MG43315U - 3Q12 PPF RXS - MEIPG v2 MG43315U - 3Q12 PPF

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Transcript of MG43315U - 3Q12 PPF RXS - MEIPG v2 MG43315U - 3Q12 PPF

MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEIPG_v2.qxdPreferred Prescriptions®/ RX Selections™
Member Guide Please bring this guide with you on your next doctor visit.
Express Scripts manages your prescription drug benefit for your employer, plan sponsor, or health plan. Medco is now a part of the Express Scripts family of pharmacies.
PMS 301C Black
NOTES
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Preferred Prescriptions®/RX Selections™ 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 bring 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 formulary and nonformulary drugs. It only lists the most commonly prescribed drugs. Visit Express-Scripts.com anytime to check the price and coverage of medications under your plan. Simply select “Price a medication” from the left hand menu and search for your medication to see pricing. Click “View coverage notes” on the pricing results page to see any coverage details. If you are a first-time visitor to Express-Scripts.com, please take a moment to register. (Be sure to have your member ID number and a recent prescription number handy.) Not all medications listed here are covered by every prescription drug plan.
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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 Means a preferred generic medication P Means a preferred brand-name medication NP 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.
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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Oral Penicillins G amoxicillin trihydrate G amoxicillin trihydrate/
potassium clavulanate G ampicillin trihydrate G dicloxacillin sodium G penicillin v
potassium P Augmentin Chewable
Suspension 125 - 31.25mg/5
Suspension 200 - 28.5mg/5, 250 - 62.5mg/5, 400 - 57mg/5
NP Augmentin Tablet NP Augmentin XR NP Moxatag
Oral Tetracyclines G doxycycline hyclate G doxycycline
monohydrate G minocycline HCl G tetracycline HCl
P Oracea NP Adoxa NP Adoxa Pak NP Doryx NP Dynacin NP Minocin NP Monodox NP Periostat NP Solodyn NP Vibramycin
Oral Cephalosporins G cefaclor G cefadroxil hydrate G cefdinir G cefpodoxime proxetil G cefprozil G cefuroxime axetil G cephalexin
monohydrate NP Ceclor CD NP Cedax NP Ceftin NP Duricef NP Keflex NP Omnicef NP Spectracef NP Suprax NP Vantin
ANTI-INFECTIVES (Antibiotics/Antifungals)
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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Oral Erythromycins G azithromycin G clarithromycin G clarithromycin ER G erythromycin base G erythromycin
ethylsuccinate G erythromycin
ethylsuccinate/ sulfisoxazole acetyl
G erythromycin stearate P Dificid NP Biaxin NP Biaxin XL NP EryPed NP PCE NP Zithromax NP Zmax
Oral Quinolones G ciprofloxacin HCl G levofloxacin G ofloxacin P Avelox P Cipro Suspension NP Cipro Tablet NP Cipro XR NP Factive NP Floxin NP Levaquin NP Noroxin NP Proquin XR
Oral Sulfas G erythromycin
G sulfisoxazole NP Bactrim DS NP Gantrisin NP Septra DS
Oral Urinary Tract Agents G methenamine
hippurate G methenamine
mandelate G nitrofurantoin G nitrofurantoin
macrocrystal G phenazopyridine HCl G trimethoprim NP Furadantin NP Hiprex NP Macrobid NP Macrodantin NP Monurol NP Primsol
Oral Antifungal Agents G clotrimazole G fluconazole G flucytosine G griseofulvin G griseofulvin
ultramicrosize G itraconazole G ketoconazole G nystatin G terbinafine HCl G voriconazole
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Hypnotic Agents G chloral hydrate G estazolam G flurazepam HCl G temazepam G triazolam G zaleplon G zolpidem tartrate P Lunesta P Silenor NP Ambien NP Ambien CR NP Doral NP Edluar NP Halcion NP Intermezzo NP Restoril NP Rozerem NP Sonata NP Zolpimist
Tricyclic Antidepressants G amitriptyline HCl G amoxapine G clomipramine HCl G desipramine HCl G doxepin HCl G imipramine HCl G imipramine
pamoate G nortriptyline HCl G protriptyline HCl G trimipramine maleate NP Anafranil NP Norpramin NP Pamelor NP Surmontil NP Tofranil NP Tofranil-PM NP Vivactil
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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P Lamisil Oral Granules P Noxafil P Sporanox Oral
Solution NP Ancobon NP Diflucan NP Grifulvin V NP Gris-Peg NP Lamisil Tablet NP Mycostatin NP Mycelex Troche NP Nizoral
NP Oravig NP Sporanox Capsule NP Vfend
PSYCHOTHERAPEUTICS (Anxiety/Depression)
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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Miscellaneous Antidepressants G bupropion HCl G maprotiline HCl G mirtazapine G trazodone HCl G venlafaxine HCl P Cymbalta P Pristiq NP Desyrel NP Effexor NP Effexor XR NP Oleptro ER NP Remeron NP Wellbutrin NP Wellbutrin SR NP Wellbutrin XL
Antipsychotics G chlorpromazine HCl G clozapine G fluphenazine HCl G haloperidol G haloperidol lactate
concentrate, oral G loxapine succinate G olanzapine G perphenazine G quetiapine fumarate G risperidone G thiothixene G trifluoperazine HCl G ziprasidone HCl
P Abilify P Clozaril P Latuda P Moban P Orap P Seroquel XR NP Fanapt NP Geodon NP Invega NP Risperdal NP Saphris NP Seroquel NP Symbyax NP Zyprexa NP Zyprexa Zydis
Anxiolytics G alprazolam G alprazolam XR G buspirone HCl G chlordiazepoxide
HCl G clorazepate
dipotassium G diazepam G lorazepam G oxazepam NP Ativan NP Buspar NP Librium NP Niravam NP Tranxene T-Tab NP Valium NP Xanax NP Xanax XR
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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MAOI Antidepressants G phenelzine sulfate G tranylcypromine
sulfate NP Emsam NP Nardil NP Parnate
SSRI Antidepressants G citalopram HBr G escitalopram oxalate G fluoxetine HCl G fluvoxamine maleate G paroxetine HCl G sertraline HCl P Viibryd NP Celexa NP Lexapro NP Luvox CR NP Paxil NP Paxil CR NP Pexeva NP Prozac NP Prozac Weekly NP Sarafem NP Zoloft
Miscellaneous Psychotherapeutic Agents G amphetamine
aspartate/ amphetamine sulfate/ dextroamphetamine
G lithium citrate G methamphetamine
HCl G methylphenidate HCl G modafinil P Daytrana P Intuniv P Metadate CD P Strattera P Vyvanse P Xyrem NP Adderall NP Adderall XR NP Concerta NP Desoxyn NP Dexedrine NP Focalin NP Focalin XR NP Kapvay NP Liquadd NP Lithobid NP Methylin Oral
Solution NP Methylin Chewable
Tablet NP Nuvigil NP Provigil NP Ritalin NP Ritalin LA NP Ritalin SR
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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Beta Blockers G acebutolol HCl G atenolol G betaxolol HCl G bisoprolol fumarate G carvedilol G labetalol HCl G metoprolol succinate G metoprolol tartrate G nadolol G pindolol G propranolol HCl G timolol maleate P Bystolic P Coreg CR NP Coreg NP Corgard NP Inderal NP Inderal LA NP Innopran XL NP Kerlone NP Levatol NP Lopressor NP Sectral NP Tenormin NP Toprol XL NP Trandate NP Zebeta
Calcium Blockers G diltiazem HCl G nimodipine G verapamil HCl P Cardizem LA 120mg
NP Calan SR NP Cardizem NP Cardizem CD NP Cardizem LA 180mg,
240mg, 300mg, 360mg, 420mg
NP Cardizem SR NP Covera-HS NP Dilacor XR NP Isoptin S.R. NP Nimotop NP Tiazac NP Verelan NP Verelan PM
Dihydropyridines G amlodipine besylate G felodipine G isradipine G nifedipine G nisoldipine NP Adalat CC NP Cardene SR NP DynaCirc CR NP Norvasc NP Procardia XL NP Sular
Nitroglycerin Patches G nitroglycerin patch P Nitro-Dur Patch NP Minitran Patch
CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol)
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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Adrenergic Antagonists & Related Drugs G clonidine HCl G doxazosin mesylate G guanfacine HCl G methyldopa G prazosin HCl G reserpine G terazosin HCl NP Cardura NP Cardura XL NP Catapres NP Catapres-TTS NP Hytrin NP Minipress NP Nexiclon XR NP Tenex
Angiotensin II Blockers & Renin Inhibitors G eprosartan
mesylate G irbesartan G irbesartan/
hydrochlorothiazide G losartan potassium G losartan/
hydrochlorothiazide G valsartan/
hydrochlorothiazide P Amturnide P Atacand P Atacand HCT P Benicar P Benicar HCT P Diovan P Micardis P Micardis HCT
P Tekamlo P Tekturna P Tekturna HCT P Valturna NP Avalide NP Avapro NP Cozaar NP Diovan HCT NP Edarbi NP Edarbyclor NP Hyzaar NP Teveten NP Teveten HCT
Antilipidemics G atorvastatin calcium G cholestyramine/
aspartame G cholestyramine/
sucrose G colestipol HCl G fenofibrate,
micronized G fluvastatin sodium G gemfibrozil G lovastatin G pravastatin G simvastatin P Altoprev P Antara P Crestor P Fenoglide P Lipofen P Lovaza P Niaspan P Simcor P Tricor P Triglide P Trilipix P Vytorin P Welchol
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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P Zetia NP Advicor NP Caduet NP Colestid NP Fibricor NP Lescol NP Lescol XL NP Lipitor NP Livalo NP Lofibra NP Lopid NP Mevacor NP Pravachol NP Questran NP Questran Light NP Zocor
ACE Inhibitors G benazepril HCl G captopril G enalapril maleate G fosinopril sodium G lisinopril G moexipril G perindopril erbumine G quinapril G ramipril G trandolapril NP Accupril NP Aceon NP Altace NP Lotensin NP Mavik NP Monopril NP Prinivil NP Univasc NP Vasotec NP Zestril
Combination Antihypertensives G amlodipine
hydrochlorothiazide G quinapril/
hydrochlorothiazide G trandolapril/
verapamil P Azor P Exforge P Exforge HCT P Tarka P Tribenzor P Twynsta NP Accuretic NP Clorpres
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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Insulin Therapy P Apidra P Apidra Solostar P Humalog P Humalog Mix 50/50 P Humalog Mix 75/25 P Humulin P Lantus P Lantus SoloStar P Levemir P NovoLog P NovoLog Mix 70/30 NP Novolin
Non-Insulin Hypoglycemic Agents G acarbose G chlorpropamide G glimepiride G glipizide G glipizide/
metformin HCl G glyburide G glyburide/
metformin HCl G glyburide, micronized G metformin HCl G nateglinide
G pioglitizone HCl G pioglitizone HCl/
metformin HCl G tolazamide G tolbutamide P Actoplus Met XR P Bydureon P Byetta P Duetact P Janumet P Janumet XR P Januvia P Jentadueto P Juvisync P Kombiglyze XR P Onglyza P Prandimet P Prandin P Riomet P Symlin P Tradjenta P Victoza NP Actoplus Met NP Actos NP Amaryl NP Avandamet NP Avandaryl NP Avandia
ENDOCRINE (Diabetes/Hormones/Contraceptives)
NP Corzide NP Dutoprol NP Lopressor HCT NP Lotensin HCT NP Lotrel NP Prinzide
NP Tenoretic NP Uniretic NP Vaseretic NP Zestoretic NP Ziac
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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 Cycloset NP DiaBeta NP Fortamet NP Glucophage NP Glucophage XR NP Glucotrol NP Glucotrol XL NP Glucovance NP Glumetza NP Glynase NP Glyset NP Metaglip NP Precose NP Starlix
Blood Glucose Test Strips G alcohol antiseptic
pads P Accu-Chek Active Test
Strips P Accu-Chek Aviva Plus
Test Strips P Accu-Chek Aviva Test
Strips P Accu-Chek Comfort
Test Strips P Accu-Chek Smartview
Test Strips P Fast Take Test Strips P One Touch Test Strips P One Touch Ultra Test
Strips P One Touch Verio Test
Strips P Surestep Pro Test
Strips P Surestep Test Strips
Contraceptive Agents G desogestrel-ethinyl
estradiol G norethindrone a-e
G norethindrone- mestranol
G norgestrel-ethinyl estradiol
P Beyaz P Ella P Loestrin 24 Fe P Lo Loestrin Fe P Natazia P NuvaRing P Safyral
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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P Yaz NP Alesse NP Brevicon NP Cyclessa NP Demulen NP Desogen NP Estrostep Fe NP Femcon Fe NP Levlite NP Loestrin NP Loestrin Fe NP Lo/Ovral NP LoSeasonique NP Lybrel NP Mircette NP Modicon NP Nordette NP Norinyl NP Ortho-Cept NP Ortho-Cyclen NP Ortho Evra NP Ortho Micronor NP Ortho-Novum NP Ortho Tri-Cyclen NP Ortho Tri-Cyclen Lo NP Ovcon NP Ovral NP Plan B One-Step NP Seasonale NP Seasonique NP Tri-Norinyl NP Yasmin
Estrogens/Estrogen Combinations G estradiol G estradiol/
norethindrone acetate
G estropipate
G norethindrone/ ethinyl estradiol
P Cenestin P Climara P Combipatch P Divigel P Enjuvia P Estrace Vaginal
Cream P Estraderm P Estring P Evamist P Premarin Tablet P Premphase P Prempro P Vagifem P Vivelle P Vivelle-Dot NP Activella NP Alora NP Angeliq NP Climara Pro NP Elestrin NP Estrace Tablet NP Estrasorb NP Estrogel NP Femhrt NP Femring NP Femtrace NP Menest NP Menostar NP Ogen NP Ortho-Prefest NP Prefest NP Premarin Vaginal
Cream
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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NSAIDs G etodolac G flurbiprofen G ibuprofen G indomethacin G ketoprofen G meclofenamate
sodium G meloxicam G nabumetone G naproxen G naproxen sodium G oxaprozin G piroxicam G sulindac G tolmetin sodium P Flector
P Vimovo P Voltaren Gel NP Anaprox DS NP Ansaid NP Arthrotec NP Cambia NP Cataflam NP Clinoril NP Daypro NP diclofenac
potassium NP diclofenac sodium NP Duexis NP EC-Naprosyn NP Feldene NP Indocin NP Lodine NP Mobic
NSAIDS (Pain Relievers)
Ulcer Drugs G cimetidine HCl liquid G cimetidine tablet G famotidine G lansoprazole G misoprostol G nizatidine G omeprazole G omeprazole/sodium
bicarbonate G pantoprazole sodium G ranitidine HCl
P Axid Oral Solution P Nexium NP Aciphex NP Axid Capsule NP Cytotec NP Dexilant NP Pepcid NP Prevacid NP Prilosec Rx NP Protonix NP Tagamet NP Zantac Rx NP Zegerid Rx
G I (Ulcer)
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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 Motrin NP Nalfon NP Naprelan NP Naprosyn NP Pennsaid NP Relafen NP Sprix
NP Toradol NP Voltaren Tablets NP Voltaren-XR
NSAID COX-2 Inhibitors P Celebrex
G flavoxate G oxybutynin chloride G tolterodine tartrate G trospium chloride P Detrol LA P Enablex P Gelnique
P Oxytrol P Sanctura XR P Toviaz P Vesicare NP Detrol NP Ditropan XL NP Sanctura
DRUGS TO TREAT OVERACTIVE BLADDER
Beta Agonists Oral G albuterol sulfate G metaproterenol
sulfate G terbutaline sulfate NP Alupent NP Proventil
Beta Agonist Inhalers G albuterol G albuterol sulfate G levalbuterol HCl G metaproterenol
sulfate
P Foradil P Perforomist P Proair HFA P Serevent Diskus P Ventolin HFA NP Accuneb NP Arcapta Neohaler NP Brovana NP Maxair Autohaler NP Proventil HFA NP Xopenex NP Xopenex HFA
Inhaled Steroids G budesonide
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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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P Alvesco P Asmanex P Pulmicort Flexhaler P Pulmicort 1mg/2mL
Respules P QVAR NP Aerobid NP Aerobid-M NP Azmacort NP Flovent Diskus NP Flovent HFA NP Pulmicort 0.25mg/2mL NP Pulmicort 0.5mg/2mL
Nasal Corticosteroids G flunisolide G fluticasone propionate G triamcinolone
acetonide P Nasonex P Qnasl P Rhinocort Aqua P Veramyst NP Beconase AQ NP Flonase NP Nasacort AQ NP Omnaris
Miscellaneous Pulmonary Agents G acetylcysteine G cromolyn sodium
ampul for nebulization
G ipratropium/albuterol sulfate
G ipratropium bromide solution
G montelukast sodium G zafirlukast P Adcirca P Advair Diskus P Advair HFA P Atrovent HFA P Berinert P Cinryze P Combivent P Combivent Respimat P Daliresp P Dulera P Intal Inhaler P Kalydeco P Letairis P Pulmozyme P Revatio P Spiriva P Symbicort P Tracleer P Tyvaso P Ventavis NP Accolate NP Duoneb NP Firazyr NP Kalbitor NP Singulair NP Xolair NP Zyflo NP Zyflo CR
MG43315U - 3Q12 PPF RXS - MEIPG_v2_MG43315U - 3Q12 PPF RXS - MEI
Key: G = Means a preferred generic medication. P = Means a preferred brand-name medication. NP = 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 alendronate sodium G calcitonin, salmon,
synthetic G ibandronate sodium P Actonel P Atelvia P Evista P Forteo NP Actonel with Calcium NP Boniva
NP Fosamax NP Fosamax Plus D NP Miacalcin Nasal Spray NP Prolia
OSTEOPOROSIS/PAGET’S DISEASE
Anticonvulsants/ Anti-Seizure G carbamazepine G clonazepam…