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2019 Express Scripts National Preferred Formulary

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2019 Express Scripts National Preferred Formulary The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription 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. 2019 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by National Preferred Formulary all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card. KEY BD AUTOSHIELD clonidine enalapril GENOTROPIN [INJ] [INJ] - Injectable Drug DUO NEEDLES clopidogrel ENBREL [INJ] GENVOYA Brand-name drugs are listed BD ULTRAFINE clotrimazole/betamethasone enoxaparin [INJ] GILENYA in CAPITAL letters. INSULIN SYRINGES dipropionate ENSTILAR GILOTRIF Generic drugs are listed BD ULTRAFINE PEN NEEDLES COLCRYS ENTRESTO glimepiride in lower case letters. BELBUCA COMBIGAN EPCLUSA glipizide benazepril COMBIPATCH EPIDIOLEX glipizide ext-release A benzonatate COMBIVENT RESPIMAT EPIDUO FORTE GLUCAGEN [INJ] BEPREVE COPAXONE 40 MG [INJ] epinephrine autoinjector GLUCAGON [INJ] ABILIFY MAINTENA [INJ] BETASERON [INJ] CORLANOR (by Mylan) [INJ] glyburide ABSORICA BETHKIS COSENTYX [INJ] EPIPEN, EPIPEN JR [INJ] GLYXAMBI ACANYA BEVESPI AEROSPHERE CREON ergocalciferol GONAL-F, GONAL-F RFF, acetaminophen/codeine BIKTARVY CRINONE ERIVEDGE GONAL-F RFF ACTEMRA [INJ] bisoprolol/hctz cyanocobalamin [INJ] ERLEADA REDI-JECT [INJ] acyclovir blisovi fe cyclobenzaprine erythromycin eye ointment GRALISE ADEMPAS BOSULIF ESBRIET GRANIX [INJ] ADVAIR DISKUS BREO ELLIPTA D escitalopram GRASTEK ADVAIR HFA BRILINTA esomeprazole magnesium guanfacine ext-release AFSTYLA [INJ] budesonide nebulization DALIRESP delayed-release AIMOVIG [INJ] suspension DARAPRIM estradiol H AKYNZEO bupropion DAYTRANA estradiol patches albuterol nebulization bupropion ext-release DESCOVY estradiol/norethindrone HARVONI solution buspirone desloratadine acetate HELIXATE FS [INJ] alendronate butalbital/acetaminophen/ desvenlafaxine succinate ESTRING HUMALOG [INJ] allopurinol caffeine ext-release eszopiclone HUMIRA [INJ] ALPHAGAN P 0.1% BYDUREON [INJ] dexamethasone EUFLEXXA [INJ] HUMULIN [INJ] alprazolam BYETTA [INJ] DEXCOM RECEIVER, SENSOR, ezetimibe hydralazine ALREX BYSTOLIC TRANSMITTER ezetimibe/simvastatin hydrochlorothiazide amiodarone BYVALSON dexmethylphenidate hydrocodone/acetaminophen AMITIZA ext-release F hydrocodone/ amitriptyline C dextroamphetamine/ chlorpheniramine polistirex amlodipine amphetamine famotidine ext-release amlodipine/benazepril CABOMETYX dextroamphetamine/ FARXIGA hydrocortisone topical amlodipine/valsartan CANASA amphetamine ext-release fenofibrate hydromorphone amoxicillin CARAC diazepam fenofibrate micronized hydroxychloroquine amoxicillin/potassium CARAFATE SUSPENSION diclofenac sodium fenofibric acid hydroxyzine hcl clavulanate carbidopa/levodopa delayed-release delayed-release hydroxyzine pamoate anastrozole carvedilol dicyclomine fentanyl patches HYSINGLA ER ANDRODERM cefdinir digoxin FETZIMA ANORO ELLIPTA cefuroxime axetil diltiazem ext-release FINACEA FOAM I APRISO celecoxib diphenoxylate/atropine finasteride ARCAPTA NEOHALER cephalexin divalproex delayed-release FIRAZYR [INJ] ibandronate ARIKAYCE CERDELGA divalproex ext-release FLECTOR IBRANCE aripiprazole CEREZYME [INJ] DIVIGEL FLOVENT DISKUS ibuprofen ARISTADA [INJ] CETROTIDE [INJ] donepezil FLOVENT HFA ILEVRO ARMONAIR RESPICLICK CHANTIX doxazosin fluconazole INCRUSE ELLIPTA ARNUITY ELLIPTA chlorhexidine gluconate doxycycline hyclate fluocinonide indomethacin ASMANEX HFA chlorthalidone doxycycline monohydrate fluoxetine INLYTA ASMANEX TWISTHALER CIMDUO DUAVEE fluticasone nasal spray INVOKAMET atenolol CIPRODEX DULERA folic acid INVOKAMET XR atenolol/chlorthalidone ciprofloxacin duloxetine delayed-release FORTEO [INJ] INVOKANA atomoxetine citalopram DUPIXENT [INJ] FRAGMIN [INJ] irbesartan atorvastatin clarithromycin DYMISTA FREESTYLE LIBRE READER, IRESSA AVONEX [INJ] CLENPIQ SENSOR isosorbide mononitrate AZASITE clindamycin hcl E furosemide ext-release azelastine nasal spray clindamycin phosphate FYCOMPA azithromycin topical EDARBI J clindamycin phosphate/ EDARBYCLOR G B benzoyl peroxide ELIDEL JANUMET, JANUMET XR clobetasol propionate ELIQUIS gabapentin JANUVIA baclofen clomiphene citrate EMGALITY [INJ] GELNIQUE JARDIANCE BARACLUDE SOLUTION clonazepam EMVERM gemfibrozil JENTADUETO (continued) Go to express-scripts.com/2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com . © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 1 PRMT22157-19 (01/01/19) JENTADUETO XR montelukast P rosuvastatin TRESIBA [INJ] JIVI [INJ] morphine sulfate ext-release RUCONEST [INJ] triamcinolone topical junel MOVANTIK pantoprazole delayed-release triamterene/hctz junel fe MOXEZA paroxetine hcl S tri-lo-marzia moxifloxacin eye solution PAZEO trinessa K mupirocin penicillin v potassium SANCUSO TRIPTODUR [INJ] MUSE PENTASA SAVELLA tri-sprintec ketoconazole topical MYDAYIS PERFOROMIST SEGLUROMET TRULANCE ketorolac MYRBETRIQ PHOSLYRA SEREVENT DISKUS TRULICITY [INJ] KITABIS PAK PICATO sertraline TUDORZA PRESSAIR KOGENATE FS [INJ] N pioglitazone sildenafil TYMLOS [INJ] KOVALTRY [INJ] PLEGRIDY [INJ] SIMPONI 100 MG (for KYLEENA nabumetone polymyxin/trimethoprim ulcerative colitis only) [INJ] U NAMZARIC eye solution simvastatin L naproxen, naproxen sodium POMALYST SKYLA UCERIS FOAM NARCAN NASAL SPRAY potassium chloride SOLIQUA [INJ] ULORIC labetalol NASCOBAL ext-release SOLODYN UPTRAVI lamotrigine neomycin/polymyxin/ PRALUENT [INJ] SOMATULINE DEPOT [INJ] lansoprazole delayed-release hydrocortisone ear solution pramipexole SOOLANTRA V LANTUS [INJ] NEXIUM PACKETS pravastatin SPIRIVA RESPIMAT latanoprost eye solution niacin ext-release prednisolone acetate spironolactone valacyclovir LATUDA nifedipine ext-release eye suspension sprintec valsartan LETAIRIS nitrofurantoin macrocrystal prednisolone sodium SPRYCEL valsartan/hctz LEVEMIR [INJ] NITYR phosphate STEGLATRO VARUBI levetiracetam NORDITROPIN [INJ] prednisone STELARA SC [INJ] VASCEPA levocetirizine nortriptyline PREMARIN CREAM STIOLTO RESPIMAT VELPHORO levofloxacin NOVAREL [INJ] PREMARIN TABLETS STRENSIQ [INJ] VELTASSA levothyroxine sodium NOVOEIGHT [INJ] PREMPHASE STRIVERDI RESPIMAT venlafaxine lidocaine patches NOVOFINE AUTOSHIELD PREMPRO SUBOXONE SL FILM venlafaxine ext-release LINZESS NEEDLES PREPOPIK sulfamethoxazole/ VENTOLIN HFA liothyronine NOVOFINE NEEDLES PROAIR HFA trimethoprim verapamil ext-release LIPOFEN NOVOTWIST NEEDLES PROAIR RESPICLICK sumatriptan VESICARE lisinopril NUCALA [INJ] PROCRIT [INJ] SUPREP VIBERZI lisinopril/hctz NUCYNTA, NUCYNTA ER progesterone micronized SUTENT VIIBRYD LIVALO NUEDEXTA PROLASTIN C [INJ] SYMBICORT VIMPAT LO LOESTRIN FE NUVARING PROLENSA SYMFI VIOKACE LOKELMA NUWIQ [INJ] promethazine SYMFI LO VOSEVI lorazepam nystatin promethazine/ SYMLINPEN [INJ] VYVANSE losartan nystatin topical dextromethorphan SYMPROIC losartan/hctz propranolol SYNJARDY, SYNJARDY XR W LOTEMAX O propranolol ext-release lovastatin PULMICORT FLEXHALER T warfarin LUMIGAN ODACTRA PYLERA LYRICA OFEV TACLONEX SUSPENSION X ofloxacin Q tacrolimus topical M olanzapine tadalafil XALKORI olmesartan QBREXZA tamoxifen XARELTO meclizine olmesartan/hctz QNASL tamsulosin ext-release XELJANZ, XELJANZ XR medroxyprogesterone olopatadine eye solution QUDEXY XR TARCEVA XIFAXAN meloxicam omega-3 acid ethyl esters quetiapine TASIGNA XIGDUO XR MESTINON SYRUP omeprazole delayed-release QUILLICHEW ER TAYTULLA XIIDRA metaxalone ondansetron QUILLIVANT XR TAZORAC GEL XOFLUZA metformin ondansetron orally quinapril TAZORAC 0.05% CREAM XOLAIR [INJ] metformin ext-release disintegrating tablets QVAR TECFIDERA XTANDI methimazole ONETOUCH KITS/METERS; QVAR REDIHALER TEKTURNA, TEKTURNA HCT XULTOPHY [INJ] methocarbamol ULTRA 2, ULTRAMINI, terazosin methotrexate VERIO, VERIO FLEX, R terconazole vaginal Y methylphenidate VERIO IQ, VERIO SYNC testosterone cypionate [INJ] methylphenidate ext-release ONETOUCH TEST STRIPS; rabeprazole delayed-release THALOMID YONSA methylprednisolone ULTRA, VERIO RAGWITEK timolol maleate eye solution yuvafem metoclopramide ONEXTON raloxifene tizanidine metoprolol succinate OPSUMIT ramipril TOBI PODHALER Z ext-release ORACEA RANEXA TOBRADEX OINTMENT metoprolol tartrate ORFADIN ranitidine TOBRADEX ST ZARXIO [INJ] metronidazole ORTHOVISC [INJ] RAPAFLO tobramycin eye solution ZENPEP metronidazole topical oseltamivir RASUVO [INJ] tobramycin/dexamethasone ZEPATIER metronidazole vaginal OTEZLA REBIF [INJ] eye suspension zolpidem microgestin fe OTOVEL RECTIV topiramate zolpidem ext-release MINIVELLE OTREXUP [INJ] RELISTOR [INJ] TOUJEO [INJ] ZOMIG NASAL minocycline OVIDREL [INJ] REMICADE [INJ] TOVIAZ ZONTIVITY MIRENA oxcarbazepine RESTASIS TRACLEER ZOVIRAX CREAM mirtazapine oxybutynin ext-release RETACRIT [INJ] TRADJENTA ZTLIDO MIRVASO oxycodone REVLIMID tramadol ZUBSOLV MITIGARE oxycodone/acetaminophen RHOPRESSA TRAVATAN Z ZYLET moderiba
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