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Prmt2053t-14.basic-t.130904

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit 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 a generic version
becomes available during the year. Not all the drugs listed are covered by all

2014 Express Scripts
prescription-drug benefit programs; check your benefit materials for the specific drugs
covered and the copayments for your prescription-drug benefit program. For specific

Basic Formulary
questions about your coverage, please call the phone number printed on your ID card.
ANTIINFECTIVES
Glucose Elevating Drugs
Antivirals
Angiotensin II Receptor
Class III Narcotics
Antagonists + HCT Combos
Growth Hormones
hydrocodone/acetaminophen FINACEA, FINACEA PLUS losartan/hydrochlorothiazide Other Cardiovascular Drugs
CNS Stimulants
Cephalosporins
Antipsoriasis & Antieczema Incretin Mimetics
Anti-Arrhythmic Drugs
Drugs
AUTONOMIC & CNS
MEDICATIONS
Macrolides
Beta-Adrenergic
Insulins
Antagonists
Corticosteroid Drugs
Anticonvulsants
Oral Antifungals
Drugs to Prevent & Treat
Headaches
Penicillins
Miscellaneous
Insulin Sensitizers
Dermatologicals
Oral Hypoglycemics
Quinolones
Tetracyclines
Calcium Antagonists
Antidementia Drugs
PRAMOSONE, PRAMOSONE E metformin ext-release Sodium-Glucose Co-
Antidepressants
Drugs to Treat Multiple
Transporter 2 Inhibitors
Sclerosis
Topical Anti-Inflammatory
Topical Antibacterials
Diuretics
Drugs
Thyroid Supplements
Topical Antifungals
EAR-NOSE MEDICATIONS
Other Endocrine Drugs
REBIF, REBIF REBIDOSE [INJ] Drugs Affecting The Ear
Endothelin Receptor
Non-Narcotic Analgesics
Urinary Antiinfectives
Antagonists
Antiparkinson Drugs
Other Antiinfective Drugs
Sedative/Hypnotics
Drugs Affecting The Nose
HMG-CoA Reductase
GASTROINTESTINAL
Inhibitors
MEDICATIONS
Antipsychotic Drugs
Selective Serotonin
Antispasmodics/Drugs
Reuptake Inhibitors
Affecting GI Motility
ANTINEOPLASTIC/IMMUNO-
ENDOCRINE MEDICATIONS
HMG-CoA Combinations
SUPPRESSANT DRUGS
H. Pylori Drugs
Amylin Analogues
Proton Pump Inhibitors
Antivertigo & Antiemetics
Hypolipoproteinemics
Androgen Drugs
Tertiary Amines
Other GI Drugs
Other Autonomic/CNS Drugs Dipeptidyl Peptidase-IV
Anxiolytics
Inhibitors & Combos
CARDIOVASCULAR
Other Drugs For ADHD
MEDICATIONS
Nitrates
Class II Narcotics
ACE Inhibitors +
DERMATOLOGICAL
Glucocorticoids
HCT Combos
MEDICATIONS
Other Antihypertensives
morphine sulfate ext-release Antiacne Drugs
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2014 Express Scripts Holding Company
#2053 BASIC-T
All Rights Reserved
PRMT2053T-14 (09/04/13)
RESPIRATORY MEDICATIONS
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected Antihistamines
alternatives that are on the formulary. Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Estrogen Drugs
Nonformulary Medications Formulary Alternative(s)
IMMUNOLOGICALS
Freestyle meters/strips, OneTouch meters/strips Antihistamine/Antitussives
Erythroid Stimulants
Interferons
Estrogen/Progestin
Antitussive & Expectorants
morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, Combinations
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl MUSCULOSKELETAL
Beta-2 Adrenergics
MEDICATIONS
CNS Muscle Relaxants
Ovulatory Stimulants
Freestyle meters/strips, OneTouch meters/strips candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, Prenatal Vitamins
Leukotriene Modifiers
Drugs to Prevent & Treat
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Gout
Other Drugs For Asthma
morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, Progestin Drugs
Injectable Drugs For
Arthritis
Non-Steroidal Anti-
Inflammatory Agents
Specialized OB/GYN Drugs
morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER, Vaginal Antiinfectives
UROLOGICAL MEDICATIONS
Anticholinergic
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, Other OB/GYN Products
Antispasmodics
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, OPHTHALMIC MEDICATIONS
NUTRITION & BLOOD
Antibacterial Drugs
MODIFIERS
Antiplatelet Drugs
Drugs Used For BPH
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Erectile Dysfunction Agents
Blood Detoxicants
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Oral and Inj. Anticoagulants Antiglaucoma Drugs
DIABETIC SUPPLIES
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, Therapeutic Vitamins &
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Minerals
Meters & Strips
Corticosteroid Drugs
Freestyle meters/strips, OneTouch meters/strips flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl Other Ophthalmic Drugs
Thrombin Inhibitors
flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl latanoprost, travoprost, Lumigan, Travatan Z OBSTETRICAL &
GYNECOLOGICAL
MEDICATIONS
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
For the member: Generic medications contain the same active ingredients as their corresponding
Contraceptives
Miscellaneous Supplies
brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2014 Express Scripts Holding Company
#2053 BASIC-T
All Rights Reserved
PRMT2053T-14 (09/04/13)

Source: http://cms.bsu.edu/-/media/WWW/DepartmentalContent/Payroll/PDFs/2014%20Basic%20Formulary%20List.pdf

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