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2020 National Preferred Formulary List for BJC Healthcare

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2020 National Preferred Formulary List for BJC Healthcare 2020 Express Scripts National Preferred Formulary List For BJC HealthCare The 2020 National Preferred Formulary drug list for BJC HealthCare is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. 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 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 For the member: FDA-approved generic medications meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example: ibuprofen A ADDAMEL N [INJ] alprazolam orally disintegrating tablets ampicillin adefovir ALPROLIX [INJ] [SP] ampicillin sodium [INJ] abacavir [SP] ADEMPAS [SP] alprostadil [INJ] ampicillin sodium/sulbactam [INJ] abacavir/lamivudine [SP] adenosine [INJ] ALREX AMYTAL [INJ] abacavir/lamivudine/zidovudine [SP] ADVAIR HFA altavera AMZEEQ ABELCET [INJ] ADVATE [INJ] [SP] ALUNBRIG [SP] anagrelide ABILIFY MAINTENA [INJ] ADYNOVATE [INJ] [SP] alyacen anastrozole abiraterone acetate [SP] AFINITOR 10 MG TABLETS [SP] amabelz ANDRODERM ABRAXANE [INJ] [SP] AFINITOR DISPERZ [SP] amantadine ANORO ELLIPTA acamprosate delayed-release afirmelle AMBISOME [INJ] APLISOL [INJ] acarbose AFLURIA [INJ] ambrisentan [SP] APOKYN [INJ] [SP] ACCU-CHEK FASTCLIX LANCETS [OTC] AFLURIA QUAD [INJ] amcinonide apraclonidine eye solution ACCU-CHEK MULTICLIX LANCET KIT [OTC] AFSTYLA [INJ] [SP] amethia aprepitant ACCU-CHEK MULTICLIX LANCETS [OTC] AIMOVIG [INJ] amethia lo apri ACCU-CHEK SOFTCLIX LANCET KIT [OTC] AJOVY [INJ] amethyst APTIVUS [SP] ACCU-CHEK SOFTCLIX LANCETS [OTC] albendazole amifostine [INJ] AQUASOL A [INJ] acebutolol albumin human [INJ] amikacin [INJ] ARALAST NP [INJ] [SP] acetaminophen/codeine albuterol amiloride aranelle acetazolamide albuterol ext-release amiloride/hydrochlorothiazide ARIKAYCE [SP] acetazolamide ext-release albuterol nebulization solution aminocaproic acid aripiprazole acetazolamide sodium [INJ] albuterol sulfate hfa (by Cipla, Par, aminocaproic acid [INJ] aripiprazole orally disintegrating tablets acetic acid ear solution Perrigo, Proficient Rx & Teva) aminophylline [INJ] ARISTADA [INJ] acetic acid irrigation solution alclometasone AMINOSYN [INJ] ARISTOSPAN [INJ] acetic acid/hydrocortisone ear solution ALDURAZYME [INJ] [SP] amiodarone armodafinil acetic acid/oxyquinoline vaginal alendronate amiodarone [INJ] ARMONAIR RESPICLICK acetylcysteine [INJ] alfentanil [INJ] amitriptyline ARMOUR THYROID acetylcysteine inhalation solution ALFERON N [INJ] amitriptyline/chlordiazepoxide ARNUITY ELLIPTA acitretin alfuzosin ext-release amlodipine ARRANON [INJ] [SP] ACTEMRA [INJ] [SP] ALIMTA [INJ] amlodipine/atorvastatin arsenic trioxide [INJ] ACTHIB [INJ] ALINIA amlodipine/benazepril ascorbic acid [INJ] ACTHREL [INJ] ALIQOPA [INJ] [SP] amlodipine/olmesartan ashlyna ACTIMMUNE [INJ] [SP] aliskiren amlodipine/valsartan ASMANEX HFA ACTIVASE [INJ] allopurinol amlodipine/valsartan/hydrochlorothiazide ASMANEX TWISTHALER acyclovir allopurinol sodium [INJ] ammonium lactate 12% topical aspirin/dipyridamole ext-release acyclovir ointment almotriptan amoxapine atazanavir [SP] acyclovir sodium [INJ] alosetron amoxicillin atenolol ADACEL [INJ] ALPHAGAN P 0.1% amoxicillin/potassium clavulanate atenolol/chlorthalidone ADAKVEO [INJ] [SP] ALPHANATE [INJ] [SP] amoxicillin/potassium clavulanate ATGAM [INJ] adapalene ALPHANINE SD [INJ] [SP] ext-release atomoxetine adapalene/benzoyl peroxide alprazolam amphetamine sulfate atorvastatin ADCETRIS [INJ] [SP] alprazolam ext-release amphotericin [INJ] atovaquone (continued) Go to express-scripts.com/2020drugs 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, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com . © 2020 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 1 COMPBJCANP-20 (07/01/20) atovaquone/proguanil betamethasone valerate C celecoxib atropine [INJ] BETASERON [INJ] [SP] CELONTIN atropine sulfate eye ointment betaxolol cabergoline cephalexin atropine sulfate eye solution betaxolol eye solution CABLIVI [INJ] [SP] CEPROTIN [INJ] [SP] aubra bethanechol CABOMETYX [SP] CERDELGA [SP] aubra eq BETHKIS [SP] caffeine citrated CEREZYME [INJ] [SP] AUGMENTIN 125-31.25 MG/5 ML BEVESPI AEROSPHERE caffeine citrated [INJ] cetirizine syrup aurovela bexarotene [SP] caffeine/sodium benzoate [INJ] CETROTIDE [INJ] [SP] aurovela 24 fe BEXSERO [INJ] calcipotriene cevimeline aurovela fe bicalutamide calcipotriene/betamethasone dipropionate CHANTIX AUSTEDO [SP] BICILLIN C-R [INJ] calcitonin salmon nasal chateal aviane BICILLIN L-A [INJ] calcitriol chateal eq AVONEX [INJ] [SP] BIKTARVY [SP] calcitriol [INJ] CHEMET AVYCAZ [INJ] bimatoprost eye solution calcitriol ointment CHENODAL [SP] ayuna biolon [INJ] calcium acetate chloramphenicol [INJ] azacitidine [INJ] [SP] BIOTHRAX [INJ] calcium chloride [INJ] chlordiazepoxide AZASITE bisoprolol CALCIUM DISODIUM VERSENATE [INJ] chlordiazepoxide/clidinium azathioprine [SP] bisoprolol/hydrochlorothiazide calcium gluconate [INJ] chlorhexidine gluconate azathioprine sodium [INJ] [SP] bivalirudin [INJ] CALDOLOR VIALS [INJ] chloroprocaine hcl [INJ] AZEDRA [INJ] [SP] blanche camila chloroquine azelaic acid bleomycin [INJ] camrese chlorothiazide azelastine eye solution BLINCYTO [INJ] [SP] camrese lo chlorothiazide sodium [INJ] azelastine nasal spray blisovi 24 fe candesartan chlorpromazine azelastine/fluticasone blisovi fe candesartan/hydrochlorothiazide chlorpromazine [INJ] azithromycin BOOSTRIX [INJ] CAPASTAT SULFATE [INJ] chlorthalidone azithromycin [INJ] bosentan [SP] capecitabine [SP] chlorzoxazone aztreonam [INJ] BOSULIF [SP] CAPRELSA [SP] CHOLBAM [SP] azurette BOTOX [INJ] [SP] captopril cholestyramine BREO ELLIPTA captopril/hydrochlorothiazide cholestyramine light B bretylium tosylate [INJ] carbachol [INJ] choline salicylate/magnesium salicylate BREVITAL [INJ] CARBAGLU [SP] chromium chloride [INJ] bacitracin [INJ] briellyn carbamazepine ciclopirox bacitracin eye ointment BRILINTA carbamazepine ext-release ciclopirox shampoo bacitracin/polymyxin eye ointment brimonidine eye solution carbidopa cidofovir [INJ] baclofen BRINEURA [INJ] [SP] carbidopa/levodopa cilostazol baclofen [INJ] bromfenac eye solution carbidopa/levodopa ext-release CIMDUO [SP] BAL IN OIL [INJ] bromocriptine carbidopa/levodopa orally cimetidine balanced salt eye irrigation solution brompheniramine/pseudoephedrine/ disintegrating tablets cinacalcet bal-care dha prenatal vitamins codeine carbidopa/levodopa/entacapone CINRYZE [INJ] [SP] balsalazide brompheniramine/pseudoephedrine/ carbinoxamine CINVANTI [INJ] BALVERSA [SP] dextromethorphan carboplatin [INJ] ciprofloxacin balziva budesonide ext-release carmustine [INJ] ciprofloxacin ear solution BANZEL budesonide nebulization suspension carteolol eye solution ciprofloxacin eye solution BAQSIMI bumetanide carvedilol ciprofloxacin lactate/dextrose [INJ] BARACLUDE SOLUTION bumetanide [INJ] carvedilol phosphate ext-release cisplatin [INJ] BAVENCIO [INJ] [SP] bupivacaine [INJ] caspofungin [INJ] citalopram BAXDELA bupivacaine/dextrose [INJ] CATHFLO ACTIVASE [INJ] cladribine [INJ] BAXDELA [INJ] bupivacaine/epinephrine [INJ] CAVERJECT [INJ] clarithromycin b-complex [INJ] buprenorphine CAYSTON [SP] clarithromycin ext-release BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine [INJ] caziant clemastine BD NANO 2ND GEN PEN NEEDLES buprenorphine patches cefaclor CLENPIQ BD ULTRAFINE INSULIN SYRINGES [OTC] buprenorphine/naloxone cefaclor ext-release clindamycin hcl BD ULTRAFINE PEN NEEDLES [OTC] bupropion cefadroxil clindamycin palmitate bekyree bupropion ext-release cefazolin [INJ] clindamycin phosphate [INJ] BELBUCA bupropion ext-release (smoking deterrent) cefdinir clindamycin phosphate topical benazepril buspirone cefditoren clindamycin phosphate vaginal benazepril/hydrochlorothiazide busulfan [INJ] cefepime [INJ] clindamycin phosphate/benzoyl peroxide BENDEKA [INJ] [SP] butalbital/acetaminophen cefepime/dextrose [INJ] clindamycin phosphate/dextrose [INJ] BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine cefixime clindamycin phosphate/tretinoin BENLYSTA [INJ] [SP] butalbital/acetaminophen/caffeine/ cefotaxime [INJ] CLINIMIX [INJ] BENZNIDAZOLE codeine cefotetan [INJ] CLINIMIX E [INJ] benzonatate butalbital/aspirin/caffeine cefoxitin [INJ] clobazam benzoyl peroxide butalbital/aspirin/caffeine/codeine cefoxitin/dextrose [INJ] clobetasol propionate benztropine butorphanol [INJ] cefpodoxime clobetasol propionate
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