Advanced Reference Formulary Member Guide [PDF]

Advanced Reference Formulary Member Guide Please take this guide with you on your next doctor visit.

Express Scripts manages your prescription benefit for your health plan.

Express Scripts manages your prescription drug benefit for your health plan. The Advanced Reference Formulary Member Guide is a formulary list of medications that may be covered under your prescription drug plan. This list was reviewed by an independent group of practicing doctors and pharmacists, and it contains medications made by most pharmaceutical manufacturers. It includes medications for many covered conditions.

SAVING MONEY ON PRESCRIPTIONS

Your plan may prefer some medications over others. These are called preferred drugs. You may pay: •  Lowest co-payment/co-insurance for generic drugs •  Higher co-payment/co-insurance for preferred brand-name drugs •  Highest co-payment/co-insurance for nonpreferred brand-name drugs Your doctor may be able to help you save money by prescribing generic and preferred brand-name drugs if appropriate. So be sure to take this guide with you on every visit to your doctor. Some commonly prescribed nonpreferred drugs are also listed in this guide for your reference. Please note: This guide does not contain a complete list of preferred and nonpreferred drugs.

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FINDING MEDICATIONS WITH LOWER CO-PAYMENTS/CO-INSURANCE

This guide lists medications two ways to help you find some generic, preferred, and nonpreferred brand-name drugs. SECTION I - ALPHABETICALLY BY DRUG CATEGORY (SUCH AS RESPIRATORY) Within each category, medications are listed in alphabetical order, with generic, preferred brand-name, and nonpreferred brand-name drugs sorted separately: G P NP

Means a preferred generic medication Means a preferred brand-name medication Means a nonpreferred brand-name medication

SECTION II - ALPHABETICALLY BY BRAND NAME After each nonpreferred brand-name drug, you will find possible generic and preferred brand-name alternatives.

SAFETY CONSIDERATION SYMBOLS

Here is a quick guide for you and your doctor, which explains our safety symbols. These symbols appear next to certain medications. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

The information in this guide was in effect at the time of printing and may be subject to change.

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SECTION I: THERAPEUTIC DRUG CATEGORIES ANTI-INFECTIVES (Antibiotics/Antifungals) Oral Penicillins

NP

G G G

G G G G G G G

G G

P NP NP NP NP NP

NP NP NP NP NP NP

G G P NP NP NP NP NP NP NP Key: G = P = NP = = =

cefaclor cefadroxil hydrate cefdinir cefpodoxime proxetil cefprozil cefuroxime axetil cephalexin monohydrate Cedax Ceftin Keflex Omnicef Spectracef Suprax

Oral Erythromycins

Oral Tetracyclines

G G

Vibramycin

Oral Cephalosporins

amoxicillin trihydrate amoxicillin trihydrate/ potassium clavulanate ampicillin trihydrate dicloxacillin sodium penicillin v potassium Augmentin Suspension 125 - 31.25mg/5 Augmentin ES Augmentin Suspension 250 - 62.5mg/5 Augmentin Tablet Augmentin XR Moxatag

G G G G G

doxycycline hyclate doxycycline monohydrate minocycline HCl tetracycline HCl Oracea Adoxa Doryx Dynacin Minocin Monodox Periostat Solodyn

G G NP NP NP NP

azithromycin clarithromycin clarithromycin ER erythromycin base erythromycin ethylsuccinate erythromycin ethylsuccinate/ sulfisoxazole acetyl erythromycin stearate Biaxin Biaxin XL Dificid EryPed

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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NP NP NP

PCE Zithromax Zmax

G G G G NP NP NP NP NP NP NP NP

ciprofloxacin HCl levofloxacin moxifloxacin ofloxacin Avelox Cipro Suspension Cipro Tablet Cipro XR Factive Levaquin Noroxin Proquin XR

G

erythromycin ethylsuccinate/ sulfisoxazole acetyl sulfadiazine sulfamethoxazole/ trimethoprim sulfisoxazole Bactrim DS Septra DS

Oral Quinolones

G NP NP

G G G G G Key: G = P = NP = = =

G G G G G

clotrimazole fluconazole flucytosine griseofulvin griseofulvin ultramicrosize itraconazole ketoconazole nystatin terbinafine HCl voriconazole Lamisil Oral Granules Noxafil Sporanox Oral Solution Ancobon Diflucan Grifulvin V Gris-Peg Lamisil Tablet Mycostatin Nizoral Oravig Sporanox Capsule Vfend

G G G G G P P P NP NP NP NP NP NP NP NP NP NP

Oral Urinary Tract Agents

G

Furadantin Hiprex Macrobid Macrodantin Monurol Primsol

Oral Antifungal Agents

Oral Sulfas

G G

NP NP NP NP NP NP

methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal phenazopyridine HCl trimethoprim

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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PSYCHOTHERAPEUTICS (Anxiety/Depression) Hypnotic Agents

G G G G G G

NP NP NP NP NP NP NP NP NP

estazolam eszoplicone flurazepam HCl zaleplon zolpidem tartrate zolpidem tartrate controlled release Ambien Ambien CR Doral Edluar Halcion Lunesta Restoril Rozerem Sonata

G G G G G G G G G NP NP NP NP NP NP NP

amitriptyline HCl amoxapine clomipramine HCl desipramine HCl doxepin HCl imipramine HCl nortriptyline HCl protriptyline HCl trimipramine maleate Anafranil Norpramin Pamelor Surmontil Tofranil Tofranil-PM Vivactil

Miscellaneous Antidepressants

G G G G G G G

G G G NP NP NP NP NP NP NP NP NP

Tricyclic Antidepressants

Key: G = P = NP = = =

bupropion HCl tablet bupropion HCl tablet, sustained action desvenlafaxine ER duloxetine maprotiline HCl mirtazapine mirtazapine orally disintegrating tablets trazodone HCl venlafaxine HCl venlafaxine HCl ER Cymbalta Desyrel Effexor Effexor XR Pristiq ER Remeron Wellbutrin Wellbutrin SR Wellbutrin XL

Antipsychotics

G G G G G G G G G G

chlorpromazine HCl clozapine fluphenazine HCl haloperidol haloperidol lactate concentrate, oral loxapine succinate olanzapine quetiapine risperidone trifluoperazine HCl

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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G P P P NP NP NP NP NP NP NP NP NP NP NP

ziprasidone HCl Moban Orap Seroquel XR Abilify Clozaril Fanapt Geodon Invega Latuda Risperdal Saphris Seroquel Symbyax Zyprexa

G G G G

alprazolam alprazolam XR buspirone HCl chlordiazepoxide HCl clorazepate dipotassium diazepam lorazepam oxazepam Ativan Buspar Niravam Tranxene T-Tab Valium Xanax Xanax XR

MAOI Antidepressants

G G

G G G NP NP NP NP NP NP NP

Key: G = P = NP = = =

G G G G G G G NP NP NP NP NP NP NP NP NP NP

citalopram HBr escitalopram oxalate fluoxetine HCl fluvoxamine ER fluvoxamine maleate paroxetine HCl sertraline HCl Celexa Lexapro Luvox CR Paxil Paxil CR Pexeva Prozac Prozac Weekly Sarafem Zoloft

SSRI Antidepressants

Anxiolytics

G

NP NP NP

phenelzine sulfate tranylcypromine sulfate Emsam Nardil Parnate

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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CARDIOVASCULAR

(Blood Pressure/Heart/Cholesterol)

Beta Blockers

G G G G G G G G G G G G

G P P NP NP NP NP NP NP NP NP NP NP NP NP NP

G

acebutolol HCl atenolol betaxolol HCl bisoprolol fumarate carvedilol labetalol HCl metoprolol succinate metoprolol tartrate nadolol pindolol propranolol HCl propranolol HCl capsule, sustained action 24 hr timolol maleate Bystolic Coreg CR Coreg Corgard Inderal Inderal LA Innopran XL Kerlone Levatol Lopressor Sectral Tenormin Toprol XL Trandate Zebeta

G G G G NP NP NP NP NP NP NP NP NP

Dihydropyridines

G G G G G

G NP NP NP NP NP NP

Calcium Blockers

G G

Key: G = P = NP = = =

diltiazem HCl capsule, sustained release 24 hr nimodipine verapamil HCl verapamil HCl capsule, 24 hr sustained release verapamil HCl tablet, sustained action Calan SR Cardizem Cardizem CD Cardizem LA Covera-HS Isoptin S.R. Tiazac Verelan Verelan PM

diltiazem HCl diltiazem HCl capsule, sustained release 12 hr

amlodipine besylate felodipine isradipine nifedipine nifedipine tablet, sustained release nisoldipine Adalat CC Cardene SR DynaCirc CR Norvasc Procardia XL Sular

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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Nitroglycerin Patches

G

NP NP

G P P P P NP NP NP NP NP NP NP NP NP NP

nitroglycerin patch, spray Minitran Patch Nitro-Dur Patch

Adrenergic Antagonists & Related Drugs

G G

G G G G G G NP NP NP NP NP NP NP NP

clonidine HCl clonidine transdermal patch doxazosin mesylate guanfacine HCl methyldopa prazosin HCl reserpine terazosin HCl Cardura Cardura XL Catapres Catapres-TTS Hytrin Minipress Nexiclon XR Tenex

Antilipidemics

G G G G G G G

Angiotensin II Blockers & Renin Inhibitors

G G G G G G G G G

Key: G = P = NP = = =

valsartan HCTZ Benicar Benicar HCT Tekturna Tekturna HCT Atacand Atacand HCT Avalide Avapro Cozaar Diovan Diovan HCT Exforge Exforge HCT Hyzaar

G G G G G

amlodipine/valsartan candesartan candesartan/HCT irbesartan irbesartan HCTZ losartan potassium losartan potassium/ HCTZ telmisartan/ amlodipine valsartan

G G NP NP NP NP NP

atorvastatin cholestyramine/ aspartame cholestyramine/ sucrose colestipol HCl fenofibrate, micronized fenofibrate tablet fenofibric acid delayed release fluvastatin gemfibrozil lovastatin niacin omega-3-acid ethyl esters pravastatin simvastatin Advicor Antara Altoprev Caduet Colestid

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP

Crestor Fenoglide Lescol Lescol XL Lipitor Livalo Lofibra Lopid Lovaza Mevacor Niaspan Pravachol Questran Questran Light Simcor Tricor Triglide Trilipix Vytorin Welchol Zetia Zocor

NP NP

Combination Antihypertensives

G G G G G G G G G G G G G

ACE Inhibitors

G G G G G G G G G G NP NP NP NP NP NP NP Key: G = P = NP = = =

Vasotec Zestril

G G G

benazepril HCl captopril enalapril maleate fosinopril sodium lisinopril moexipril perindopril erbumine quinapril ramipril trandolapril Accupril Aceon Altace Lotensin Mavik Prinivil Univasc

NP NP NP NP NP NP NP NP NP NP NP NP NP NP

amlodipine besylate/ benazepril atenolol/ chlorthalidone benazepril HCl/HCTZ bisoprolol fumarate/ HCTZ captopril/HCTZ enalapril maleate/ HCTZ fosinopril/HCTZ hydralazine HCl/HCTZ lisinopril/HCTZ methyldopa/HCTZ metoprolol/HCTZ moexipril/HCTZ nadolol/ bendroflumethiazide propranolol HCl/HCTZ quinapril/HCTZ trandolapril/ verapamil Accuretic Azor Clorpres Corzide Lopressor HCT Lotensin HCT Lotrel Prinzide Tarka Tenoretic Uniretic Vaseretic Zestoretic Ziac

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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ENDOCRINE (Diabetes/Hormones/Contraceptives) Insulin Therapy

P P P P P P NP

Humalog Humalog Mix 50/50 Humalog Mix 75/25 Humulin Lantus Lantus SoloStar Levemir

G G G G G

acarbose chlorpropamide glimepiride glipizide glipizide/ metformin HCl glyburide glyburide/ metformin HCl glyburide, micronized metformin HCl metformin HCl tablet, sustained release 24 hr nateglinide pioglitazone pioglitazone/ metformin HCl repaglinide tolazamide tolbutamide Avandamet Avandaryl

Non-Insulin Hypoglycemic Agents

G G G G G G G G G G G P P

Key: G = P = NP = = =

P P P P P P NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP

Avandia Bydureon Janumet Januvia Kombiglyze XR Symlin Actoplus Met Actos Amaryl Byetta Cycloset DiaBeta Duetact Fortamet Glucophage Glucophage XR Glucotrol Glucotrol XL Glucovance Glynase Glyset Metaglip Prandimet Prandin Precose Riomet Starlix

G

alcohol antiseptic pads One Touch Test Strips One Touch Ultra Test Strips

Blood Glucose Test Strips

P P

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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Contraceptive Agents

G G G G G G G

G G G G G G G P P P P P P P NP NP Key: G = P = NP = = =

desogestrel-ethinyl estradiol desogestrel-ethinyl estradiol/ethinyl estradiol ethinyl estradiol/ drospirenone ethynodiol d-ethinyl estradiol levonorgestrel levonorgestrelethinyl estradiol levonorgestrelethinyl estradiol/ ethinyl estradiol norethindrone norethindrone a-e estradiol norethindrone a-e estradiol/ferrous fumarate norethindroneethinyl estradiol norethindronemestranol norgestimateethinyl estradiol norgestrel-ethinyl estradiol Beyaz Ella Loestrin 24 Fe Lo Loestrin Fe Natazia NuvaRing Safyral Brevicon Cyclessa

NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP NP

Demulen Desogen Estrostep Fe Femcon Fe Loestrin Loestrin Fe Lo/Ovral LoSeasonique Lybrel Mircette Modicon Nordette Norinyl Ortho-Cept Ortho-Cyclen Ortho Evra Ortho Micronor Ortho-Novum Ortho Tri-Cyclen Ortho Tri-Cyclen Lo Ovcon Ovral Plan B One-Step Seasonale Seasonique Tri-Norinyl Yasmin Yaz

G G

estradiol estradiol/ norethindrone acetate estropipate methyltestosterone/ estrogens, esterified

Estrogens/Estrogen Combinations

G G

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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G P P P P P P P P P P P P P NP NP NP NP NP NP NP

norethindrone/ ethinyl estradiol Cenestin Combipatch Enjuvia Estrace Vaginal Cream Estraderm Estring Evamist Premarin Tablet Premphase Prempro Vagifem Vivelle Vivelle-Dot Activella Alora Angeliq Climara Climara Pro Divigel Elestrin

NP NP NP NP NP NP NP NP NP NP NP NP

Estrace Tablet Estrasorb Estrogel Femhrt Femring Femtrace Menest Menostar Ogen Ortho-Prefest Prefest Premarin Vaginal Cream

G G G P NP NP NP NP NP NP

pantoprazole sodium rabeprazole ranitidine HCl Nexium Aciphex Axid Capsule Axid Oral Solution Cytotec Dexilant Pepcid

G I (Ulcer) Ulcer Drugs

G G G G G G G G

Key: G = P = NP = = =

cimetidine HCl liquid cimetidine tablet famotidine lansoprazole misoprostol nizatidine omeprazole omeprazole/sodium bicarbonate

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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NP NP NP NP

Prevacid Prilosec Rx Protonix Tagamet

NP NP

Zantac Rx Zegerid Rx

NSAIDS (Pain Relievers) NSAIDs

G G G G G G G G G

G G G G G G G G NP NP NP Key: G = P = NP = = =

NP NP NP

diclofenac sodium etodolac etodolac tablet, sustained release 24 hr flurbiprofen ibuprofen indomethacin capsule, sustained action ketoprofen ketoprofen capsule, 24 hr sustained release pellets meclofenamate sodium meloxicam nabumetone naproxen naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium Anaprox DS Ansaid Arthrotec

NP NP NP NP NP NP NP NP NP NP NP NP NP NP P

Clinoril Daypro diclofenac potassium EC-Naprosyn Feldene Indocin indomethacin Lodine Mobic Motrin Naprelan Naprosyn naproxen sodium tablet, sustained action Relafen Toradol Voltaren Voltaren-XR Flector

NSAID COX-2 Inhibitors

P

Celebrex

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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MIGRAINE/HEADACHE THERAPY G G G G G G

G G G G G P NP NP NP

NP NP NP NP NP NP NP NP NP NP NP

acetaminophen/ butalbital acetaminophen/ caffeine/butalbital aspirin/caffeine/ butalbital dihydroergotamine mesylate ergotamine/caffeine isometheptene mucate/ acetaminophen/ dichloralphenazone naratriptan HCl rizatriptan rizatriptan/MLT sumatriptan succinate zolmitriptan Ergomar Amerge Axert Cafergot tablet

Imitrex Maxalt Maxalt MLT Midrin Migranal Phrenilin Phrenilin Forte Relpax Treximet Zomig Zomig ZMT

DRUGS TO TREAT ALZHEIMER’S DISEASE G G G NP NP NP NP NP

Key: G = P = NP = = =

donepezil HCl galantamine ER rivastigmine Aricept Exelon patch Namenda Razadyne Razadyne ER

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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DRUGS TO TREAT OVERACTIVE BLADDER G G G G G G P P

P NP NP NP NP NP NP NP

flavoxate oxybutynin chloride oxybutynin chloride ER tolterodine trospium trospium ER Gelnique Toviaz

Vesicare Detrol Detrol LA Ditropan XL Enablex Oxytrol Sanctura Sanctura XR

RESPIRATORY (Allergy/Asthma) Beta Agonists Oral

G G G G

albuterol sulfate albuterol sulfate SR metaproterenol sulfate terbutaline sulfate

Beta Agonist Inhalers

G G G

P P P P NP NP NP NP

albuterol albuterol sulfate levalbuterol HCl nebulizer solution Foradil Proair HFA Serevent Diskus Ventolin HFA Accuneb Arcapta Brovana Perforomist

G

budesonide

fluticasone propionate Asmanex Pulmicort Flexhaler Pulmicort Respules QVAR Aerobid Aerobid-M

G G G

flunisolide fluticasone propionate triamcinolone acetonide Qnasl Flonase Nasacort AQ Nasonex

Nasal Corticosteroids

P NP NP NP

Miscellaneous Pulmonary Agents

G G

Inhaled Steroids

Key: G = P = NP = = =

G P P P P NP NP

acetylcysteine cromolyn sodium ampul for nebulization

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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G G G G G G P P P P P P NP NP NP NP NP NP NP NP NP NP NP NP NP NP

Key: G = P = NP = = =

Antihistamine/ Decongestant Combinations

desloratadine ipratropium/albuterol sulfate ipratropium bromide solution montelukast sildenafil citrate zafirlukast Atrovent HFA Combivent Pulmozyme Spiriva Tracleer Ventavis Accolate Adcirca Atrovent Inhalation Solution Cinryze Daliresp Duoneb Kalbitor Letairis Revatio Tablet Singulair Symbicort Xolair Zyflo Zyflo CR

G

NP NP NP

pseudoephidrine w/chlorpheniramine Clarinex-D 12 hr Clarinex-D 24 hr Deconamine Liquid

Antihistamines

G G G G G G G G NP NP NP NP NP NP

clemastine fumarate cyproheptadine HCl diphenhydramine HCl fexofenadine HCl hydroxyzine HCl hydroxyzine pamoate levocetirizine promethazine HCl Allegra ODT Allegra Oral Suspension Clarinex Phenergan Vistaril Xyzal

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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OSTEOPOROSIS/PAGET’S DISEASE G G G G G P P NP NP NP NP NP NP NP

Key: G = P = NP = = =

alendronate sodium calcitonin, salmon, synthetic ibandronate sodium raloxifene risedronate 150mg Atelvia Forteo Actonel Boniva 150mg Evista Fosamax Plus D Fosamax Solution Fosamax Tablet Prolia

Means a preferred generic medication. Means a preferred brand-name medication. Means a nonpreferred brand-name medication. Means weigh risk of birth defects or other adverse outcomes. Means do not use in pregnancy.

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SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED ALTERNATIVES Nonpreferred Product

Abilify®

Possible Preferred Products

Accolate®

clozapine (generic), quetiapine (generic), risperidone (generic), ziprasidone HCl (generic), Seroquel XR® (AstraZeneca) zafirlukast (generic)

Accuneb®

albuterol sulfate (generic)

Accupril® Accuretic® Aceon®

quinapril (generic) quinapril/hydrochlorothiazide (generic) enalapril (generic), lisinopril, (generic), benazepril (generic), ® Aciphex omeprazole (generic), pantoprazole (generic), rabeprazole (generic), Nexium® (AstraZeneca) ® Activella 1-0.5mg estradiol/norethindrone acetate (generic) Activella® estradiol/norethindrone acetate (generic), 0.5-0.1mg Premphase® (Wyeth), Prempro® (Wyeth) ® Actonel alendronate sodium (generic), Ibandronate sodium with Calcium (generic) ® Adalat CC nifedipine ER (generic), amlodipine besylate (generic) Adcirca® sildenafil citrate (generic) Adderall XR® amphetamine aspartate/amphetamine sulfate/ dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) ® Advicor lovastatin (generic), omega-3-acid ethyl esters (generic), Niaspan® (Abbot) ® Aerobid fluticasone propionate (generic), Asmanex® (Schering), Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax) Aerobid-M® fluticasone propionate (generic), Asmanex® (Schering), Pulmicort Inhaler® (AstraZeneca), QVAR® (Ivax) Aggrenox® dipyridamole (generic), ticlopidine (generic), cilostazol (generic), aspirin (generic) ® Allegra ODT OTC fexofenadine HCl (generic) Alora® estradiol patch (generic), Estraderm® (Novartis), Vivelle® (Novartis) Altoprev® atorvastatin (generic), lovastatin (generic), omega-3acid ethyl esters (generic), simvastatin (generic), pravastatin (generic) Amaryl® glimepiride (generic) *Branded generics have the same co-payment as regular generics.

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Nonpreferred Product

Ambien® Ambien CR

®

Amerge® Anafranil® Anaprox DS® Angeliq® Ansaid® Antara® Anzemet® Aricept® Arixtra® Arthrotec® Atacand® Atacand HCT® Ativan® Atrovent® solution Augmentin® chewable tablet 125-31.25mg 200-28.5mg, 400-57mg Augmentin® suspension 200-28.5mg/5, 250-62.5mg/5, 400-57mg/5 Augmentin® tablet Augmentin ES® Augmentin XR® Avalide® Avapro® Avelox® Avodart® Axert® Axid® Capsule

Possible Preferred Products

eszoplicone (generic), zolpidem tartrate (generic), zaleplon (generic) eszoplicone (generic), zolpidem tartrate controlled release (generic) naratriptan HCl (generic), sumatriptan succinate (generic) clomipramine HCl (generic) naproxen sodium (generic) estradiol/norethindrone acetate (generic), Premphase® (Wyeth), Prempro® (Wyeth) flurbiprofen (generic) fenofibrate (generic), gemfibrozil (generic) granisetron (generic), ondansetron (generic) donepezil HCl (generic) enoxaparin (generic), fondaparinux (generic) ibuprofen (generic), naproxen (generic) candesartan (generic), telmisartan/amlodipine (generic) candesartan/HCT (generic), telmisartan/amlodipine (generic) lorazepam (generic) ipratropium bromide (generic) amoxicillin trihydrate/potassium clavulanate (generic)

amoxicillin trihydrate/potassium clavulanate (generic)

amoxicillin trihydrate/potassium clavulanate (generic) amoxicillin trihydrate/potassium clavulanate (generic) amoxicillin trihydrate/potassium clavulanate (generic) irbesartan/HCTZ (generic), telmisartan/amlodipine (generic) irbesartan (generic), telmisartan/amlodipine (generic) levofloxacin (generic) dutaseride (generic), finasteride (generic) naratriptan HCl (generic), sumatriptan succinate (generic) nizatidine (generic), rabeprazole (generic)

*Branded generics have the same co-payment as regular generics.

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Nonpreferred Product

Azilect® Azor® Bactrim DS® Biaxin® Biaxin XL® Boniva® Brevicon® Brovana® Buspar® Butisol Sodium® Byetta®

Caduet®

Calan SR® Carafate® Tablet Cardene SR® Cardizem® Cardizem CD® Cardizem LA® Cardura® carisoprodol Cataflam® Catapres® Catapres-TTS® Ceclor CD® Cedax® Ceftin® Cefzil® Celexa® Celontin® Cipro® Tablet Clarinex®

Possible Preferred Products

selegiline (generic) amlodipine besylate (generic) sulfamethoxazole/trimethoprim (generic) clarithromycin (generic) clarithromycin ER (generic) ibandronate sodium (generic) Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*) Foradil® (Schering),Proair HFA® (Teva), Serevent Diskus® (GlaxoSmithKline) buspirone HCl (generic)

Bydureon® (Amylin), Januvia® (Merck), Janumet® (Merck)

amlodipine besylate (generic), atorvastatin (generic), lovastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic), simvastatin (generic) verapamil HCl tablet, sustained action (generic) sucralfate (generic) amlodipine besylate (generic), nifedipine ER (generic) diltiazem HCl (generic) diltiazem HCl capsule, sustained release 24 hr (generic) diltiazem HCl (generic), verapamil SR (generic), doxazosin mesylate (generic) chlorzoxazone (generic), cyclobenzaprine (generic), diazepam (generic) etodolac (generic), ibuprofen (generic), naproxen (generic) clonidine HCl tablet (generic) clonidine HCl patch (generic) cefaclor (generic), cefdinir (generic), cefuroxime axetil (generic) cefaclor (generic), cefdinir (generic), cefuroxime axetil (generic) cefuroxime axetil (generic) cefaclor (generic), cefdinir (generic), cefuroxime axetil (generic) citalopram (generic) ethosuximide (generic) ciprofloxacin HCl tablet (generic) desloratadine (generic), OTC fexofenadine (generic), OTC Claritin, OTC Zyrtec, OTC Benadryl (diphenhydramine)

*Branded generics have the same co-payment as regular generics.

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Nonpreferred Product

Possible Preferred Products

Clarinex Reditabs® OTC fexofenadine (generic), OTC Claritin, OTC Zyrtec, OTC Benadryl (diphenhydramine) Cleocin HCl® clindamycin HCl (generic) Climara Pro® Combipatch® (Novartis) Clinoril® sulindac (generic) Clorpres® clonidine HCl (generic), chlorthalidone (generic) Colestid® cholestyramine (generic), colestipol (generic), omega-3-acid ethyl esters (generic) Coreg® carvedilol (generic) Corgard® Concerta®

Corzide® Covera-HS® Cozaar® Crestor® Cyclessa® Cycloset® Cymbalta®

Cytotec® Daypro® Daytrana®

Demulen® Desogen® Desyrel® Detrol®

nadolol (generic) amphetamine aspartate/amphetamine sulfate/ dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) bisoprolol fumarate/hydrochlorothiazide (generic), metoprolol/hydrochlorothiazide (generic), propranolol HCl/hydrochlorothiazide (generic) verapamil HCl capsule, 24 hr sustained release (generic) losartan potassium (generic), telmisartan/amlodipine (generic) atorvastatin (generic), fluvastatin (generic), lovastatin (generic), simvastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic) Caziant® (Watson-branded generic*), Cesia® (Pharmedixbranded generic*), Velivet® (Barr-branded generic*) metformin HCl (generic), Januvia® (Merck), Janumet® (Merck) bupropion SR (generic), bupropion XL (generic), desvenlafaxine (generic), duloxetine HCl (generic), mirtazapine (generic), venlafaxine (generic), venlafaxine HCl ER (generic) misoprostol (generic), rabeprazole (generic) oxaprozin (generic) amphetamine aspartate/amphetamine sulfate/ dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) Zovia® (Watson-branded generic*) Apri® (Barr-branded generic*), Solia® (Prasco Labs-branded generic*) trazodone HCl (generic) tolterodine (generic)

*Branded generics have the same co-payment as regular generics.

21

Nonpreferred Product

Detrol LA® Dexilant® DiaBeta® Diclofenac Potassium Diclofenac Sodium Diflucan® Dilacor XR® Dilatrate SR® Dilaudid® liquid

Diovan® Dispermox® Ditropan XL® Doral® Doryx Duoneb® Dynacin® DynaCirc CR® EC-Naprosyn® Edluar® Effexor® Effexor XR® Elestrin® ®

Possible Preferred Products

tolterodine (generic) omeprazole (generic), pantoprazole (generic), rabeprazole (generic) glyburide (generic) etodolac (generic), ibuprofen (generic), naproxen (generic) etodolac (generic), ibuprofen (generic), naproxen (generic) fluconazole (generic) diltiazem XR (generic) isosorbide dinitrate (generic), isosorbide mononitrate (generic), isosorbide mononitrate sustained release (generic) oxycodone (generic), morphine sulfate sustained release (generic), morphine sulfate (generic), codeine sulfate (generic), fentanyl (generic), hydromorphone (generic) candesartan (generic), losartan (generic), telmisartan/amlodipine (generic), valsartan (generic) amoxicillin trihydrate suspension (generic), amoxicillin trihydrate chewable tablet (generic) oxybutynin chloride ER (generic) eszoplicone (generic), zaleplon (generic), zolpidem tartrate (generic) doxycycline hyclate (generic) ipratropium/albuterol sulfate (generic) minocycline HCl (generic) amlodipine besylate (generic), nifedipine ER (generic) naproxen (generic) eszoplicone (generic), zolpidem tartrate (generic) desvenlafaxine (generic), venlafaxine HCl (generic) venlafaxine HCl ER (generic) estradiol patch (generic), Estraderm® (Novartis), Vivelle® (Novogyne)

Emsam® Enablex®

tranylcypromine sulfate (generic), Nardil® (Parke-Davis) oxybutynin (generic), oxybutynin chloride (generic), oxybutynin chloride ER (generic), tolterodine (generic), trospium (generic), trospium ER (generic) Enduronyl Forte® hydrochlorothiazide (generic), methyldopa/HCTZ (generic) EryPed® Chewable erythromycin ethylsuccinate (generic) Tablet 200mg

*Branded generics have the same co-payment as regular generics.

22

Nonpreferred Product

EryPed® Suspension 400mg/5ml Estrace® Tablet Estrasorb® Estrogel® Estrostep Fe® Exforge® Exforge HCT®

Factive® Feldene® Femcon Fe® Femhrt® Femring® Femtrace® Fenoglide® Flomax® Flonase® Fortamet® Fosamax® Fragmin® Geodon® Glucophage® Glucophage XR® Glucotrol® Glucotrol XL® Glucovance® Glynase® Glyset®

Possible Preferred Products

erythromycin ethylsuccinate (generic) estradiol (generic) estradiol patch (generic) estradiol patch (generic), Estraderm® (Novartis), Vivelle® (Novartis) Apri® (Barr-branded generic*), Kariva® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*) amlodipine/benazepril (generic), amlodipine/lisinopril (generic), amlodipine/enalapril (generic), amlodipine/valsartan (generic) amlodipine/benazepril (generic), amlodipine/lisinopril (generic), amlodipine/enalapril (generic), amlodipine/valsartan (generic), hydrochlorothiazide (generic) ciprofloxacin (generic), levofloxacin HCl (generic) piroxicam (generic) Zeosa (Teva-branded generic*) estradiol/norethindrone acetate (generic), Premphase® (Wyeth), Prempro® (Wyeth) Estring® (Pfizer), Premarin Vaginal Cream® (Wyeth) estradiol (generic) fenofibrate micronized (generic), gemfibrozil (generic), omega-3-acid ethyl esters (generic) doxazosin (generic), terazosin (generic) fluticasone propionate (generic) metformin HCl ER (generic), metformin HCl tablet (generic) alendronate sodium (generic) enoxaparin (generic), fondaparinux (generic) ziprasidone (generic), olanzapine (generic) metformin HCl (generic) metformin HCl ER (generic), metformin HCl tablet (generic) glipizide (generic) glipizide ER (generic) glyburide/metformin HCl (generic) glyburide, micronized (generic) acarbose (generic)

*Branded generics have the same co-payment as regular generics.

23

Nonpreferred Product

Grifulvin V® Gris-Peg® Guanabenz Acetate® Halcion® Hiprex® Hytrin® Hyzaar® Imitrex® Inderal® Inderal LA® Indocin® Innopran XL® Invega® Isoptin S.R.® Kapidex® Keflex® Kerlone® Ketek® Lamisil® Lescol® Lescol XL® Letairis® Levaquin® Levatol® Levemir® Levlen®

Possible Preferred Products

griseofulvin ultramicrosize (generic), itraconazole (generic), ketoconazole (generic), terbinafine HCl (generic) griseofulvin ultramicrosize (generic), itraconazole (generic), ketoconazole (generic), terbinafine HCl (generic) clonidine HCl (generic), methyldopa (generic) estazolam (generic), eszoplicone (generic), zolpidem tartrate (generic) methenamine hippurate (generic) terazosin (generic) losartan potassium/HCTZ (generic), telmisartan/amlodipine (generic) sumatriptan succinate (generic) propranolol HCl (generic) propranolol capsule, sustained action (generic) indomethacin (generic) propranolol capsule, sustained action (generic) quetiapine (generic), risperidone (generic), ziprasidone HCl (generic), Seroquel XR® (AstraZeneca) verapamil HCl tablet, sustained action (generic) omeprazole (generic), pantoprazole (generic), Nexium® (AstraZeneca) cephalexin monohydrate (generic) betaxolol HCl (generic) amoxicillin trihydrate/potassium clavulanate (generic), azithromycin (generic), levofloxacin HCl (generic) terbinafine HCl (generic) atorvastatin (generic), fluvastatin (generic), lovastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic), simvastatin (generic) atorvastatin (generic), fluvastatin (generic), lovastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic), simvastatin (generic) Tracleer® (Actelion) levofloxacin (generic) acebutolol HCl (generic), atenolol (generic), metoprolol tartrate (generic) Lantus® (Aventis), Humulin N® (Eli Lilly and Company) Levora® (Watson-branded generic*), Portia® (Barr-branded generic*)

*Branded generics have the same co-payment as regular generics.

24

Nonpreferred Product

Possible Preferred Products

Lexapro®

escitalopram (generic), paroxetine CR (generic), paroxetine (generic), fluoxetine (generic), citalopram (generic), sertraline (generic) Lexapro® solution escitalopram (generic), citalopram solution (generic), fluoxetine HCl solution (generic), paroxetine HCl suspension (generic) Lipitor® atorvastatin (generic), fluvastatin (generic), lovastatin (generic), simvastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic) Lodine® etodolac (generic) Loestrin® Junel® (Barr-branded generic*), Microgestin® (Watson-branded generic*) Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*) Loestrin 24 Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*) Lofibra® fenofibrate (generic), omega-3-acid ethyl esters (generic) Lo Loestrin Fe® Junel Fe® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*) Lo/Ovral® Low-Ogestrel® (Watson-branded generic*) Lopid® gemfibrozil (generic), omega-3-acid ethyl esters (generic) Lopressor® metoprolol tartrate (generic) Lopressor HCT® metoprolol/hydrochlorothiazide (generic) LoSeasonique® Aviane® (Barr-branded generic*), Lutera® (Watson-branded generic*) Lotensin® benazepril HCl (generic) Lotensin HCT® benazepril HCl/hydrochlorothiazide (generic) Lotrel® amlodipine besylate/benazepril (generic) Lotrel® 5-40mg, amlodipine/benazepril (generic), amlodipine/lisinopril 10-40mg (generic), amlodipine/enalapril (generic), amlodipine/valsartan (generic) fenofibrate micronized (generic), gemfibrozil (generic), Lovaza® OTC Fish Oil, omega-3-acid ethyl esters (generic) ® Lovenox enoxaparin (generic) fluvoxamine maleate (generic), fluvoxamine ER Luvox CR® (generic) ® Lyrica carbamazepine (generic), gabapentin (generic), lamotrigine (generic), topiramate (generic) ® Macrobid nitrofurantoin macrocrystal (generic) Macrodantin® nitrofurantoin (generic) Mandelamine® methenamine mandelate (generic) Mavik® trandolapril HCl (generic) *Branded generics have the same co-payment as regular generics.

25

Nonpreferred Product

Possible Preferred Products

Maxalt®

naratriptan HCl (generic), rizatriptan (generic), sumatriptan (generic) naratriptan HCl (generic), rizatriptan/MLT (generic), Maxalt MLT sumatriptan (generic) ® estradiol (generic), estropipate (generic), Cenestin® Menest (Duramed/Barr), Enjuvia® (Duramed/Barr), Premarin® (Wyeth) Menostar Patch® Vivelle Patch® (Novartis) amphetamine aspartate/amphetamine sulfate/ Metadate CD® dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) ® amphetamine aspartate/amphetamine sulfate/ Metadate ER dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) ® Metaglip glipizide/metformin (generic) Mevacor® lovastatin (generic), omega-3-acid ethyl esters (generic) ® Midrin isometheptene/apap/dichloralphenazone (generic) naratriptan HCl (generic), sumatriptan nasal spray Migranal® (generic), Zomig® Nasal Spray (AstraZeneca) Minipress® prazosin HCl (generic) Minocin® minocycline HCl (generic) Mircette® Kariva® (Barr-branded generic*) Mobic® meloxicam (generic) Necon® (Watson-branded generic*), Nortrel® Modicon® (Barr-branded generic*) Monistat 3 Vaginal miconazole 3 vaginal suppository (generic) Suppository® Monodox® doxycycline monohydrate (generic) ciprofloxacin HCl (generic), sulfamethoxazole/ Monurol® trimethoprim (generic), trimethoprim (generic) ® Motrin ibuprofen (generic) Moxatag® amoxicillin (generic) etodolac (generic), ibuprofen (generic), indomethacin Nalfon® (generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic) Namenda donepezil HCl (generic), galantamine (generic), Dose Pack® galantamine ER (generic), rivastigmine (generic) ® galantamine oral solution (generic), Exelon Oral Namenda Oral Solution Solution® (Novartis) ® Namenda Tablet donepezil HCl (generic), galantamine (generic), galantamine ER (generic), rivastigmine (generic) ®

*Branded generics have the same co-payment as regular generics.

26

Nonpreferred Product

Possible Preferred Products

Naprelan® Naprosyn® Nasacort AQ® Nasonex® Natazia® Nexiclon XR® Niravam® Nitrostat® Nizoral® Nordette® Norinyl® Norpramin® Norvasc® Ogen® Omnicef® Oravig® Ortho-Cept® Ortho-Cyclen® Ortho Evra® Ortho Micronor® Ortho-Novum® 1/35, 7/7/7 Ortho-Novum® 1/50 Ortho-Prefest® Ortho Tri-Cyclen

®

Ortho Tri-Cyclen Lo® Ovcon® Ovral®

naproxen sodium (generic) naproxen (generic) flunisolide (generic), fluticasone propionate (generic), triamcinolone acetonide (generic) flunisolide (generic), fluticasone propionate (generic), triamcinolone acetonide (generic) Necon® (Watson-branded generic*) clonidine HCl (generic) alprazolam (generic) nitrolingual (generic), nitroglycerine (generic) ketoconazole (generic) Levora® (Watson-branded generic*), Portia® (Barr-branded generic*) Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*) desipramine HCl (generic) amlodipine besylate (generic) estropipate (generic) cefdinir (generic) clotrimazole (generic), fluconazole (generic), nystatin (generic) Apri®(Barr-branded generic*), Solia® (Prasco Labs-branded generic*) MonoNessa® (Watson-branded generic*), Previfem® (Teva-branded generic*), Sprintec® (Barr-branded generic*) MonoNessa® (Watson-branded generic*), TriNessa® (Watson-branded generic*) norethindrone acetate (generic) Necon® (Watson-branded generic*), Nortrel® (Barr-branded generic*) Necon® (Watson-branded generic*) estradiol/norethindrone acetate (generic), Premphase® (Wyeth), Prempro® (Wyeth) TriNessa® (Watson-branded generic*), Tri-Previfem® (Teva-branded generic*), Tri-Sprintec® (Barr-branded generic*) TriNessa® (Watson-branded generic*), Tri-Previfem® (Teva-branded generic*), Tri-Sprintec® (Barr-branded generic*) Necon® (Watson-branded generic*) Ogestrel® (Watson-branded generic*)

*Branded generics have the same co-payment as regular generics.

27

Nonpreferred Product

Possible Preferred Products

Oxycontin®

oxycodone (generic), morphine sulfate sustained release (generic), morphine sulfate (generic), codeine sulfate (generic), fentanyl (generic), hydromorphone (generic) OxyFAST® oxycodone (generic), morphine sulfate sustained release (generic), morphine sulfate (generic), codeine sulfate (generic), fentanyl (generic), hydromorphone (generic) ® OxyIR oxycodone (generic), morphine sulfate sustained release (generic), morphine sulfate (generic), codeine sulfate (generic), fentanyl (generic), hydromorphone (generic) Oxytrol® oxybutynin (generic), oxybutynin chloride (generic), oxybutynin chloride ER (generic), tolterodine (generic), trospium (generic), trospium ER Pacerone® 100mg, amiodarone (generic) 200mg, 300mg Pamelor® nortriptyline HCl (generic) Parnate® tranylcypromine sulfate (generic) ® Paxil paroxetine HCl (generic) Paxil CR® paroxetine HCl sustained release tab (generic) PCE® erythromycin (generic) Pepcid famotidine (generic), cimetidine HCl liquid (generic), Suspension® rabeprazole (generic) Pepcid Tablet® famotidine (generic), rabeprazole (generic) Perforomist® Foradil® (Schering Corporation), Serevent Diskus® (GlaxoSmithKline) Periostat® doxycycline hyclate (generic) Pexeva® paroxetine HCl (generic) ® Phenergan promethazine HCl (generic) Phrenilin® acetaminophen/caffeine/butalbital (generic), aspirin/caffeine butalbital (generic) ® Phrenilin Forte acetaminophen/caffeine/butalbital (generic), aspirin/caffeine butalbital (generic) Plavix clopidogrel (generic) Ponstel® etodolac (generic), ibuprofen (generic), indomethacin capsule (generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic) ® Prandimet metformin HCl (generic), Prandin® (Novo Nordisk) Pravachol® pravastatin (generic), omega-3-acid ethyl esters (generic) Precose® acarbose (generic) ® Prevacid lansoprazole (generic), omeprazole (generic), pantoprazole (generic), rabeprazole (generic), Nexium® (AstraZeneca) *Branded generics have the same co-payment as regular generics.

28

Nonpreferred Product

Prilosec Rx® Primsol Prinivil® Prinzide® Pristiq ER® ®

Procardia XL® Proquin XR® ProSom® Protonix® Suspension Protonix® Tablet Provigil®

Prozac® Prozac Weekly® Questran® Questran Light® Raniclor® Razadyne® Razadyne ER® Relafen® Relpax® Remeron® Restoril® Riomet Solution® Risperdal Oral Solution® Risperdal Tablet®

Possible Preferred Products

omeprazole (generic), pantoprazole (generic), rabeprazole (generic), Nexium® (AstraZeneca) trimethoprim (generic) lisinopril (generic) lisinopril/hydrochlorothiazide (generic) citalopram (generic), desvenlafaxine ER (generic), paroxetine CR 12.5mg and 25mg, paroxetine (generic), fluoxetine (generic), sertraline (generic) nifedipine ER tablet, sustained release osmotic push (generic) ciprofloxacin HCl (generic) estazolam (generic) Nexium® Suspension (AstraZeneca), rabeprazole (generic) pantoprazole sodium (generic), omeprazole (generic), rabeprazole (generic), Nexium® (AstraZeneca) amphetamine aspartate/amphetamine sulfate/ dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic), modafinil (generic) fluoxetine HCl (generic) fluoxetine HCl (generic) cholestyramine (generic), omega-3-acid ethyl esters (generic), prevalite (generic) cholestyramine/aspartame (generic), omega-3-acid ethyl esters (generic), prevalite (generic) cefaclor suspension (generic), cefaclor capsule (generic) galantamine (generic) galantamine ER (generic) nabumetone (generic) naratriptan HCl (generic), sumatriptan (generic) mirtazapine soltabs (generic), mirtazapine tabs (generic) eszoplicone (generic) metformin HCl (generic) risperidone (generic) risperidone (generic)

Risperdal M Tab® risperidone orally disintegrating tablet (generic) Rozerem® estazolam (generic), eszoplicone (generic), zolpidem tartrate (generic) *Branded generics have the same co-payment as regular generics.

29

Nonpreferred Product

Sanctura® Sanctura XR® Sarafem® Seasonale® Seconal Sodium® Sectral® Septra DS® Serophene® Seroquel Simcor® Skelaxin® Solodyn® Sonata® Spectracef® Sporanox® capsule Starlix® Suboxone® tablets Sular® Suprax® Surmontil® Symbicort® Symbyax®

Possible Preferred Products

trospium (generic) trospium ER (generic) fluoxetine HCl (generic) Jolessa® (Barr-branded generic*), Quasense® (Watson-branded generic*), Lybrel® (Wyeth), Seasonique® (Duramed/Barr) acebutolol HCl (generic) sulfamethoxazole/trimethoprim (generic) clomiphene citrate (generic) quetiapine (generic) omega-3-acid ethyl esters (generic), simvastatin (generic) cyclobenzaprine (generic), chlorzoxazone (generic), diazepam (generic) minocycline HCl (generic), doxycycline monohydrate (generic) eszoplicone (generic), zaleplon (generic) cefaclor (generic), cefdinir (generic), cefuroxime axetil (generic) itraconazole (generic) repaglinide (generic) buprenorphine/naloxone (generic), Suboxone® film nisoldipine (generic) cefdinir (generic), cefuroxime axetil (generic) trimipramine maleate (generic)

olanzapine (generic), fluoxetine HCl (generic), quetiapine (generic), risperidone (generic), Seroquel XR® (AstraZeneca) Tagamet® cimetidine (generic), rabeprazole (generic) Tarka® amlodipine besylate/benazepril (generic) Tenex® guanfacine HCl (generic) Tenoretic® atenolol/chlorthalidone (generic) Tenormin® atenolol (generic) Terazol® terconazole (generic) ® Thioridazine HCl chlorpromazine HCl (generic), haloperidol (generic), quetiapine (generic), risperidone (generic) Tiazac® 120mg, diltiazem HCl capsule, sustained release 24 hr 180mg, 240mg, (generic) 300mg, 360mg Tiazac® 420mg diltiazem HCl capsule (generic) *Branded generics have the same co-payment as regular generics.

30

Nonpreferred Product

Possible Preferred Products

Tofranil® Tofranil® PM

imipramine HCl (generic) amitriptyline, (generic), desipramine (generic), nortriptyline (generic), trimipramine maleate (generic) Toprol XL® metoprolol succinate (generic) etodolac (generic), ibuprofen (generic), indomethacin Toradol® capsule (generic), meclofenamate sodium (generic), naproxen (generic), sulindac (generic) Trandate® labetalol HCl (generic) Tranxene T-Tab® clorazepate dipotassium (generic) Enpresse® (Barr-branded generic*), Trivora® Tri-Levlen® (Watson-branded generic*) Necon® (Watson-branded generic*), Nortrel® Tri-Norinyl® (Barr-branded generic*) fenofibrate micronized (generic), fenofibrate tablet Tricor® (generic), gemfibrozil (generic), omega-3-acid ethyl esters (generic) fenofibrate micronized (generic), gemfibrozil (generic), Triglide® omega-3-acid ethyl esters (generic) ® Enpresse® (Barr-branded generic*), Trivora® Triphasil (Watson-branded generic*) Tussionex dextromethorphan HBr/pseudoephedrine HCl/ brompheniramine (generic), guaifenesin/ dextromethorphan HBr tablet (generic), guaifenesin/codeine phosphate Uniretic® moexipril/hydrochlorothiazide (generic) Univasc® benazepril (generic), enalapril maleate (generic), lisinopril (generic), moexipril (generic) ® Uroxatral alfuzosin (generic), doxazosin (generic), terazosin (generic) ® Valium diazepam (generic) Vantin® cefpodoxime proxetil (generic) Vaseretic® enalapril maleate/hydrochlorothiazide (generic) Vasotec® enalapril maleate (generic) Verelan® verapamil ER (generic) Verelan PM® verapamil ER PM (generic) Vfend® voriconazole (generic) Vibramycin® Syrup doxycycline monohydrate suspension (generic) Vistaril® hydroxyzine pamoate (generic) Vivactil® protriptyline HCl (generic) Voltaren® etodolac (generic), ibuprofen (generic), naproxen (generic) ® Voltaren-XR etodolac (generic), ibuprofen (generic), naproxen (generic) *Branded generics have the same co-payment as regular generics.

31

Nonpreferred Product

Possible Preferred Products

Vytorin®

atorvastatin (generic), fluvastatin (generic), lovastatin (generic), simvastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic) Vyvanse® amphetamine aspartate/amphetamine sulfate/ dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) Welchol® cholestyramine (generic), colestipol (generic), lovastatin (generic), simvastatin (generic), omega-3acid ethyl esters (generic), pravastatin (generic) Wellbutrin® bupropion HCl (generic) Wellbutrin SR® bupropion HCl tablet, sustained release (generic) Wellbutrin XL® bupropion tablet, sustained release (generic) Wytensin® clonidine HCl (generic), methyldopa (generic) Xanax® alprazolam (generic) Xanax XR® alprazolam XR (generic) Xifaxan® 200mg azithromycin (generic), ciprofloxacin HCl (generic) Xolair® fluticasone propionate (generic), Asmanex® (Schering), Pulmicort® (AstraZeneca), QVAR® (Ivax) Xopenex® Solution albuterol (generic), metaproterenol (generic) Xyrem® amphetamine aspartate/amphetamine sulfate/ dextroamphetamine (generic), dexmethylphenidate (generic), methylphenidate SR (generic), D-amphetamine sulfate (generic), methylphenidate (generic) Xyzal Solution® OTC fexofenadine HCl (generic), Allegra Suspension® (Aventis) Xyzal Tablet® levocetirizine (generic) Yasmin® Ocella® (Barr-branded generic*) Zantac Rx® Syrup rabeprazole (generic), ranitidine HCl tablet (generic) Zantac Rx® Tablet rabeprazole (generic), ranitidine HCl tablet (generic) Zebeta® bisoprolol fumarate (generic) Zegerid® omeprazole (generic), rabeprazole (generic), Nexium® (AstraZeneca) Zestoretic® lisinopril/hydrochlorothiazide (generic) Zestril® lisinopril (generic) Zetia® lovastatin (generic), simvastatin (generic), omega-3acid ethyl esters (generic), pravastatin (generic) ® Ziac bisoprolol fumarate/hydrochlorothiazide (generic) Zithromax® azithromycin (generic) Zmax® azithromycin (generic) *Branded generics have the same co-payment as regular generics.

32

Nonpreferred Product

Zocor® Zoloft® Zomig® Zomig ZMT® Zyflo® Zyflo CR® Zyprexa®

Possible Preferred Products

atorvastatin (generic), fluvastatin (generic), lovastatin (generic), omega-3-acid ethyl esters (generic), pravastatin (generic), simvastatin (generic) sertraline HCl (generic) naratriptan HCl (generic), sumatriptan (generic) naratriptan HCl (generic), sumatriptan (generic), zolmitriptan (generic) montelukast (generic) montelukast (generic) olanzapine (generic), ziprasidone (generic)

*Branded generics have the same co-payment as regular generics.

33

2015 PREFERRED DRUG LIST EXCLUSIONS The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

TAKE ACTION TO AVOID PAYING FULL PRICE.

If you are currently using one of the excluded medications, please ask your doctor to consider writing a new prescription for one of the following preferred alternatives. Drug Class AUTONOMIC & CENTRAL NERVOUS SYSTEM Interferon Beta Medications for Multiple Sclerosis

Excluded Medications

Preferred Alternatives

Betaseron

Avonex, Extavia, Plegridy, Rebif

Long-Acting Opioid Oral Analgesics

Kadian, Oxycodone ER, Zohydro ER

morphine sulfate ER, oxymorphone ER, Nucynta ER, Opana ER, Oxycontin

Transmucosal Fentanyl Analgesics

Abstral, Fentora, Subsys

fentanyl lozenge, Lazanda

Triptans

Axert, Frova

rizatriptan, sumatriptan, zolmitriptan, Relpax

CARDIOVASCULAR Angiotensin II Receptor Antagonists + Diuretic Combinations

Edarbi/Edarbyclor, Teveten HCT

candesartan/HCTZ, , irbesartan/HCTZ, losartan/HCTZ, valsartan/HCTZ, Benicar/HCT

DERMATOLOGICAL Topical Acne/Antibiotic Combinations

BenzaClin Gel Pump, Veltin

clindamycin/benzoyl peroxide, clindamycin PLUS tretinoin, Acanya, Ziana

DIABETES Blood Glucose Meters & Strips

Abbott (Freestyle, Precision), Bayer (Breeze, Contour), Nipro (TRUEtest, TRUEtrack), Roche (Accu-Chek)

LifeScan (OneTouch)

34

Drug Class

Excluded Medications

Preferred Alternatives

Dipeptidyl Peptidase-4 Inhibitors & Combinations

Jentadueto, Kazano, Nesina, Tradjenta

Janumet, Janumet XR, Januvia, Kombiglyze XR, Onglyza

Glucagon-Like Peptide-1 Agonists

Tanzeum, Victoza

Bydureon, Byetta, Trulicity

Insulins

Novolin

Humulin

Apidra, NovoLog

Humalog

Beconase AQ, Omnaris, Veramyst, Zetonna

flunisolide, fluticasone propionate, triamcinolone acetonide, Nasonex, Qnasl

Cetraxal

ciprofloxacin otic solution, Ciprodex

Nutropin/Nutropin AQ, Omnitrope, Saizen, Tev-Tropin

Genotropin, Humatrope, Norditropin

Fortesta, Testim, Testosterone Gel, Vogelxo

AndroGel, Axiron

Duexis

famotidine PLUS ibuprofen

Vimovo

omeprazole PLUS naproxen

Pancreaze, Pertzye, Ultresa

pancrelipase, Creon, Zenpep

HEMATOLOGICAL ErythropoiesisStimulating Agents

Aranesp, Epogen

Procrit

HEPATITIS Antivirals

Moderiba, RibaPak, RibaTab

ribavirin capsules, ribavirin tablets

Hepatitis C (genotype 1)

Harvoni, Incivek, Olysio, Sovaldi*

Viekira Pak

Pegylated Interferons

PegIntron

Pegasys

Cimzia, Simponi, Xeljanz

Enbrel, Humira, Stelara

EAR/NOSE Nasal Steroids

Otic Fluoroquinolone Antibiotics ENDOCRINE (OTHER) Growth Hormones Topical Testosterone Products GASTROINTESTINAL Anti-Inflammatory/ Anti-Ulcer Agents Pancreatic Enzymes

INFLAMMATORY CONDITIONS Tumor Necrosis Factor Antagonists and Other Drugs for Inflammatory Conditions

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Drug Class

Excluded Medications

Preferred Alternatives

OBSTETRICAL & GYNECOLOGICAL Ovulatory Stimulants (Follitropins)

Bravelle, Follistim AQ

Gonal-f

OPHTHALMIC Antiglaucoma Drugs (Ophthalmic Prostaglandins)

Zioptan

latanoprost ophthalmic solution, travoprost ophthalmic solution, Lumigan, Travatan Z

OSTEOARTHRITIS Hyaluronic Acid Derivatives

Euflexxa, Gel-One, Hyalgan, Supartz

Monovisc, Orthovisc, Synvisc, Synvisc-One

RESPIRATORY Pulmonary Anti-Inflammatory Inhalers

Alvesco, Arnuity Ellipta, Flovent Diskus/HFA

Asmanex Twisthaler/HFA, Pulmicort Flexhaler, QVAR

Pulmonary Anti-Inflammatory/ Beta Agonist Combination Inhalers

Breo Ellipta

Dulera, Symbicort

Short-Acting Beta-2 Adrenergic Inhalers

Proventil HFA, Xopenex HFA

ProAir HFA, Ventolin HFA

Levitra, Staxyn, Stendra

Cialis, Viagra

UROLOGICAL Erectile Dysfunction Oral Agents

Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to Express-Scripts.com/covered to compare drug prices. Other prescription benefit considerations may apply.

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EXCLUDED MEDICATIONS/PRODUCTS AT A GLANCE Abbott (FreeStyle, Precision) Abstral Alvesco Apidra Aranesp Arnuity Ellipta AxertBayer (Breeze, Contour) Beconase AQ BenzaClin Gel Pump Betaseron Bravelle Breo Ellipta Cetraxal Cimzia Duexis Edarbi/Edarbyclor Epogen Euflexxa Fentora Flovent Diskus/HFA Follistim AQ Fortesta Frova Gel-One Harvoni Hyalgan Incivek Jentadueto Kadian Kazano Levitra Moderiba Nesina Nipro (TRUEtest, TRUEtrack) Novolin NovoLog

Nutropin/Nutropin AQ Olysio Omnaris Omnitrope Oxycodone ER Pancreaze PegIntron Pertzye Proventil HFA RibaPak RibaTab Roche (Accu-Chek) Saizen Simponi Sovaldi* Staxyn Stendra Subsys Supartz Tanzeum Testim Testosterone Gel Teveten HCT Tev-Tropin Tradjenta Ultresa Veltin Veramyst Victoza Vimovo Vogelxo Xeljanz Xopenex HFA Zetonna Zioptan Zohydro ER

* Sovaldi may be covered for chronic hepatitis C genotypes 2-6 with a coverage review

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This guide does not contain a complete list of formulary and nonformulary drugs. It only lists the most commonly prescribed drugs.