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2021 Home Delivery and Retail 90-Day Supply List

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2021 Home Delivery and Retail 90-Day Supply List This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Not all of the drugs listed are covered by all prescription plans; check your benefit materials and formulary 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. For the member: FDA-approved generic medications meet strict standards and contain 2021 Home Delivery and Retail the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. 90-Day Supply List For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. KEY anastrozole bicalutamide cartia xt D Brand-name drugs are listed ANGELIQ BIDIL carvedilol in CAPITAL letters. ANORO ELLIPTA BIJUVA carvedilol er DALIRESP Generic drugs are listed ANTARA bimatoprost CASODEX darifenacin er in lower case letters. APLENZIN BINOSTO CATAPRES dasetta apri bisoprolol fumarate CATAPRES-TTS daysee A APRISO bisoprolol-hydrochlorothiazide CAVERJECT DDAVP aranelle blisovi 24 fe caziant deblitane acarbose ARAVA blisovi fe CEQUA delyla ACCOLATE ARCAPTA NEOHALER BONIVA TABLETS cevimeline hcl denta 5000 plus ACCUPRIL ARICEPT BREO ELLIPTA chateal dentagel ACCURETIC ARMONAIR RESPICLICK BREVICON chateal eq DEPEN acebutolol hcl ARMOUR THYROID briellyn chlorothiazide DEPO-PROVERA 150 MG acetazolamide ARNUITY ELLIPTA BRILINTA chlorthalidone DEPO-SUBQ PROVERA 104 acetazolamide er AROMASIN brimonidine tartrate eye drops cholestyramine desmopressin acetate tablets ACTIGALL ashlyna bromocriptine mesylate cholestyramine light and nasal spray ACTIVE OB ASMANEX BROVANA cilostazol desogesterel-e.estradiol/ ACTIVELLA ASMANEX HFA budesonide cimetidine e.estradiol ACTONEL aspirin-dipyridamole er bumetanide cinacalcet hcl desogestrel-ethinyl estradiol ACTOPLUS MET ATELVIA BUPHENYL citalopram hbr DESVENLAFAXINE ER ACTOPLUS MET XR atenolol bupropion hcl CITRANATAL 90 DHA DESVENLAFAXINE FUMARATE ER ACTOS atenolol-chlorthalidone bupropion hcl er CITRANATAL ASSURE desvenlafaxine succinate er ADALAT CC atomoxetine hcl bupropion hcl sr CITRANATAL B-CALM DEXILANT ADVAIR DISKUS atorvastatin calcium bupropion xl CITRANATAL DHA diazoxide ADVAIR HFA ATROVENT HFA buspirone hcl CITRANATAL HARMONY digitek afirmelle aubra BYDUREON CITRANATAL RX digox AFREZZA aubra eq BYDUREON BCISE CLIMARA digoxin AGRYLIN aurovela BYETTA CLINPRO 5000 DILATRATE-SR AIMOVIG AUTOINJECTOR aurovela 24 fe BYSTOLIC clonidine hcl diltiazem 12 hr er AJOVY aurovela fe BYVALSON clonidine hcl er diltiazem 24 hr cd albuterol sulfate AVANDAMET clonidine patch diltiazem 24 hr er tablets and syrup AVANDIA C clopidogrel diltiazem 24 hr la ALDACTAZIDE aviane c-nate dha diltiazem 24 hr xr ALDACTONE AYGESTIN cabergoline colesevelam hcl diltiazem hcl alendronate sodium ayuna CADUET COLESTID dilt-xr alfuzosin hcl er AZILECT CALAN colestipol hcl dipyridamole aliskiren AZOPT CALAN SR COMBIPATCH disopyramide phosphate allopurinol AZULFIDINE calcitonin-salmon COMBIVENT RESPIMAT DITROPAN XL ALORA azurette camila complete natal dha DIURIL ALTACE camrese COMTAN DIVIGEL altavera B camrese lo CONCEPT DHA donepezil hcl ALVESCO candesartan cilexetil CONCEPT OB donepezil hcl odt alyacen bal-care dha candesartan-hydrochlorothiazide CONTRAVE ER dorzolamide hcl amabelz BAL-CARE DHA ESSENTIAL captopril COREG CR dorzolamide-timolol AMARYL BALCOLTRA captopril-hydrochlorothiazide CORGARD dothelle dha amethia balziva CARAFATE CORLANOR dotti amethia lo BASAGLAR KWIKPEN carbidopa cromolyn nebulizer solution doxazosin mesylate amethyst bekyree carbidopa-levodopa cromolyn sodium doxercalciferol amiloride hcl benazepril hcl carbidopa-levodopa er oral concentrate D-PENAMINE amiloride-hydrochlorothiazide benazepril-hydrochlorothiazide carbidopa-levodopa-entacapone cryselle DRISDOL amiodarone hcl BETAPACE CARDIZEM cyanocobalamin injection drospirenone-e.estradiol- amlodipine besylate BETAPACE AF CARDIZEM CD cyclafem levomefol amlodipine besylate-benazepril betaxolol hcl CARDIZEM LA CYCLESSA drospirenone-ethinyl estradiol amlodipine-atorvastatin bethanechol chloride CARDURA CYCLOSET DUAVEE amlodipine-olmesartan BETIMOL CARDURA XL cyred DUET DHA 400 amlodipine-valsartan BETOPTIC S CARNITOR cyred eq DUET DHA BALANCED amlodipine-valsartan-hctz BEVESPI AEROSPHERE CARNITOR SF CYTOTEC DUETACT anagrelide hcl BEYAZ carteolol hcl DULERA (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment. © 2020 Express Scripts. All Rights Reserved. Page 1 DL466313-STD CRP2009_004721.1 (09/01/20) All trademarks are the property of their respective owners. duloxetine hcl fenofibrate H K losartan potassium dutasteride fenofibric acid losartan-hydrochlorothiazide dutasteride-tamsulosin FENOGLIDE hailey k effervescent LOTENSIN DYAZIDE FETZIMA hailey 24 fe kaitlib fe LOTENSIN HCT DYRENIUM FIBRICOR hailey fe kalliga lovastatin finasteride heather KAPVAY LOVAZA E flavoxate hcl HECTOROL kariva low-ogestrel flecainide acetate hemenatal ob kelnor lo-zumandimine EDARBI FLOLIPID hemenatal ob + dha KHEDEZLA LUMIGAN EDARBYCLOR FLOMAX HUMALOG kimidess lutera EDECRIN FLOVENT DISKUS HUMALOG JUNIOR KWIKPEN klor-con LYUMJEV EDEX FLOVENT HFA HUMALOG KWIKPEN klor-con ef LYUMJEV KWIKPEN effer-k fludrocortisone acetate HUMALOG MIX klor-con m lyza EFFIENT flunisolide HUMALOG MIX KWIKPEN klor-con sprinkle elinest FLUORIDEX HUMULIN 70-30 KWIKPEN KOSHER PRENATAL PLUS IRON M ELIQUIS fluoridex daily defense HUMULIN N k-sol elite-ob FLUORIDEX SENSITIVITY RELIEF HUMULIN N KWIKPEN K-TAB ER macnatal cn dha ELIXOPHYLLIN fluoxetine hcl HUMULIN R kurvelo marlissa eluryng fluoxetine hcl dr HUMULIN R KWIKPEN MARNATAL-F EMGALITY flutamide hydralazine hcl L matzim la emoquette fluticasone propionate hydrochlorothiazide MAXINATE ENABLEX fluvastatin sodium labetalol hcl MAXZIDE enalapril maleate fluvastatin sodium er I LANOXIN medroxyprogesterone acetate enalapril-hydrochlorothiazide fluvoxamine maleate lansoprazole melodetta 24 fe ENBRACE HR fluvoxamine maleate er ibandronate sodium LANTUS memantine hcl enpresse focalgin 90 dha IMVEXXY LANTUS SOLOSTAR memantine hcl er enskyce focalgin ca incassia larin MENEST entacapone FOLET ONE INCRUSE ELLIPTA larin 24 fe MENOSTAR ENTRESTO folic acid 1 mg indapamide larin fe mesalamine eplerenone folivane-ob INSPRA larissia mesalamine dr eprosartan mesylate FORFIVO XL introvale LASIX mesalamine er ergoloid mesylates FORTAMET INVOKAMET latanoprost metaproterenol sulfate errin FOSAMAX INVOKAMET XR layolis fe metformin hcl escitalopram oxalate FOSAMAX PLUS D INVOKANA leena metformin hcl er esomeprazole magnesium fosinopril sodium ipratropium bromide leflunomide methazolamide estarylla fosinopril-hydrochlorothiazide ipratropium-albuterol LESCOL methimazole estradiol fulvestrant irbesartan LESCOL XL methyldopa estradiol transdermal patch furosemide irbesartan-hydrochlorothiazide lessina methyldopa-hydrochlorothiazide estradiol-norethindrone tablets fyavolv isibloom letrozole metipranolol ESTRING ISOCHRON LEVEMIR metolazone ESTROGEL G ISOPTO CARPINE LEVEMIR FLEXTOUCH metoprolol succinate estropipate ISORDIL LEVITRA METOPROLOL SUCCINATE ethacrynic acid galantamine hbr ISORDIL TITRADOSE levobunolol hcl ER-HCTZ ethynodiol-ethinyl estradiol galantamine hbr er isosorbide dinitrate levocarnitine metoprolol tartrate etidronate disodium GASTROCROM isosorbide dinitrate er levocarnitine sf metoprolol-hydrochlorothiazide etonogestrel-ethinyl estradiol GELNIQUE isosorbide mononitrate levomefolate dha mexiletine hcl euthyrox gemfibrozil isosorbide mononitrate er levonest MIACALCIN EVAMIST gianvi isoxsuprine hcl levonorgestrel-e.estradiol mibelas 24 fe EVISTA gildagia isradipine levonorgestrel-ethinyl estradiol microgestin EVOXAC glimepiride levora-28 MICROGESTIN 24 FE EXELON glipizide J levo-t microgestin fe exemestane glipizide er levothyroxine sodium miglitol ezetimibe glipizide xl jaimiess levoxyl mili ezetimibe-simvastatin glipizide-metformin JALYN lillow mimvey GLUCOTROL JANUMET LINZESS mimvey lo F GLUCOTROL XL JANUMET XR liothyronine sodium MINIPRESS GLUCOVANCE JANUVIA LIPOFEN MINITRAN falmina glyburide JARDIANCE lisinopril minoxidil famotidine tablets glyburide micronized jasmiel lisinopril-hydrochlorothiazide MIRAPEX FARESTON glyburide-metformin hcl jencycla LIVALO MIRAPEX ER FARXIGA GLYCATE jevantique lo LO LOESTRIN FE MIRCETTE FASLODEX glycopyrrolate jinteli LODOSYN mirtazapine fayosim GLYNASE jolessa lojaimiess misoprostol febuxostat GLYSET jolivette lomedia 24 fe m-natal plus felodipine er GLYXAMBI juleber LONHALA MAGNAIR REFILL moexipril hcl FEMARA GRASTEK junel LOPID moexipril-hydrochlorothiazide FEMCON FE guanfacine hcl junel fe lopreeza mometasone furoate FEMHRT guanfacine hcl er junel fe 24 LOPRESSOR mono-linyah FEMRING LOPRESSOR HCT mononessa femynor loryna montelukast sodium (continued) This is not an all-inclusive list of long-term medicines, and is subject to change at Express Scripts’ discretion. Generics drugs are usually available at the lowest copayment. © 2020 Express Scripts. All Rights Reserved. Page 2 DL466313-STD CRP2009_004721.1 (09/01/20) All trademarks are the property of their respective owners. MOTEGRITY O pnv-omega propafenone hcl RYTHMOL SR MULTAQ pnv-select propafenone hcl er MUSE OB COMPLETE pnv-vp-u PROPECIA S mynatal OB COMPLETE GOLD portia propranolol hcl mynatal advance OB COMPLETE ONE POTABA propranolol hcl
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