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2020 Express Scripts Drug List for the NYC PICA Plan

2020 Express Scripts Drug List for the NYC PICA Plan

The following is a list of the included in the NYC PICA 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.

PLEASE NOTE: Brand-name drugs may move to nonformulary status if 2020 Express Scripts List a generic version becomes available during the year. For specific for the New York City PICA Program questions about your coverage, please call the phone number printed on your member ID card.

INJECTABLES BUPRENEX hcl icatibant [PA] [SP] NATPARA [PA] buprenorphine hydrochloride IFE-BIMIX 30/1 NEMBUTAL SODIUM NOTE: Coverage based on benefit butorphanol tartrate duramorph IFE-PG20 NESACAINE design. CABLIVI [PA] [SP] EDEX [PA] INCRELEX [PA] [SP] NESACAINE-MPF caffeine & sodium benzoate EGRIFTA [SP] infed NEULASTA [PA] [SP] ABILIFY MAINTENA disodium versenate EGRIFTA SV INFUMORPH NEXAVIR ACTEMRA [PA] [SP] CAPASTAT SULFATE EMGALITY [PA] INVANZ NIVESTYM [PA] [SP] ACTEMRA ACTPEN [PA] [SP] CARBOCAINE ENBREL [PA] [SP] INVEGA SUSTENNA NORDITROPIN FLEXPRO [PA] [SP] ADAGEN CAVERJECT [PA] enoxaparin sodium [SP] INVEGA TRINZA NOVAREL [FER] adrenalin chloride cefazolin sodium sulfate isoniazid NUTROPIN [SP] [ST] a-hydrocort cefepime hcl epinephrine auto-injector isoproterenol hcl NUTROPIN AQ [SP] [ST] AIMOVIG [PA] CEFOTAN ertapenem ISUPREL octreotide acetate [SP] AJOVY [PA] cefotaxime sodium valerate KENALOG ALFENTA cefotetan fentanyl citrate KETALAR orphenadrine citrate alfentanil hydrochloride ceftazidime FIRAZYR [PA] [SP] hcl OTREXUP [ST] amikacin sulfate ceftriaxone decanoate ketamine hcl-ns OVIDREL [FER] ampicillin sodium cefuroxime sodium fluphenazine hcl ketamine hcl-water oxacillin sodium ampicillin/sulbactam CELESTONE folic acid ketorolac tromethamine PALYNZIQ [PA] [SP] AMYTAL SODIUM CEREBYX fondaparinux sodium [SP] KEVZARA [PA] [SP] papaverine hcl AQUASOL A CETROTIDE [FER] FORTAZ LEUKINE [SP] papaverine-alprostadil ARCALYST [PA] [SP] chloroprocaine hcl FORTEO [PA] [SP] LEVSIN papaverine- ARISTADA hcl fosphenytoin sodium lidocaine hcl papaverine-phentolmn-alprostdl ARISTADA INITIO CLAFORAN FRAGMIN [SP] lidocaine hcl w/epinephrine PEGASYS [PA] [SP] ARISTOSPAN CLEOCIN PHOSPHATE FULPHILA [PA] [SP] lidocaine hcl-ns PEGASYS PROCLICK [PA] [SP] ARIXTRA [SP] clindamycin phosphate furosemide LINCOCIN PEG-INTRON [PA] [SP] ascorbic acid COGENTIN FUZEON [SP] lincomycin hcl PEG-INTRON REDIPEN [PA] [SP] ATIVAN colistimethate sodium GENOTROPIN [PA] [SP] penicillin g procaine ATROPEN COLY-MYCIN M PARENTERAL gentamicin sulfate LUPRON DEPOT-PED [PA] [SP] PENTAM 300 sulfate COPAXONE [PA] [SP] gentamicin-sodium citrate chloride pentamidine isethionate AVEED [PA] CORTROSYN GEODON MARCAINE sodium AVONEX [PA] [SP] COSENTYX [PA] [SP] glatiramer acetate [PA] [SP] MARCAINE WITH EPINEPHRINE PERSERIS AZACTAM cosyntropin glatopa [PA] [SP] MAXIPIME PHENERGAN aztreonam CRYSVITA [SP] glycopyrrolate medroxyprogesterone acetate sodium baci-im cyanocobalamin GLYRX-PF MENOPUR [FER] PHENTOLAMINE-ALPROSTADIL bacitracin D.H.E.45 GONAL-F/RFF [FER] meperidine hcl hcl BAL IN OIL DDAVP H.P. ACTHAR [PA] [SP] methadone hcl physostigmine salicylate b-complex DELESTROGEN HAEGARDA [PA] [SP] methocarbamol PHYTONADIONE BENLYSTA [SP] DEMEROL HALDOL methylergonovine maleate PLEGRIDY [PA] [SP] BENTYL DEPO-ESTRADIOL HALDOL DECANOATE methylprednisolone polocaine benztropine mesylate DEPO-MEDROL methylprednisolone acetate polymyxin b sulfate betamethasone acet and na phos DEPO-PROVERA methylprednisolone sod succ PRALUENT [PA] betamethasone acetate-sod phos DEPO-SUBQ PROVERA haloperidol lactate methylprednisolone-bupivacaine edisylate betamethasone sod phos-water DEPO- [PA] HEMABATE MIACALCIN PROCRIT [PA] [SP] BETASERON [PA] [SP] desmopressin acetate HEMLIBRA [PA] [SP] hcl [FER] BICILLIN C-R acetate la heparin sodium MITIGO hcl BICILLIN L-A dexamethasone acetate-sod HUMIRA [PA] [SP] morphine sulfate PROTOPAM CHLORIDE BOTOX [PA] [SP] phos HUMIRA PEDIATRIC [PA] [SP] morphine sulfate/ns pyridoxine hcl bumetanide dexamethasone sodium hydralazine hcl MOZOBIL [SP] gluconate bupivacaine hcl phosphate hydromorphone hcl MYALEPT R.E.C.K. (ROPIV-EPI-CLON- bupivacaine hcl-epinephrine hydromorphone hcl-water MYOBLOC [PA] [SP] KETOR) bupivacaine w/dextrose dicyclomine hcl hydroxocobalamin nafcillin sodium ranitidine hcl bupivacaine-dexamethasone sod mesylate hcl nalbuphine hcl RASUVO [ST] bupivacaine-ketorolac-ketamine DILAUDID sulfate NAROPIN REBIF [PA] [SP] (continued) Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. THIS DOCUMENT LIST IS EFFECTIVE MARCH 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. APNA ANP All trademarks are the property of their respective owners. Page 1 PRMTPICA-20 (02/11/20) REBIF REBIDOSE UDENYCA [PA] [SP] CYCLOPHOSPHAMIDE LYNPARZA [PA] [SP] TARGRETIN [SP] RELISTOR UNASYN cytarabine [INJ] LYSODREN TASIGNA [PA] [SP] REMODULIN vancomycin hcl DAURISMO [PA] [SP] MARINOL TAZVERIK [PA] [SP] REPATHA [PA] VAZCULEP diclofenac sodium MATULANE [SP] TEMODAR [PA] [SP] RETACRIT [PA] [SP] k MEGACE temozolomide [PA] [SP] REVCOVI XGEVA DROXIA TEPADINA RISPERDAL CONSTA XYLOCAINE EFUDEX MEKINIST [PA] [SP] THALOMID [PA] [SP] ROBAXIN XYLOCAINE WITH EPINEPHRINE ELIGARD [INJ] [PA] [SP] MEKTOVI [PA] [SP] thiamine hcl [INJ] ROBINUL XYOSTED [PA] EMCYT melphalan hcl thiotepa ropivacaine hcl/pf ZANTAC RX ERIVEDGE [PA] [SP] mercaptopurine TIBSOVO [PA] [SP] ropivacaine hcl-ns ZARXIO [SP] [ST] ERLEADA [PA] [SP] MESNEX TIGAN [INJ] ropivacaine--ketorolc ZEMBRACE SYMTOUCH erlotinib hcl [PA] [SP] methotrexate TOLAK ropivacaine-ketorolac-ketamine ZINACEF ERWINAZE methotrexate sodium [INJ] citrate SANDOSTATIN [SP] ZINBRYTA [PA] [SP] etoposide hcl TRELSTAR [ST] SAXENDA [PA] ZORBTIVE [PA] [SP] metoclopramide hcl odt TRELSTAR LA [ST] SENSORCAINE ZYPREXA exemestane MUSTARGEN tretinoin SENSORCAINE WITH DEXTROSE FARESTON MYLERAN trexall SENSORCAINE WITH FARYDAK [PA] [SP] NERLYNX [PA] [SP] hcl EPINEPHRINE FASLODEX [INJ] NEXAVAR [PA] [SP] TURALIO [PA] [SP] SENSORCAINE-MPF [PA] [SP] FEMARA NILANDRON TYKERB [PA] [SP] SEROSTIM [SP] ACTIMMUNE [INJ] [SP] FIRMAGON [INJ] [PA] [SP] UVADEX SKYRIZI (2 SYRINGES) KIT AFINITOR [PA] [SP] floxuridine NINLARO [PA] [SP] VALCHLOR [SP] [PA] [SP] AFINITOR DISPERZ [PA] [SP] FLUOROPLEX NUBEQA [PA] [SP] VANTAS [SP] SOLU-CORTEF ALDARA ODOMZO [PA] [SP] VARUBI SOLU-MEDROL ALECENSA [PA] [SP] [PA] [SP] ONCASPAR [INJ] VELCADE [INJ] [SP] SOMATULINE DEPOT [SP] ALFERON N GILOTRIF [PA] [SP] hcl VENCLEXTA [SP] SOMAVERT [PA] [SP] ALKERAN GLEOSTINE ondansetron odt VENCLEXTA STARTING PACK [SP] STELARA [PA] [SP] ALUNBRIG [PA] [SP] hcl PANRETIN VERZENIO [PA] [SP] STRENSIQ [SP] AMELUZ HERCEPTIN HYLECTA [SP] PICATO VIDAZA [SP] STREPTOMYCIN SULFATE HEXALEN POMALYST [SP] VISTOGARD [SP] succinate ANZEMET HYCAMTIN prochlorperazine maleate VITRAKVI [PA] [SP] SUMAVEL DOSEPRO HYDREA PURIXAN [SP] VIZIMPRO [PA] [SP] SUSTOL AROMASIN hydroxyurea REGLAN VOTRIENT [PA] [SP] SYMJEPI azacitidine IBRANCE [PA] [SP] REVLIMID [PA] [SP] XALKORI [PA] [SP] TAKHZYRO [PA] [SP] BALVERSA [PA] [SP] ICLUSIG [PA] [SP] RITUXAN HYCELA [PA] [SP] XELODA [SP] TALWIN bexarotene IDHIFA [PA] [SP] ROZLYTREK [PA] [SP] XERMELO [PA] [SP] TAZICEF imatinib mesylate [PA] [SP] RUBRACA [PA] [SP] XOSPATA [PA] TEGSEDI [PA] [SP] bleo 15k IMBRUVICA [PA] [SP] RYDAPT [PA] [SP] XTANDI [PA] [SP] sulfate bleomycin sulfate [INJ] imiquimod SANCUSO YONSA [PA] [SP] [PA] BOSULIF [PA] [SP] IMLYGIC [SP] SOLARAZE [PA] ZEJULA [PA] [SP] [PA] BRAFTOVI [PA] [SP] INLYTA [PA] [SP] SOLTAMOX ZELBORAF [PA] [SP] tetracaine hcl BRUKINSA [PA] [SP] INTRON A [INJ] [SP] SPRYCEL [PA] [SP] ZOFRAN ticarcillin disod-clavulanate CABOMETYX [PA] [SP] IRESSA [PA] [SP] STIVARGA [PA] [SP] ZOFRAN ODT TIGAN CALQUENCE [PA] [SP] JAKAFI [PA] [SP] SUTENT [PA] [SP] ZOLADEX [INJ] [SP] tobramycin sulfate capecitabine [SP] LENVIMA [PA] [SP] SYLATRON [SP] ZOLINZA [SP] TREMFYA [PA] [SP] CAPRELSA [PA] [SP] SYNDROS ZUPLENZ treprostinil [SP] CARAC leucovorin calcium SYNRIBO ZYDELIG [PA] [SP] triamcinolone acet-bupivacaine CASODEX LEUKERAN TABLOID ZYKADIA [PA] [SP] triamcinolone acetonide COMETRIQ [PA] [SP] leuprolide acetate [INJ] [PA] [SP] TAFINLAR [PA] [SP] triamcinolone diacetate COMPAZINE LEVULAN TAGRISSO [PA] [SP] tricitrasol compro LONSURF [SP] TALZENNA [PA] [SP] TRIPTODUR [SP] COPIKTRA [PA] [SP] LORBRENA [PA] [SP] citrate TYMLOS [SP] COTELLIC [PA] [SP] LUPRON DEPOT [INJ] [SP] [ST] TARCEVA [PA] [SP]

KEY [FER] - in which there is a lifetime limit of 3 cycles of therapy per when covered; available through Freedom Fertility Pharmacy (800.660.4283) [INJ] - injectable medication [PA] - Prior Authorization is required for coverage [SP] - available through Accredo Specialty Pharmacy (800.467.2006) [ST] - Step Therapy may apply to certain indications or some or all strengths of the drug For the member: FDA-approved generic meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. 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.

Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. THIS DOCUMENT LIST IS EFFECTIVE MARCH 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. APNA ANP All trademarks are the property of their respective owners. Page 2 PRMTPICA-20 (02/11/20)

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