Formulary List 2015

The following is a list of the most commonly prescribed drugs. It represents an abbreviated
version 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.
2015 Express Scripts
High Performance Formulary
A
C
ABILIFY, ABILIFY DISCMELT
acetaminophen/codeine
acyclovir
AGGRENOX
albuterol nebulization
solution
alendronate sodium
allopurinol
ALPHAGAN P 0.1%
alprazolam
amiodarone
amitriptyline
amlodipine
amlodipine/benazepril
amoxicillin
amoxicillin/potassium
clavulanate
AMPYRA
anastrozole
ANORO ELLIPTA
antipyrine/benzocaine
apri
APRISO
arbinoxa
atenolol
atenolol/chlorthalidone
atorvastatin
AUVI-Q [INJ]
AVONEX [INJ]
AXIRON
azathioprine
azelastine nasal spray
azithromycin
calcipotriene
CANASA
carbidopa/levodopa
carvedilol
cefdinir
cefuroxime
CELEBREX
cephalexin
chlorhexidine gluconate
chlorthalidone
chorionic
gonadotropin [INJ]
CIPRODEX
ciprofloxacin
citalopram
clarithromycin
clindamycin hcl
clindamycin phosphate
clindamycin phosphate/
benzoyl peroxide
clobetasol propionate
clomiphene citrate
clonazepam
clonidine
clopidogrel
clotrimazole/
betamethasone
dipropionate
COLCRYS
COMBIVENT RESPIMAT
CONCEPTION KIT
COPAXONE 20 MG [INJ]
CREON
cyanocobalamin [INJ]
cyclobenzaprine
B
baclofen
benazepril
benazepril/
hydrochlorothiazide
benzonatate
bisoprolol/
hydrochlorothiazide
BRILINTA
budesonide nebulization
suspension
bupropion
bupropion ext-release
(12 hour)
bupropion ext-release
(24 hour)
buspirone
butalbital/acetaminophen/
caffeine
BYDUREON [INJ]
BYETTA [INJ]
D
donepezil
doxazosin
doxepin
doxycycline hyclate
doxycycline monohydrate
DULERA
duloxetine delayed-release
E
eliphos
ELIQUIS
enalapril
ENBREL [INJ]
ENDOMETRIN
enoxaparin [INJ]
ergocalciferol
erythromycin eye ointment
escitalopram
estradiol
estradiol/norethindrone
acetate
eszopiclone
etodolac
EUFLEXXA [INJ]
EXFORGE, EXFORGE HCT
EXTAVIA [INJ]
F
famotidine
fenofibrate
fenofibrate micronized
fenofibric acid
delayed-release
fentanyl patch
finasteride
fluconazole
fluocinonide
fluoxetine
fluticasone nasal spray
folic acid
FORADIL
FORTEO [INJ]
FREESTYLE METERS/KITS;
FREESTYLE FREEDOM,
FREESTYLE LITE,
FREESTYLE INSULINX
FREESTYLE TEST STRIPS;
FREESTYLE,
FREESTYLE LITE,
FREESTYLE INSULINX
furosemide
desloratadine
desonide
dexamethasone
dextroamphetamine/
amphetamine
dextroamphetamine/
amphetamine
ext-release
diazepam
diclofenac sodium
delayed-release
dicyclomine hcl
digoxin
diltiazem ext-release
(24 hour)
G
diphenoxylate/atropine
divalproex delayed-release gabapentin
GANIRELIX ACETATE [INJ]
divalproex ext-release
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 prescriptiondrug benefit programs; check your benefit materials for the specific drugs covered and
the copayments for your prescription-drug benefit program. For specific questions about
your coverage, please call the phone number printed on your member ID card.
gemfibrozil
gianvi
gildress fe
GILENYA
glimepiride
glipizide
glipizide ext-release
GLUCAGEN [INJ]
GLUCAGON [INJ]
glyburide
glyburide/metformin
GONAL-F [INJ]
GONAL-F RFF [INJ]
GRASTEK
H
HUMALOG [INJ]
HUMIRA [INJ]
HUMULIN [INJ]
hydralazine
hydrochlorothiazide
hydrocodone/
acetaminophen
hydrocodone/
chlorpheniramine
polistirex
hydrocodone/homatropine
hydrocodone/ibuprofen
hydrocortisone topical
hydromorphone
hydroxychloroquine
hydroxyzine hcl
hydroxyzine pamoate
I
ibandronate
ibuprofen
indomethacin
INVOKANA
irbesartan
isosorbide mononitrate
ext-release
J
JANUMET, JANUMET XR
JANUVIA
JENTADUETO
junel fe
K
ketoconazole topical
L
labetalol hcl
lamotrigine
lansoprazole
delayed-release
LANTUS [INJ]
latanoprost
LEVEMIR [INJ]
levetiracetam
levocetirizine
levofloxacin
levothyroxine sodium
lidocaine patch
LINZESS
liothyronine
lisinopril
lisinopril/
hydrochlorothiazide
lorazepam
losartan
losartan/
hydrochlorothiazide
lovastatin
LYRICA
N
nabumetone
NAMENDA XR
naproxen, naproxen sodium
neomycin/polymyxin/
hydrocortisone ear drops
niacin ext-release
nifedipine ext-release
nitrofurantoin
monohydrate/
macrocrystals
nortriptyline
NUEDEXTA
nystatin oral suspension
nystatin topical
nystatin/triamcinolone
O
M
MAKENA [INJ]
meclizine hcl
medroxyprogesterone
acetate
meloxicam
metaxalone
metformin
metformin ext-release
methadone
methimazole
methocarbamol
methotrexate
methylphenidate
methylphenidate
ext-release
methylprednisolone
metoclopramide hcl
metoprolol succinate
ext-release
metoprolol tartrate
metronidazole
metronidazole topical
metronidazole vaginal gel
microgestin fe
minocycline
mirtazapine
modafinil
mometasone
montelukast
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2015 THROUGH DECEMBER 31, 2015. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at Express-Scripts.com.
© 2015 Express Scripts
All Rights Reserved
morphine sulfate
ext-release
moxifloxacin
multivitamins/fluoride
mupirocin
MUSE
olanzapine
OLYSIO
omeprazole delayed-release
OMNITROPE [INJ]
ondansetron
ondansetron orally
disintegrating tablets
OPSUMIT
ORENCIA [INJ]
orsythia
OTEZLA
oxcarbazepine
oxybutynin
oxybutynin ext-release
oxycodone
oxycodone/acetaminophen
P
pantoprazole
delayed-release
paroxetine
PEGASYS [INJ]
penicillin v potassium
PERFOROMIST
pioglitazone
polymyxin/trimethoprim
potassium chloride
ext-release
POTIGA
pramipexole
(continued)
#1703 HP-A
PRMT1703A-15 (08/01/14)
pravastatin
prednisolone acetate
eye suspension
prednisolone sodium
phosphate
prednisone
PROAIR HFA
PROCRIT [INJ]
PRODIGY INSULIN SYR,
PEN NEEDLES
progesterone micronized
promethazine
promethazine/
dextromethorphan
propranolol
propranolol ext-release
PROTOPIC
Q
quetiapine
quinapril
QVAR
R
rabeprazole
delayed-release
RAGWITEK
raloxifene
ramipril
ranitidine
REBIF [INJ]
RECTIV
RELISTOR [INJ]
RENVELA
RESTASIS
RIOMET
risperidone
rizatriptan
rizatriptan orally
disintegrating tablets
ropinirole
S
SAVELLA
sertraline
simvastatin
spironolactone
sprintec
STRATTERA
sulfamethoxazole/
trimethoprim
sumatriptan
SYMBICORT
SYMLINPEN [INJ]
T
TAMIFLU
tamoxifen
tamsulosin ext-release
TAZORAC
TECFIDERA
telmisartan
telmisartan/
hydrochlorothiazide
temazepam
terazosin
terconazole
testosterone
cypionate [INJ]
TEV-TROPIN [INJ]
timolol maleate
eye solution
tizanidine
tobramycin eye solution
tobramycin/
dexamethasone susp
tolterodine ext-release
topiramate
TRACLEER
TRADJENTA
tramadol
tramadol/acetaminophen
trazodone hcl
triamcinolone acetonide
topical
triamterene/
hydrochlorothiazide
trinessa
tri-previfem
tri-sprintec
TUDORZA
U
UCERIS
ULORIC
V
VAGIFEM
valacyclovir
valsartan
valsartan/
hydrochlorothiazide
VASCEPA
venlafaxine
venlafaxine ext-release
verapamil ext-release
veripred
VGO
VIAGRA
VICTRELIS
VIMPAT
VIRAMUNE XR
VYVANSE
W
warfarin
X
XARELTO
XIFAXAN
Z
ZETIA
zolpidem
zolpidem ext-release
ZOMIG NASAL
ZUBSOLV
ZYTIGA
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the
formulary. Column 1 lists examples of nonformulary medications. Column 2 lists some alternatives that can be prescribed.
Nonformulary Medications Formulary Alternative(s)
ABSTRAL
ACCU-CHEK
METERS/STRIPS
ADVAIR DISKUS/HFA
ALVESCO
ANDROGEL
APIDRA
ARANESP
ASMANEX
AXERT
BECONASE AQ
BENZACLIN GEL PUMP
BETASERON
BRAVELLE
BREEZE, CONTOUR
METERS/STRIPS
BREO ELLIPTA
CETRAXAL
CIALIS
CIMZIA
DUEXIS
EDARBI/EDARBYCLOR
EPIPEN, EPIPEN JR
EPOGEN
FENTORA
FLOVENT DISKUS/HFA
FOLLISTIM AQ
FORTESTA
FROVA
GEL-ONE
GENOTROPIN
HUMATROPE
HYALGAN
INCIVEK
KADIAN
KAZANO
KOMBIGLYZE XR
LAZANDA
LEVITRA
LUMIGAN
MONOVISC
NASONEX
NESINA
NORDITROPIN
NOVOLIN
NOVOLOG
fentanyl citrate
FREESTYLE METERS/STRIPS
DULERA, SYMBICORT
QVAR
AXIRON
HUMALOG
PROCRIT
QVAR
rizatriptan, sumatriptan, zolmitriptan
flunisolide, fluticasone,
triamcinolone acetonide
clindamycin phosphate/
benzoyl peroxide
AVONEX, EXTAVIA, REBIF
GONAL-F, GONAL-F RFF
FREESTYLE METERS/STRIPS
DULERA, SYMBICORT
ciprofloxacin ear solution, CIPRODEX
VIAGRA
ENBREL, HUMIRA
ibuprofen + famotidine
candesartan/hctz, irbesartan/hctz,
losartan/hctz, telmisartan/hctz,
valsartan/hctz
AUVI-Q
PROCRIT
fentanyl citrate
QVAR
GONAL-F, GONAL-F RFF
AXIRON
rizatriptan, sumatriptan, zolmitriptan
EUFLEXXA
OMNITROPE, TEV-TROPIN
OMNITROPE, TEV-TROPIN
EUFLEXXA
OLYSIO, VICTRELIS
morphine sulfate ext-release,
hydromorphone ext-release,
oxymorphone ext-release
JANUMET, JANUMET XR, JENTADUETO
JANUMET, JANUMET XR, JENTADUETO
fentanyl citrate
VIAGRA
latanoprost, travoprost
EUFLEXXA
flunisolide, fluticasone,
triamcinolone acetonide
JANUVIA, TRADJENTA
OMNITROPE, TEV-TROPIN
HUMULIN
HUMALOG
Nonformulary Medications Formulary Alternative(s)
NUCYNTA ER
morphine sulfate ext-release,
hydromorphone ext-release,
oxymorphone ext-release
NUTROPIN/NUTROPIN AQ
OMNITROPE, TEV-TROPIN
OMNARIS
flunisolide, fluticasone,
triamcinolone acetonide
ONETOUCH METERS/STRIPS FREESTYLE METERS/STRIPS
ONGLYZA
JANUVIA, TRADJENTA
OPANA ER
morphine sulfate ext-release,
hydromorphone ext-release,
oxymorphone ext-release
OXYCONTIN
morphine sulfate ext-release,
hydromorphone ext-release,
oxymorphone ext-release
pancrelipase delayed-release, CREON
PANCREAZE
PEGASYS
PEGINTRON
pancrelipase delayed-release, CREON
PERTZYE
PROAIR HFA
PROVENTIL HFA
PULMICORT FLEXHALER
QVAR
flunisolide, fluticasone,
QNASL
triamcinolone acetonide
OMNITROPE, TEV-TROPIN
SAIZEN
ENBREL, HUMIRA
SIMPONI
STAXYN
VIAGRA
STELARA
ENBREL, HUMIRA
STENDRA
VIAGRA
SUBSYS
fentanyl citrate
SUPARTZ
EUFLEXXA
SYNVISC, SYNVISC-ONE
EUFLEXXA
TANZEUM
BYDUREON, BYETTA
TESTIM
AXIRON
TESTOSTERONE GEL
AXIRON
TEVETEN HCT
candesartan/hctz, irbesartan/hctz,
losartan/hctz, telmisartan/hctz,
valsartan/hctz
TRAVATAN Z
latanoprost, travoprost
TRUETEST, TRUETRACK
FREESTYLE METERS/STRIPS
METERS/STRIPS
ULTRESA
pancrelipase delayed-release, CREON
VELTIN
clindamycin phosphate + tretinoin
VENTOLIN HFA
PROAIR HFA
VERAMYST
flunisolide, fluticasone,
triamcinolone acetonide
VICTOZA
BYDUREON, BYETTA
VIMOVO
omeprazole delayed-release +
naproxen sodium
VOGELXO
AXIRON
XELJANZ
ENBREL, HUMIRA
XOPENEX HFA
PROAIR HFA
ZENPEP
pancrelipase delayed-release, CREON
ZETONNA
flunisolide, fluticasone,
triamcinolone acetonide
ZIOPTAN
latanoprost, travoprost
ZOHYDRO ER
morphine sulfate ext-release,
hydromorphone ext-release,
oxymorphone ext-release
KEY
[INJ] - Injectable Drug
For the member: Generic medications contain the same active ingredients as their corresponding 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 medically appropriate.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2015 THROUGH DECEMBER 31, 2015. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at Express-Scripts.com.
© 2015 Express Scripts
All Rights Reserved
#1703 HP-A
PRMT1703A-15 (08/01/14)

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