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Drug Formulary List 2021 Express Scripts National Preferred Formulary List For BJC HealthCare The 2021 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 sodium [INJ] adefovir ALPROLIX [INJ] [SP] ampicillin sodium/sulbactam [INJ] abacavir [SP] ADEMPAS [SP] alprostadil [INJ] AMYTAL [INJ] abacavir/lamivudine [SP] adenosine [INJ] altavera AMZEEQ abacavir/lamivudine/zidovudine [SP] ADVAIR HFA ALUNBRIG [SP] anagrelide ABELCET [INJ] ADVATE [INJ] [SP] alyacen anastrozole ABILIFY MAINTENA [INJ] ADYNOVATE [INJ] [SP] amabelz ANDRODERM abiraterone acetate [SP] AFINITOR 10 MG TABLETS [SP] amantadine ANORO ELLIPTA ABRAXANE [INJ] [SP] AFINITOR DISPERZ [SP] AMBISOME [INJ] APLISOL [INJ] acamprosate delayed-release afirmelle ambrisentan [SP] APOKYN [INJ] [SP] acarbose AFLURIA QUAD [INJ] amcinonide apraclonidine eye solution ACCU-CHEK FASTCLIX LANCETS [OTC] AFSTYLA [INJ] [SP] amethia aprepitant ACCU-CHEK MULTICLIX LANCET KIT [OTC] AIMOVIG [INJ] amethia lo apri ACCU-CHEK MULTICLIX LANCETS [OTC] AJOVY [INJ] amethyst APTIVUS [SP] ACCU-CHEK SOFTCLIX LANCET KIT [OTC] albendazole amifostine [INJ] AQUASOL A [INJ] ACCU-CHEK SOFTCLIX LANCETS [OTC] albumin human [INJ] amikacin [INJ] ARALAST NP [INJ] [SP] acebutolol albuterol amiloride aranelle acetaminophen/codeine albuterol ext-release amiloride/hydrochlorothiazide ARIKAYCE [SP] acetazolamide albuterol nebulization solution aminocaproic acid aripiprazole acetazolamide ext-release albuterol sulfate hfa (by Cipla, Lupin, aminocaproic acid [INJ] aripiprazole orally disintegrating tablets acetazolamide sodium [INJ] Par, Perrigo, Proficient Rx & Teva) aminophylline [INJ] ARISTADA [INJ] acetic acid ear solution alclometasone AMINOSYN [INJ] ARISTOSPAN [INJ] acetic acid irrigation solution ALDURAZYME [INJ] [SP] amiodarone armodafinil acetic acid/hydrocortisone ear solution ALECENSA [SP] amiodarone [INJ] ARMOUR THYROID acetic acid/oxyquinoline vaginal alendronate amitriptyline ARNUITY ELLIPTA acetylcysteine [INJ] alfentanil [INJ] amitriptyline/chlordiazepoxide ARRANON [INJ] [SP] acetylcysteine inhalation solution ALFERON N [INJ] amlodipine arsenic trioxide [INJ] acitretin alfuzosin ext-release amlodipine/atorvastatin ascorbic acid [INJ] ACTEMRA [INJ] [SP] ALIMTA [INJ] amlodipine/benazepril ashlyna ACTHIB [INJ] ALINIA amlodipine/olmesartan ASMANEX HFA ACTHREL [INJ] ALIQOPA [INJ] [SP] amlodipine/valsartan ASMANEX TWISTHALER ACTIMMUNE [INJ] [SP] aliskiren amlodipine/valsartan/hydrochlorothiazide aspirin/dipyridamole ext-release ACTIVASE [INJ] allopurinol ammonium lactate 12% topical atazanavir [SP] acyclovir allopurinol sodium [INJ] amoxapine atenolol acyclovir ointment almotriptan amoxicillin atenolol/chlorthalidone acyclovir sodium [INJ] alosetron amoxicillin/potassium clavulanate ATGAM [INJ] ADACEL [INJ] ALPHAGAN P 0.1% amoxicillin/potassium clavulanate atomoxetine ADAKVEO [INJ] [SP] ALPHANATE [INJ] [SP] ext-release atorvastatin adapalene ALPHANINE SD [INJ] [SP] amphetamine sulfate atovaquone adapalene/benzoyl peroxide alprazolam amphotericin [INJ] atovaquone/proguanil ADCETRIS [INJ] [SP] alprazolam ext-release ampicillin atropine [INJ] (continued) Go to express-scripts.com/2021drugs 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, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com . © 2021 Express Scripts. All Rights Reserved. #2884 NP-A All trademarks are the property of their respective owners. Page 1 COMPBJCANP-21 (04/01/21) atropine sulfate eye ointment betamethasone valerate CABLIVI [INJ] [SP] CEPROTIN [INJ] [SP] atropine sulfate eye solution BETASERON [INJ] [SP] CABOMETYX [SP] CERDELGA [SP] AUBAGIO [SP] betaxolol caffeine citrated CEREZYME [INJ] [SP] aubra betaxolol eye solution caffeine citrated [INJ] cetirizine syrup aubra eq bethanechol caffeine/sodium benzoate [INJ] CETROTIDE [INJ] [SP] AUGMENTIN 125-31.25 MG/5 ML BEVESPI AEROSPHERE calcipotriene cevimeline aurovela bexarotene [SP] calcipotriene/betamethasone dipropionate CHANTIX aurovela 24 fe BEXSERO [INJ] calcitonin salmon nasal charlotte 24 fe aurovela fe bicalutamide calcitriol chateal AUSTEDO [SP] BICILLIN C-R [INJ] calcitriol [INJ] chateal eq aviane BICILLIN L-A [INJ] calcitriol ointment CHEMET AVONEX [INJ] [SP] BIKTARVY [SP] calcium acetate CHENODAL [SP] AVYCAZ [INJ] bimatoprost eye solution calcium chloride [INJ] chloramphenicol [INJ] ayuna biolon [INJ] CALCIUM DISODIUM VERSENATE [INJ] chlordiazepoxide azacitidine [INJ] [SP] BIOTHRAX [INJ] calcium gluconate [INJ] chlordiazepoxide/clidinium AZASITE bisoprolol CALDOLOR VIALS [INJ] chlorhexidine gluconate azathioprine [SP] bisoprolol/hydrochlorothiazide camila chloroprocaine hcl [INJ] azathioprine sodium [INJ] [SP] bivalirudin [INJ] camrese chloroquine AZEDRA [INJ] [SP] blanche camrese lo chlorothiazide azelaic acid bleomycin [INJ] candesartan chlorothiazide sodium [INJ] azelastine eye solution BLINCYTO [INJ] [SP] candesartan/hydrochlorothiazide chlorpromazine azelastine nasal spray blisovi 24 fe CAPASTAT SULFATE [INJ] chlorpromazine [INJ] azelastine/fluticasone blisovi fe capecitabine [SP] chlorthalidone azithromycin BOOSTRIX [INJ] CAPRELSA [SP] chlorzoxazone azithromycin [INJ] bosentan [SP] captopril CHOLBAM [SP] AZOPT BOSULIF [SP] captopril/hydrochlorothiazide cholestyramine aztreonam [INJ] BOTOX [INJ] [SP] carbachol [INJ] cholestyramine light azurette BREO ELLIPTA CARBAGLU [SP] choline salicylate/magnesium salicylate bretylium tosylate [INJ] carbamazepine chromium chloride [INJ] B BREVITAL [INJ] carbamazepine ext-release ciclopirox BREZTRI AEROSPHERE carbidopa ciclopirox shampoo bacitracin [INJ] briellyn carbidopa/levodopa cidofovir [INJ] bacitracin eye ointment BRILINTA carbidopa/levodopa ext-release cilostazol bacitracin/polymyxin eye ointment brimonidine eye solution carbidopa/levodopa orally CIMDUO [SP] baclofen BRINEURA [INJ] [SP] disintegrating tablets cimetidine baclofen [INJ] bromfenac eye solution carbidopa/levodopa/entacapone cinacalcet BAFIERTAM [SP] bromocriptine carbinoxamine CINRYZE [INJ] [SP] BAL IN OIL [INJ] brompheniramine/pseudoephedrine/ carboplatin [INJ] CINVANTI [INJ] balanced salt eye irrigation solution codeine carmustine [INJ] ciprofloxacin bal-care dha prenatal vitamins brompheniramine/pseudoephedrine/ carteolol eye solution ciprofloxacin ear solution balsalazide dextromethorphan carvedilol ciprofloxacin eye solution BALVERSA [SP] budesonide ext-release carvedilol phosphate ext-release ciprofloxacin lactate/dextrose [INJ] balziva budesonide nebulization suspension caspofungin [INJ] ciprofloxacin/dexamethasone BANZEL bumetanide CATHFLO ACTIVASE [INJ] ear suspension BAQSIMI bumetanide [INJ] CAVERJECT [INJ] cisplatin [INJ] BARACLUDE SOLUTION bupivacaine [INJ] CAYSTON [SP] citalopram BAVENCIO [INJ] [SP] bupivacaine/dextrose [INJ] caziant cladribine [INJ] BAXDELA bupivacaine/epinephrine [INJ] cefaclor clarithromycin BAXDELA [INJ] buprenorphine cefaclor ext-release clarithromycin ext-release b-complex [INJ] buprenorphine [INJ] cefadroxil clemastine BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine patches cefazolin [INJ] clindamycin hcl BD NANO 2ND GEN PEN NEEDLES buprenorphine/naloxone cefdinir clindamycin palmitate BD ULTRAFINE INSULIN SYRINGES [OTC] bupropion cefditoren clindamycin phosphate [INJ] BD ULTRAFINE PEN NEEDLES [OTC] bupropion ext-release cefepime [INJ] clindamycin phosphate topical bekyree bupropion ext-release (smoking deterrent) cefepime/dextrose [INJ] clindamycin phosphate vaginal BELBUCA buspirone cefixime clindamycin phosphate/benzoyl peroxide benazepril busulfan [INJ] cefotaxime [INJ] clindamycin phosphate/dextrose [INJ] benazepril/hydrochlorothiazide butalbital/acetaminophen cefotetan [INJ] clindamycin phosphate/tretinoin BENDEKA [INJ] [SP] butalbital/acetaminophen/caffeine cefoxitin [INJ] CLINIMIX [INJ] BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine/ cefoxitin/dextrose [INJ] CLINIMIX E [INJ] BENLYSTA [INJ] [SP] codeine cefpodoxime clobazam BENZNIDAZOLE butalbital/aspirin/caffeine cefprozil clobetasol propionate benzonatate butalbital/aspirin/caffeine/codeine ceftazidime [INJ] clobetasol
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