2020 Express Scripts National Preferred Formulary List The 2020 National Preferred Formulary drug list 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 adenosine [INJ] amabelz anthralin ADVAIR HFA amantadine APLISOL [INJ] abacavir [SP] ADVATE [INJ] [SP] AMBISOME [INJ] APOKYN [INJ] [SP] abacavir/lamivudine [SP] ADYNOVATE [INJ] [SP] ambrisentan [SP] apraclonidine eye solution abacavir/lamivudine/zidovudine [SP] AFINITOR [SP] amcinonide aprepitant ABELCET [INJ] AFINITOR DISPERZ [SP] amethia apri ABILIFY MAINTENA [INJ] afirmelle amethia lo APRISO abiraterone acetate [SP] AFLURIA [INJ] amethyst APTIVUS [SP] ABRAXANE [INJ] [SP] AFLURIA QUAD [INJ] AMICAR SOLUTION AQUASOL A [INJ] acamprosate delayed-release AFSTYLA [INJ] [SP] amifostine [INJ] ARALAST NP [INJ] [SP] acarbose AIMOVIG [INJ] amikacin [INJ] aranelle ACCU-CHEK FASTCLIX LANCETS [OTC] AJOVY [INJ] amiloride ARIKAYCE [SP] ACCU-CHEK MULTICLIX LANCET KIT [OTC] albendazole amiloride/hydrochlorothiazide aripiprazole ACCU-CHEK MULTICLIX LANCETS [OTC] albumin human [INJ] aminocaproic acid aripiprazole orally disintegrating tablets ACCU-CHEK SOFTCLIX LANCET KIT [OTC] albuterol aminocaproic acid [INJ] ARISTADA [INJ] ACCU-CHEK SOFTCLIX LANCETS [OTC] albuterol ext-release aminophylline [INJ] ARISTOSPAN [INJ] acebutolol albuterol nebulization solution AMINOSYN [INJ] armodafinil acetaminophen/codeine alclometasone amiodarone ARMONAIR RESPICLICK acetazolamide ALDURAZYME [INJ] [SP] amiodarone [INJ] ARMOUR THYROID acetazolamide ext-release ALECENSA [SP] amitriptyline ARNUITY ELLIPTA acetazolamide sodium [INJ] alendronate amitriptyline/chlordiazepoxide ARRANON [INJ] [SP] acetic acid ear solution alfentanil [INJ] amlodipine arsenic trioxide [INJ] acetic acid irrigation solution ALFERON N [INJ] amlodipine/atorvastatin ascorbic acid [INJ] acetic acid/hydrocortisone ear solution alfuzosin ext-release amlodipine/benazepril ashlyna acetic acid/oxyquinoline vaginal ALIMTA [INJ] amlodipine/olmesartan ASMANEX HFA acetylcysteine [INJ] ALINIA amlodipine/valsartan ASMANEX TWISTHALER acetylcysteine inhalation solution ALIQOPA [INJ] [SP] amlodipine/valsartan/hydrochlorothiazide aspirin/dipyridamole ext-release acitretin aliskiren ammonium lactate 12% topical atazanavir [SP] ACTEMRA [INJ] [SP] allopurinol amoxapine atenolol ACTHIB [INJ] allopurinol sodium [INJ] amoxicillin atenolol/chlorthalidone ACTHREL [INJ] almotriptan amoxicillin/potassium clavulanate ATGAM [INJ] ACTIMMUNE [INJ] [SP] alosetron amoxicillin/potassium clavulanate atomoxetine ACTIVASE [INJ] ALPHAGAN P 0.1% ext-release atorvastatin acyclovir ALPHANATE [INJ] [SP] amphetamine sulfate atovaquone acyclovir ointment ALPHANINE SD [INJ] [SP] amphotericin [INJ] atovaquone/proguanil acyclovir sodium [INJ] alprazolam ampicillin atropine [INJ] ADACEL [INJ] alprazolam ext-release ampicillin sodium [INJ] atropine sulfate eye ointment adapalene alprazolam orally disintegrating tablets ampicillin sodium/sulbactam [INJ] atropine sulfate eye solution adapalene/benzoyl peroxide ALPROLIX [INJ] [SP] AMYTAL [INJ] aubra ADCETRIS [INJ] [SP] alprostadil [INJ] anagrelide aubra eq ADDAMEL N [INJ] ALREX anastrozole AUGMENTIN 125-31.25 MG/5 ML adefovir altavera ANDRODERM aurovela ADEMPAS [SP] alyacen ANORO ELLIPTA aurovela 24 fe (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 . © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 1 COMP1702A-20 (11/01/19) aurovela fe BEXSERO [INJ] calcitriol CETROTIDE [INJ] [SP] AUSTEDO [SP] bicalutamide calcitriol [INJ] cevimeline AVASTIN [INJ] [SP] BICILLIN C-R [INJ] calcitriol ointment CHANTIX aviane BICILLIN L-A [INJ] calcium acetate chateal avo cream BIKTARVY [SP] calcium chloride [INJ] chateal eq AVONEX [INJ] [SP] bimatoprost eye solution CALCIUM DISODIUM VERSENATE [INJ] CHEMET AVYCAZ [INJ] biolon [INJ] calcium gluconate [INJ] CHENODAL [SP] ayuna BIOTHRAX [INJ] calcium-pnv 28-1-250 prenatal vitamins chloramphenicol [INJ] azacitidine [INJ] [SP] bisoprolol CALDOLOR [INJ] chlordiazepoxide AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] bisoprolol/hydrochlorothiazide camila chlordiazepoxide/clidinium AZASITE bivalirudin [INJ] camrese chlorhexidine gluconate azathioprine [SP] blanche camrese lo chloroprocaine hcl [INJ] azathioprine sodium [INJ] [SP] bleomycin [INJ] candesartan chloroquine AZEDRA [INJ] [SP] BLINCYTO [INJ] [SP] candesartan/hydrochlorothiazide chlorothiazide azelaic acid blisovi 24 fe CAPASTAT SULFATE [INJ] chlorothiazide sodium [INJ] azelastine eye solution blisovi fe capecitabine [SP] chlorpheniramine/phenylephrine/ azelastine nasal spray BOOSTRIX [INJ] CAPRELSA [SP] dextromethorphan azithromycin bosentan [SP] captopril chlorpromazine azithromycin [INJ] BOSULIF [SP] captopril/hydrochlorothiazide chlorpromazine [INJ] aztreonam [INJ] BOTOX [INJ] [SP] CARAC chlorthalidone azurette BREO ELLIPTA CARAFATE SUSPENSION chlorzoxazone BREVITAL [INJ] carbachol [INJ] CHOLBAM [SP] B briellyn CARBAGLU [SP] cholestyramine BRILINTA carbamazepine cholestyramine light bacitracin [INJ] brimonidine eye solution carbamazepine ext-release choline salicylate/magnesium salicylate bacitracin eye ointment BRINEURA [INJ] [SP] carbidopa chromium chloride [INJ] bacitracin/polymyxin eye ointment bromfenac eye solution carbidopa/levodopa ciclopirox baclofen bromocriptine carbidopa/levodopa ext-release ciclopirox shampoo baclofen [INJ] brompheniramine/pseudoephedrine/ carbidopa/levodopa orally cidofovir [INJ] BAL IN OIL [INJ] codeine disintegrating tablets cilostazol balanced salt eye irrigation solution brompheniramine/pseudoephedrine/ carbidopa/levodopa/entacapone CIMDUO [SP] bal-care dha prenatal vitamins dextromethorphan carbinoxamine cimetidine balsalazide budesonide ext-release carboplatin [INJ] cinacalcet BALVERSA [SP] budesonide nebulization suspension carmustine [INJ] CINRYZE [INJ] [SP] balziva bumetanide carteolol eye solution CINVANTI [INJ] BANZEL bumetanide [INJ] carvedilol CIPRODEX BAQSIMI bupivacaine [INJ] carvedilol phosphate ext-release ciprofloxacin BARACLUDE SOLUTION bupivacaine/dextrose [INJ] caspofungin [INJ] ciprofloxacin ear solution BAVENCIO [INJ] [SP] bupivacaine/epinephrine [INJ] CATHFLO ACTIVASE [INJ] ciprofloxacin ext-release b-complex [INJ] buprenorphine CAVERJECT [INJ] ciprofloxacin eye solution BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine [INJ] CAYSTON [SP] ciprofloxacin lactate/dextrose [INJ] BD ULTRAFINE INSULIN SYRINGES [OTC] buprenorphine patches caziant cisplatin [INJ] BD ULTRAFINE PEN NEEDLES [OTC] buprenorphine/naloxone cefaclor citalopram BEBULIN [INJ] [SP] bupropion cefaclor ext-release cladribine [INJ] bekyree bupropion ext-release cefadroxil clarithromycin BELBUCA bupropion ext-release (smoking deterrent) cefazolin [INJ] clarithromycin ext-release benazepril buspirone cefdinir clemastine benazepril/hydrochlorothiazide busulfan [INJ] cefditoren CLENPIQ BENDEKA [INJ] [SP] butalbital/acetaminophen cefepime [INJ] clindamycin hcl BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine cefepime/dextrose [INJ] clindamycin palmitate BENLYSTA [INJ] [SP] butalbital/acetaminophen/caffeine/ cefixime clindamycin phosphate [INJ] BENZNIDAZOLE codeine cefotaxime [INJ] clindamycin phosphate topical benzonatate butalbital/aspirin/caffeine cefotetan [INJ] clindamycin phosphate vaginal benzoyl peroxide butalbital/aspirin/caffeine/codeine cefoxitin [INJ] clindamycin phosphate/benzoyl peroxide benzphetamine butorphanol [INJ] cefoxitin/dextrose [INJ] clindamycin phosphate/dextrose [INJ] benztropine butorphanol nasal cefpodoxime clindamycin phosphate/tretinoin benztropine [INJ] BYDUREON [INJ] cefprozil CLINIMIX [INJ] BEPREVE BYETTA [INJ] ceftazidime [INJ] CLINIMIX E [INJ] BESPONSA [INJ] [SP] BYSTOLIC CEFTAZIDIME/DEXTROSE [INJ] clobazam betamethasone acetate/betamethasone ceftriaxone [INJ] clobetasol propionate sodium phosphate [INJ] C ceftriaxone/dextrose [INJ] clobetasol propionate shampoo betamethasone dipropionate cefuroxime axetil clobetasol propionate/emollient betamethasone dipropionate augmented cabergoline cefuroxime