />

vinate pn care, 103<br />

vinate ultra, 103<br />

vinate-m, 103<br />

VIRACEPT, 5<br />

VIRAMUNE, 5<br />

VIRAZOLE, 11<br />

VIREAD, 5<br />

VIROPTIC, 108<br />

VISICOL, 72<br />

vis-phos n, 93<br />

visqid a-a, 17<br />

VISTARIL, 54<br />

VISTIDE, 11<br />

VISUDYNE, 109<br />

vitafol-ob, 103<br />

VITAFOL-OB+DHA, 103<br />

vitafol-pn, 103<br />

VITAMINS AND MINERALS AND RELATED<br />

PRODUCTS, 93<br />

vitanatal ob + dha, 103<br />

vitaphil, 103<br />

vitaphil + dha, 103<br />

vitaphil + dha 90, 103<br />

vitaphil aide, 103<br />

vitaspire, 103<br />

vitazol, 54<br />

VITRASERT, 109<br />

VIVACTIL, 38<br />

VIVAGLOBIN, 78<br />

VIVELLE, 97<br />

VIVELLE-DOT, 98<br />

VIVITROL, 37<br />

VOL-TAB RX, 103<br />

VOLTAREN DROPS, 109<br />

VOLTAREN GEL, 56<br />

VOLTAREN TABLET ENTERIC COATED, 85<br />

VOLTAREN-XR, 85<br />

VOLUVEN, 60<br />

VOPAC, 30<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

voriconazole, 8, 13<br />

vorinostat, 21<br />

VOSOL, 61<br />

VOSOL HC, 61<br />

VOSPIRE ER, 111<br />

VOTRIENT, 21<br />

VPRIV, 69<br />

VUSION, 12<br />

vynatal-fa, 103<br />

VYTORIN 10-10 MG TABLET, 47<br />

VYTORIN 10-20 MG TABLET, -10-40 MG<br />

TABLET, -10-80 MG TABLET, 47<br />

VYVANSE, 31<br />

warfarin sodium, 91<br />

WEBCOL, 82<br />

WELCHOL, 47<br />

WELLBUTRIN, 36<br />

WELLBUTRIN SR, 36<br />

WELLBUTRIN XL, 36<br />

WESTCORT, 58<br />

westhroid, 70<br />

WINRHO SDF, 78<br />

XALATAN, 105<br />

XENAZINE, 37<br />

XERAC AC, 59<br />

XIAFLEX, 60<br />

XIBROM, 109<br />

XIFAXAN 200 MG TABLET, 10<br />

XIFAXAN 550 MG TABLET, 10<br />

XODOL 10-300, 30<br />

XODOL 5-300, 30<br />

XODOL 7.5-300, 30<br />

XOLAIR, 114<br />

XOLEGEL, 12<br />

XOLOX, 29<br />

XOPENEX HFA, 111<br />

x-viate, 59<br />

XYLOCAINE 2% VIAL, 63<br />

XYLOCAINE 2% VIAL, -0.5% VIAL, -1%<br />

VIAL, 2<br />

XYLOCAINE IV, 2<br />

XYLOCAINE IV FOR CARDIAC, 2<br />

XYLOCAINE JEL, -SOLUTION NON-ORAL, 2<br />

XYLOCAINE WITH EPINEPHRINE, 2<br />

XYLOCAINE-MPF, 2<br />

XYLOCAINE-MPF WITH EPINEPHRINE, 2<br />

XYREM, 37<br />

XYZAL SOLUTION, 111<br />

XYZAL TABLET, 111<br />

YASMIN 28, 96<br />

YAZ, 96<br />

yellow fever vaccine, 78<br />

YF-VAX, 78<br />

zafirlukast, 111<br />

zaleplon, 38<br />

zaleplon 10 mg capsule, 38<br />

zaleplon 5 mg capsule, 38<br />

zamicet, 30<br />

ZANAFLEX, 83<br />

zanamivir, 10<br />

ZANTAC 25, 71<br />

ZANTAC INJECTION, 71<br />

ZANTAC SYRUP, -TABLET, 71<br />

ZARONTIN, 40<br />

ZAROXOLYN, 52<br />

zatean-pn, 103<br />

zatean-pn dha, 103<br />

zatean-pn plus, 103<br />

ZAVESCA, 69<br />

ZAZOLE 0.8% VAGINAL CREAM, 18<br />

ZAZOLE 80 MG VAGINAL SUPP, 18<br />

ZAZOLE VAGINAL 0.4% CREAM, 18<br />

ZEBETA, 43<br />

ZEGERID 20 MG CAPSULE, 74<br />

ZEGERID 20 MG PACKET, 74<br />

ZEGERID 40 MG CAPSULE, 74<br />

ZEGERID 40 MG PACKET, 74<br />

ZELAPAR, 37<br />

ZEMAIRA, 114<br />

zema-pak, 65<br />

ZEMPLAR CAPSULE, 93<br />

ZEMPLAR INJECTION, 93<br />

ZENAPAX, 79<br />

zenchent, 96<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY<br />

Open Comprehensive Formulary<br />

ZENPEP, 73<br />

ZERIT, 5<br />

ZERLOR, 30<br />

ZESTORETIC, 50<br />

ZESTRIL, 42<br />

ZETIA, 47<br />

ZIAC, 50<br />

ZIAGEN, 5<br />

ZIANA, 54<br />

ziconotide acetate, 22<br />

zidovudine, 4, 5<br />

zidovudine/lamivudine/abacavir, 5<br />

zileuton, 111<br />

ZINACEF, 7<br />

ZINACEF IN ISO-OSMOTIC WATER, 7<br />

ZINACEF ISO-OSMOTIC DEXTROSE, 7<br />

ziprasidone, 24<br />

ZIPSOR, 85<br />

ZIRGAN, 109<br />

ZITHRANOL-RR, 55<br />

ZITHROMAX 100 MG/5 ML SUSP, 11<br />

ZITHROMAX 200 MG/5 ML SUSP, 11<br />

ZITHROMAX 250 MG TABLET, -250 MG Z-<br />

PAK TABLET, 12<br />

ZITHROMAX 500 MG TABLET, 12<br />

ZITHROMAX INJECTION, 12<br />

ZITHROMAX PACKET, -600 MG TABLET, 12<br />

ZITHROMAX TRI-PAK, 12<br />

ZMAX, 12<br />

ZMAX ADULT-PEDIATRIC, 12<br />

ZMAX PEDIATRIC, 12<br />

ZOCOR, 47<br />

ZOFRAN INJECTION, 27<br />

ZOFRAN ODT, 27<br />

ZOFRAN SOLUTION, 27<br />

ZOFRAN TABLET, 27<br />

ZOLADEX, 21<br />

zoledronic acid, 69<br />

ZOLINZA, 21<br />

zolmitriptan, 33<br />

ZOLOFT 100 MG TABLET, -50 MG TABLET,<br />

40<br />

ZOLOFT 25 MG TABLET, 40<br />

ZOLOFT SOLUTION, 40<br />

zolpidem, 38<br />

zolpidem tartrate, 38<br />

ZOMETA, 69<br />

ZOMIG SPRAY NON-AEROSOL, 33<br />

ZOMIG TABLET, 33<br />

ZOMIG ZMT, 33<br />

ZONALON, 59<br />

ZONEGRAN, 35<br />

zonisamide, 35<br />

ZORBTIVE, 75<br />

ZORPRIN, 85<br />

ZORTRESS 0.25 MG TABLET, 21<br />

ZORTRESS 0.5 MG TABLET, -0.75 MG<br />

TABLET, 21<br />

ZOSTAVAX, 78<br />

ZOSYN, 14<br />

zovia 1-35e, 96<br />

zovia 1-50e, 96<br />

ZOVIRAX CAPSULE, -SUSPENSION ORAL, -<br />

TABLET, 11<br />

ZOVIRAX CREAM, -OINTMENT, 11<br />

ZUPLENZ, 27<br />

ZYBAN, 40<br />

ZYCLARA, 59<br />

ZYDONE, 30<br />

ZYFLO, 111<br />

ZYFLO CR, 111<br />

ZYLET, 106<br />

ZYLOPRIM, 83<br />

ZYMAR, 107<br />

ZYMAXID, 107<br />

ZYPREXA INJECTION, 25<br />

ZYPREXA RELPREVV, 25<br />

ZYPREXA TABLET, 25<br />

ZYPREXA ZYDIS, 25<br />

ZYVOX INJECTION, 10<br />

ZYVOX SUSPENSION RECONSTITUTED<br />

ORAL, -TABLET, 10<br />

S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved


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All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,<br />

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