Prmtpdla-14.130904

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.
PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version
2014 Express Scripts
becomes available during the year. Not all the drugs listed are covered by all
prescription-drug benefit programs; check your benefit materials for the specific drugs
Preferred Drug List
covered and the copayments for your prescription-drug benefit program. For specific
questions about your coverage, please call the phone number printed on your ID card.
A
D
J
K
butalbital/acetaminophen/ DIFFERIN 0.3% GEL, L
G
C
N
E
H
B
I
M
O
F
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2014 Express Scripts Holding Company
PRMTPDLA-14
All Rights Reserved
R
Excluded Medications With Covered Preferred Alternatives
The following is a list of excluded brand-name medications with covered preferred alternatives that are on the formulary. Column 1 lists excluded medications. Column 2 lists covered preferred alternatives that can be prescribed.
Excluded Medications
Covered Preferred Alternative(s)
morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl U
S
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, P
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, V
morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, 80 MG, 105 MG, 115 MG venlafaxine ext-release morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl T
W
X
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, TEKTURNA, TEKTURNA HCT Z
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl latanoprost, travoprost, Lumigan, Travatan Z Q
The 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, although they 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.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2014 Express Scripts Holding Company
PRMTPDLA-14
All Rights Reserved
2014 Preferred Drug List Exclusions
As of Jan. 1, 2014, the excluded medications shown below are not covered on the Express Scripts drug list.* In most cases, if you fill a prescription for one of these drugs after Jan. 1, you will pay the full retail price. Take action to avoid paying full price.
If you are currently using one of the excluded medications, please ask your doctor to consider writing a new prescription for one of the following safe and effective covered alternatives.
Drug Class
Excluded Medications
Covered Alternatives
ANTINEOPLASTIC/
IMMUNOSUPPRESSANT
Biologics – Injectable Tumor Necrosis
Factor Antagonists and Other Drugs for Inflammatory Conditions AUTONOMIC & CENTRAL
NERVOUS SYSTEM
CARDIOVASCULAR
Edarbi/Edarbyclor, Micardis/Micardis HCT, DIABETES
Bayer (Breeze, Contour), Nipro (TRUEtrack, EAR/NOSE
ENDOCRINE (OTHER)
Androgen Drugs
*These changes apply to most Express Scripts national drug lists; does not apply to Medicare plans.
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Drug Class
Excluded Medications
Covered Alternatives
IMMUNOLOGICAL
OBSTETRICAL & GYNECOLOGICAL
OPHTHALMIC
RESPIRATORY
UROLOGICAL
Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to Express-Scripts.com/covered to access cost-savings tools that provide pricing and coverage information
for specific medications. Other prescription benefit considerations may apply.
Excluded Medications/Products at a Glance
If you have any questions, please call the number on your member ID card. Express Scripts manages your prescription benefit for your employer, plan sponsor or health plan.
2013 Express Scripts Holding Company. All Rights Reserved. Express Scripts and “E” Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. EME19640 DL44109Q

Source: https://consolidatedhealthplan.com/files/pdf/2014-ESI-Preferred-Drug-List%20w.%20Exc%20(web).pdf