Express Scripts Generics Preferred drug list

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan.The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.2012 Express ScriptsNational Preferred FormularyPLEASE NOTE: The symbol * next to a drug signifies that it is subject to nonformulary statuswhen a generic is available throughout the year. Not all the drugs listed are covered by allprescription-drug benefit programs; check your benefit materials for the specific drugscovered and the copayments for your prescription-drug benefit program. For specificquestions about your coverage, please call the phone number printed on your ID card.AABILIFY (EXCLUDINGDISCMELT & SOLUTION)ACANYA GEL, PUMPACCU-CHEK KITS;ACTIVE, ADVANTAGE,AVIVA PLUS, COMPACTPLUS, NANO SMARTVIEWACCU-CHEK LANCETS;FASTCLIX, MULTICLIX,SOFT TOUCH, SOFTCLIXACCU-CHEK TEST STRIPS;ACTIVE, AVIVA PLUS,COMFORT CURVE,COMPACT DRUM,SMARTVIEWacetaminophen/codeineACTONELACTOPLUS MET*, XRACTOS*ACUVAILacycloviradapaleneADCIRCAADVAIR DISKUS, HFAADVICORAGGRENOXalbuterolalendronate sodiumalfuzosin erallopurinolALPHAGAN P 0.1%*ALTABAXamiodaroneAMITIZAamitriptylineamlodipine, /benazeprilamox tr/potassiumclavulanateamoxicillinamphetamine saltcombo, erAMPYRAAMTURNIDEanastrozoleANDRODERMANDROGELantipyrine/benzocaineapriARANESP [INJ]arbinoxaARICEPT 23 MGASACOL, HDASTEPROATELVIAatenolol, /chlorthalidoneatorvastatinAVELOXavianeAVODARTAZASITEazathioprineazelastineAZILECTazithromycinAZOR© 2012 Express Scripts, Inc.All Rights ReservedBbaclofenbalsalazide disodiumbenazepril, /hctzBENICAR, HCTBENZACLIN PUMP(EXCLUDING CAREKIT)benzonatateBETASERON [INJ]BONIVABRILINTAbrimonidine tartrateBROMDAYbudesonide neb suspbupropion, 12 hr, 24 hrbutalbital/apap/caffeineBUTRANSBYETTA [INJ]BYSTOLICCcalcipotrieneCANASAcarbamazepine, ercarbidopa/levodopa, ercarvedilolcefadroxilcefdinircefprozilcefuroximeCELEBREXcephalexinCETROTIDE [INJ]cholestyraminechorionicgonadotropin [INJ]CIALISciclopiroxCIPRODEXciprofloxacin, ercitalopramclarithromycin, erCLIMARA PROclindamycin hclclindamycin phosphateclobetasol propionateclomiphene citrateclonazepamclonidineclotrimazole/betamethasonedipropionateCOLCRYSCOMBIGANCOMBIPATCHCOPAXONE [INJ]COREG CR*CREONCRESTORCRINONEcrysellecyanocobalamin [INJ]cyclobenzaprineCYMBALTADDALIRESPdesonideDETROL, LA*dexamethasonedexmethylphenidatediclofenac sodiumdicyclomine hclDIFFERIN 0.3% GEL,0.1% LOTIONdigoxindiltiazem, 12 hr, 24 hrDIOVAN, HCT*divalproex sodium, erdonepezil, odtdorzolamide, /timololDOVONEX CRMdoxazosindoxepinDUAC*DUETACTDULERAEEFFIENTeliphosEMBEDAENABLEXENBREL [INJ]ENDOMETRINenoxaparin [INJ]EPIDUOEPIPEN, JR [INJ]ergocalciferolerythromycinerythromycin/benzoyl perox.escitalopramestradiol patches, tabsestradiol/norethindroneacetateetodolacEUFLEXXA [INJ]EURAXEVAMISTEXELON PATCHESEXFORGE, HCTFfamciclovirfamotidinefelodipine erfenofibratefentanyl citrateFINACEA, PLUSfinasterideFLECTORFLOVENT DISKUS, HFAfluconazolefluocinonidefluoxetine, drfluticasone nasal sprayfolic acidFORADILFORTEO [INJ]fosinopril, /hctzFOSRENOLTHIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.You can get more information and updates to this document at our website at www.express-scripts.com.Ggabapentingalantamine, erGELNIQUEgemfibrozilGENOTROPIN [INJ]glimepirideglipizide, erGLUCAGEN [INJ]glyburide, micronizedglyburide/metforminGONAL-F, RFF [INJ]HHALFLYTELY-BISACODYL*HUMALOG [INJ]HUMIRA [INJ]HUMULIN [INJ]hydralazinehydrochlorothiazidehydrocodone/acetaminophenhydrocodone/ibuprofenhydrocortisonehydromorphonehydroxychloroquineIibuprofenimiquimodINCIVEKindomethacinipratropium, /albuterolisosorbide mononitrate, erisotretinoinJJALYNJANUMET, XRJANUVIAJENTADUETOJUVISYNCKketoconazoleketorolacLlabetalol hclLAMICTAL ODT*LAMICTAL XR*lamotriginelansoprazole, odtLANTUS, SOLOSTAR [INJ]latanoprostLETAIRISLEVEMIR, FLEXPEN [INJ]levetiracetamlevofloxacinlevothyroxine sodiumlevoxylLIALDALIDODERMliothyroninelisinopril, /hctzlithium carbonateLOESTRIN 24 FE,LO LOESTRIN FElosartan, /hctzLOTEMAX SOLNlovastatinLOVAZALUMIGANLUNESTALYRICALYSTEDAMMAKENA [INJ]MAXALT, MLTmeclizine hclmedroxyprogesteroneacetatemeloxicamMENESTmetaxalonemetformin, ermethocarbamolmethotrexatemethylphenidatemethylprednisolonemetoclopramide hclmetoprolol, /hctzMETROGELmetronidazoleMIGRANALMIRAPEX ERmirtazapine, odtmometasonemorphine sulfate, erMOVIPREPMOXEZAmupirocinMUSEmycophenolate mofetilNnabumetonenadololNAMENDAnaproxen, naproxen sodiumnaratriptanNASCOBALNASONEXnateglinideneconneomycin/polymyxin/dexamethasoneneomycin/polymyxin/hcNEVANACNEXIUMNIASPANnifedipine ernisoldipine ernitrofurantoin macrocrystalnitroglycerin patchesnortriptylineNOVOFINENOVOLIN [INJ]NOVOLOG [INJ]NUCYNTA (EXCLUDINGNUCYNTA ER)NUEDEXTANUTROPIN, AQ,AQ NUSPIN [INJ]NUVARINGnystatin, /triamcinoloneOocellaofloxacinolanzapine, odtomeprazoleondansetron, odtONETOUCH KITS/METERS;BASIC, ULTRA 2,ULTRAMINI,ULTRASMARTONETOUCH TEST STRIPS;FASTTAKE, ONETOUCH,SURESTEP, ULTRAOPANA ER*ORENCIA [INJ]ORTHOVISC [INJ]oxcarbazepineoxybutynin, eroxycodone, /acetaminophenOXYCONTINPpantoprazoleparoxetinePATADAY*PATANOL*peg 3350/electrolytePEGASYS, PROCLICK [INJ]PEG-INTRON, REDIPEN [INJ]penicillin v potassiumPENTASAPERFOROMISTphenytoin sodium,extendedPLAVIX*polymyxin/trimethoprimpotassium chloride, erPRADAXApramipexolePRANDIMETPRANDIN*pravastatinPRECISION XTRAprednisoloneprednisolone acetateprednisolone sodiumphosphateprednisonePREMARIN TABSPREMPHASE(continued)#393 NP-APRMT22157-12 (06/01/12)

PREMPROPRISTIQPROAIR HFAprochlorperazinePROCRIT [INJ]PRODIGY INSULIN SYR,PEN NEEDLESpromethazine/dextromethorphanPROMETRIUMpropranolol, /hctzPROTOPICPULMICORT FLEXHALERPULMICORT RESPULES1 MG/2 ML*PYLERAQquetiapinequinapril, /hctzQVARRramiprilRANEXAranitidineRAPAFLOREBIF [INJ]RENVELAreprexainRESTASISRETIN-A MICRO GEL, PUMPREVATIO*ribavirinRIOMETrisperidone, odtrivastigmine capsropiniroleSSANCUSOSAVELLASEREVENT DISKUSSEROQUEL XRsertralineSIMCORsimvastatinSINGULAIRsodium fluoridesodium sulfacetamide/sulfurSOLARAZESOLODYN 55 MG, 65 MG,80 MG, 105 MG 115 MGSOMATULINE DEPOT [INJ]sotalolSPIRIVAsprintecSTELARA [INJ]STRATTERA*SUBOXONE*sucralfatesulfamethoxazole/trimethoprimsulfasalazinesumatriptan tab, injSUMAVEL DOSEPRO [INJ]SYMBICORTSYMBYAX*SYMLIN, SYMLINPEN [INJ]TTACLONEXTAMIFLUtamoxifentamsulosinTARKATAZORAC*TEKAMLOTEKTURNA, HCTtemazepamterazosintimolol maleatetizanidinetobramycin/dexamethasonesusptobramycin sulfatetopiramateTOVIAZTRACLEERTRADJENTATRAVATAN Ztrazodone hcltretinoinTREXIMETtriamcinolone acetonidetriamterene/hctzTRIBENZORTRICOR*TRILIPIXtrinessatri-previfemtri-sprintectrospiumUULORICVVAGIFEMvalacyclovirVALTURNAvenlafaxine, erVENTOLIN HFAVERAMYSTverapamil, erveripredVESICAREVIAGRA*VICTOZA [INJ]VICTRELISVIGAMOXVIIBRYDVIMOVOVIMPATVIVELLE-DOTVOLTAREN GEL*VYVANSEWwarfarinWELCHOLXXARELTOXERESEXIFAXANXOPENEX 3 ML NEBS*ZzamicetzarahZETIAziprasidonezolpidem, erZOMIG, ZMTZYCLARAZYLETZYMAXIDNonformulary Formulary Alternative Nonformulary Formulary AlternativeACIPHEXALAMASTALOCRILALOMIDEALORAALTOPREVALVESCOANTARAAPIDRAAPRISOASMANEXATACANDATACAND HCTAVALIDEAVAPROAXERTAXIRONAZOPTBAYER ASCENSIA,BREEZE, CONTOURBECONASE AQBEPREVEBESIVANCEBEYAZBRAVELLEBROVANACARDURA XLCENESTINCETRAXALCIPRO HCDEXILANTDIVIGELEDARBIEDLUARELESTRINEMADINEENJUVIAEPOGENESTRASORBESTROGELFACTIVEFANAPTFEMTRACEFENOGLIDEFOLLISTIM AQFORTESTAFREESTYLEFROVAGEODONHUMATROPEIMITREX NASALINVEGAExamples of Nonformulary Medications With Selected Formulary AlternativesThe following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary.Column 1 lists examples of nonformulary medications.Column 2 lists some alternatives that can be prescribed.Thank you for your compliance.lansoprazole, omeprazole, Nexiumazelastine, Pataday*, Patanol*azelastine, Pataday*, Patanol*azelastine, Pataday*, Patanol*generic patches, Vivelle-Dotatorvastatin, lovastatin, simvastatin,CrestorFlovent Diskus/HFA, Pulmicort Flexhaler,Qvarfenofibrate, Tricor*, TrilipixHumalog, Novologbalsalazide, Asacol/HD, Lialda, PentasaFlovent Diskus/HFA, Pulmicort Flexhaler,Qvarlosartan, Benicar, Diovan*losartan/hctz, Benicar HCT, Diovan HCT*losartan/hctz, Benicar HCT, Diovan HCT*losartan, Benicar, Diovan*sumatriptan tab, Maxalt/MLT,Zomig/ZMTAndroderm, Androgelbrimonidine tartrate, dorzolamide,Alphagan P 0.1%*, CombiganAccu-Chek, OneTouchfluticasone, Nasonex, Veramystazelastine, Pataday*, Patanol*ciprofloxacin, levofloxacin, Moxeza,Vigamox, Zymaxidgeneric oral contraceptives,Loestrin 24 Fe/Lo Loestrin Fe, NuvaringGonal-F/RFFPerforomistalfuzosin er, tamsulosin, Rapafloestradiol, Menest, Premarin tabsCiprodexCiprodexlansoprazole, omeprazole, Nexiumgeneric patches, Evamistlosartan, Benicar, Diovan*zolpidem/er, Lunestageneric patches, Evamistazelastine, Pataday*, Patanol*estradiol, Menest, Premarin tabsAranesp, Procritgeneric patches, Evamistgeneric patches, Evamistciprofloxacin/er, levofloxacin, ofloxacin,Aveloxolanzapine, quetiapine, risperidone,ziprasidone, Abilify (regular tabs),Seroquel XRestradiol, Menest, Premarin tabsfenofibrate, Tricor*, TrilipixGonal-F/RFFAndroderm, AndrogelAccu-Chek, OneTouchsumatriptan tab, Maxalt/MLT,Zomig/ZMTziprasidoneGenotropin, Nutropin/AQ/AQ NuspinZomig Nasalolanzapine, quetiapine, risperidone,ziprasidone, Abilify (regular tabs),Seroquel XRIQUIXKOMBIGLYZE XRLATUDALESCOL, XLLEVAQUINLEVITRALEXAPROLIPITORLIPOFENLIVALOMAXAIR AUTOHALERMENOSTARMICARDISMICARDIS HCTNATAZIANORDITROPINNOROXINOMNARISOMNITROPEONGLYZAORTHO EVRA, ORTHOTRI-CYCLEN LOOXYTROLPATANASEPENNSAIDPRECISIONPCX, Q-I-DPROQUIN XRPROVENTIL HFARELPAXRHINOCORT AQUASAFYRALSAIZENSANCTURA XRSAPHRISSULARSUMATRIPTAN NASALSYNTHROIDTESTIMTEVETENTEVETEN HCTTEV-TROPINTRIGLIDETWYNSTAVYTORINXALATANXOPENEX HFAZYPREXA,ZYDIS (ORAL)ciprofloxacin, levofloxacin, Moxeza,Vigamox, Zymaxidmetformin + Januvia or Tradjenta,Janumet/XR, Jentaduetoolanzapine, quetiapine, risperidone,ziprasidone, Abilify (regular tabs),Seroquel XRatorvastatin, lovastatin, simvastatin,CrestorlevofloxacinCialis, Viagra*escitalopramatorvastatinfenofibrate, Tricor*, Trilipixatorvastatin, lovastatin, simvastatin,CrestorProAir HFA, Ventolin HFAgeneric patches, Vivelle-Dotlosartan, Benicar, Diovan*losartan/hctz, Benicar HCT, Diovan HCT*generic oral contraceptives,Loestrin 24 Fe/Lo Loestrin Fe, NuvaringGenotropin, Nutropin/AQ/AQ Nuspinciprofloxacin/er, levofloxacin, ofloxacin,Aveloxfluticasone, Nasonex, VeramystGenotropin, Nutropin/AQ/AQ NuspinJanuvia, Tradjentageneric oral contraceptives,Loestrin 24 Fe/Lo Loestrin Fe, Nuvaringoxybutynin er, trospium, Gelniqueazelastine, AsteproFlector, Voltaren Gel*Accu-Chek, OneTouchciprofloxacin/er, levofloxacin, ofloxacin,AveloxProAir HFA, Ventolin HFAsumatriptan tab, Maxalt/MLT,Zomig/ZMTfluticasone, Nasonex, Veramystgeneric oral contraceptives,Loestrin 24 Fe/Lo Loestrin Fe, NuvaringGenotropin, Nutropin/AQ/AQ Nuspinoxybutynin er, trospium, Detrol/LA*,Enablex, Toviaz, Vesicareolanzapine, quetiapine, risperidone,ziprasidone, Abilify (regular tabs),Seroquel XRnisoldipine erZomig Nasallevothyroxine sodium, levoxylAndroderm, Androgellosartan, Benicar, Diovan*losartan/hctz, Benicar HCT, Diovan HCT*Genotropin, Nutropin/AQ/AQ Nuspinfenofibrate, Tricor*, TrilipixAzor, Exforge/HCT, Tribenzorsimvastatin or Crestor + ZetialatanoprostProAir HFA, Ventolin HFAolanzapine/odtKEYThe symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, althoughthey may look different in color or shape. They have been FDA-approved under strict standards.For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.Brand-name drugs are listed in CAPITAL letters.Generic drugs are listed in lower case letters.THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.You can get more information and updates to this document at our website at www.express-scripts.com.© 2012 Express Scripts, Inc.All Rights Reserved#393 NP-APRMT22157-12 (06/01/12)