Express Scripts Canada Express Scripts Canada Dynamic Therapeutic Formulary Drug Listing Optimizing the Value of Health Benefits The Express Scripts Canada Dynamic Therapeutic Formulary (DTF) is designed to encourage the use of clinically sound and cost-effective drugs for selected drug classes. All the drugs listed on tier one are preferred and will be covered at a higher level of reimbursement. Drugs NOT on Tier 1 are usually higher in cost without superior clinical or safety advantage when compared to Tier 1 drugs, therefore, these will be covered at a lower level of reimbursement. Please note that the lists in this document are not meant to replace the advice of your Health Care Professional, but rather they are meant to provide general information about drug coverage. 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. • Brand-name drugs are listed in BLACK letters • Generic drugs are listed in GREEN letters The list is not all-inclusive and does not guarantee coverage. Drugs NOT on Tier 1 Preferred drugs on Tier 1 ACROMEGALY SOMAVERT SANDOSTATIN (OCTREOTIDE) SOMATULINE AUTOGEL ALLERGY - EYE ALREX 0.2% PATANOL LOTEMAX 0.5% LIVOSTIN ZADITOR ATTENTION DEFICIT/HYPERACTIVITY DISORDER STRATTERA (ATOMOXETINE) VYVANSE INTUNIV XR ADDERALL XR BIPHENTIN CONCERTA (METHYLPHENIDATE ER) DEXEDRINE RITALIN/RITALIN SR (METHYLPHENIDATE) Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Drugs NOT on Tier 1 Preferred drugs on Tier 1 BENIGN PROSTATIC HYPERPLASIA Alpha Blocker Alpha Blocker RAPAFLO CARDURA (DOXAZOSIN) FLOMAX (TAMSULOSIN) HYTRIN (TERAZOSIN) XATRAL (ALFUZOSIN) BONE DISORDER E.G. OSTEOPOROSIS ACTONEL 5MG, 150MG (RISEDRONATE 5MG, 150) ACTONEL DR 35MG FOSAMAX 70MG/75ML O/L FOSAVANCE (ALENDRONATE/CHOLECALCIFEROL) ACLASTA ACTONEL 30MG, 35MG (RISEDRONATE 30MG, 35MG TAB) ACTONEL CALCIUM PLUS BONEFOS DIDROCAL DIDRONEL (ETIDRONATE) FOSAMAX 5, 10, 40, 70MG (ALENDRONATE 5, 10, 40, 70MG) CENTRAL NERVOUS SYSTEM Antidepressants CIPRALEX CIPRALEX MELTZ CYMBALTA PAXIL CR PRISTIQ Atypical Antipsychotics INVEGA INVEGA SUSTENNA RISPERDAL M (RISPERIDONE) SEROQUEL XR (QUETIAPINE XR) Antidepressants CELEXA (CITALOPRAM) EFFEXOR XR (VENLAFAXINE) LUVOX (FLUVOXAMINE) PAXIL (PAROXETINE) PROZAC (FLUOXETINE) ZOLOFT (SERTRALINE) Atypical Antipsychotics CLOZARIL (CLOZAPINE) RISPERDAL (RISPERIDONE) SEROQUEL (QUETIAPINE) ZELDOX ZYPREXA (OLANZAPINE) Hypnotic (insomnia) SILENOR IMOVANE (ZOPICLONE) SUBLINOX Benzodiazepines (anxiety, insomnia) ATIVAN (LORAZEPAM) CHLORDIAZEPOXIDE CLORAZEPATE DALMANE (FLURAZEPAM) LECTOPAM (BROMAZEPAM) LOFTRAN MOGADON (NITRAZEPAM) RESTORIL (TEMAZEPAM) SERAX (OXAZEPAM) TRIAZOLAM VALIUM (DIAZEPAM) XANAX (ALPRAZOLAM) Miscellanous CNS drugs (for diabetic peripheral neuropathic pain) CYMBALTA Miscellanous CNS drugs (for diabetic peripheral neuropathic pain) LYRICA Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Drugs NOT on Tier 1 Preferred drugs on Tier 1 CONSTIPATION Miscellaneous GI Drugs (Constipation) RESOTRAN Miscellaneous GI Drugs (Constipation) COLACE (DOCUSATE SODIUM) LACTULOSE SENOKOT (SENNOSIDE) DIABETES AVANDIA AVANDARYL AVANDAMET BYETTA GLUMETZA ET GÉNÉRIQUES (METFORMINE À LIBÉRATION PROLONGÉE) JANUMET/JANUMET XR JANUVIA KAZANO NESINA ONGLYZA VICTOZA ACTOS (PIOGLITAZONE) AMARYL (GLIMÉPIRIDE) CHLORPROPAMIDE DIAMICRON/ DIAMICRON MR (GLICLAZIDE) GLUCOBAY GLUCONORM (RÉPAGLINIDE) GLUCOPHAGE (METFORMINE) JENTADUETO KOMBOGLYZE STARLIX TRAJENTA GASTROINTESTINAL ULCERS and REFLUX Proton Pump Inhibitors DEXILANT LOSEC (OMEPRAZOLE) NEXIUM (ESOMEPRAZOLE) PANTOLOC (PANTOPRAZOLE) PREVACID (LANSOPRAZOLE) TECTA Proton Pump Inhibitors PARIET (RABEPRAZOLE) GLAUCOMA Carbonic Anhydrase Inhibitors AZARGA AZOPT (BRINZOLAMIDE) COSOPT (DORZOLAMIDE/TIMOLOL) DIAMOX (ACETAZOLAMIDE) METHAZOLAMIDE TRUSOPT (DORZOLAMIDE) Other drug classes AKARPINE (PILOCARPINE) ALPHAGAN (BRIMONIDINE) BETAGAN (LEVOBUNOLOL) BETOPTIC (BETAXOLOL) COMBIGAN DIPIVEFRIN IOPIDINE LUMIGAN MIOCARPINE MIOSTAT PROBETA TIMOPTIC (TIMOLOL) TIMPILO TRAVATAN XALACOM XALATAN (LATANOPROST) GOUT ULORIC ALLOPURINOL Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Drugs NOT on Tier 1 Preferred drugs on Tier 1 HIGH BLOOD PRESSURE & CARDIOVASCULAR CONDITIONS Angiotensin II Receptor Blockers (ARBs) EDARBI/EDARBYCLOR OLMETEC/PLUS TEVETEN/PLUS Angiotensin II Receptor Blockers (ARBs) ATACAND (CANDESARTAN) COZAAR (LOSARTAN) DIOVAN (VALSARTAN) MICARDIS (TELMISARTAN) Angiotensin Converting Enzyme (ACE) Inhibitors ACCUPRIL (QUINAPRIL) ACCURETIC COVERSYL/PLUS MAVIK TARKA Angiotensin Converting Enzyme (ACE) Inhibitors ALTACE (RAMIPRIL) INHIBACE (CILAZAPRIL) LOTENSIN (BENAZEPRIL) MONOPRIL (FOSINOPRIL) PRINIVIL (LISINOPRIL) VASOTEC (ENALIPRIL) ZESTRIL (LISINOPRIL) Direct Renin Inhibitors (DRIs) Alternative therapy may include any of the above ACE inhibitors or ARBs RASILEZ/HCTZ Beta-blockers BYSTOLIC Beta-blockers COREG (CARVEDILOL) MONOCOR (BISOPROLOL) Any other beta-blockers Antiarrhythmic Agents MULTAQ Platelet Aggregation Inhibitors EFFIENT TICLOPIDINE Antiarrhythmic Agents CORDARONE (AMIODARONE) Platelet Aggregation Inhibitors BRILINTA PLAVIX (CLOPIDOGREL) HIGH CHOLESTEROL Fibric Acid Derivatives (high cholesterol) BEZAFIBRATE (regular formulation) FENOFIBRATE (regular formulation) Fibric Acid Derivatives (high cholesterol) BEZALIP SR LIPIDIL EZ, MICRO, SUPRA (FENOFIBRATE EZ, MICRO, SUPRA) LOPID (GEMFIBROZIL) HMG-CoA Reductase Inhibitors LESCOL 20mg, 40mg, 80mg MEVACOR (LOVASTATIN) PRAVACHOL (PRAVASTATIN) HMG-CoA Reductase Inhibitors CRESTOR (ROSUVASTATIN) LIPITOR (ATORVASTATIN) ZOCOR (SIMVASTATIN) Miscellaneous Antilipemic Agents LODALIS NIASPAN Miscellaneous Antilipemic Agents CHOLESTYRAMINE COLESTID NIACIN (NICOTINIC ACID) NIACINAMIDE Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Drugs NOT on Tier 1 Preferred drugs on Tier 1 HORMONES REPLACEMENT THERAPY Estrogens (hormone replacement) ACTIVELLE/ ACTIVELLE LD AERODIOL NASAL SPRAY ALORA CLIMARA/CLIMARA PRO DIVIGEL ESTALIS ESTRACOMB ESTALIS-SEQUI ESTRADERM/ESTRADERM PROPAK ESTRADOT PATCH TRANSDER ESTROGEL FEMHRT MENOSTAR OESCLIM PAD PREFESTA VIVELLE TRANSDERMAL Estrogens (hormone replacement) DELESTROGEN ESTRACE ESTRADIOL 17-β PATCH TRANDSDER ESTRADIOL VALERATE ESTRING NEO-ESTRONE OGEN PREMARIN (CONJUGATED ESTROGENS) PREMPLUS VAGIFEM INFECTION DIFICID ZMAX SR BIAXIN (CLARITHROMYCIN) ERYC (ERYTHROMYCIN) FLAGYL (METRONIDAZOLE) VANCOCIN (VANCOMYCIN) ZITHROMAX (AZITHROMYCIN) KIDNEY IMPAIRMENT Phosphate Removing Agents FOSRENOL Phosphate Removing Agents PHOSLO RENAGEL RENVELA MIGRAINE Triptans AXERT (ALMOTRIPTAN) FROVA (FROVATRIPTAN) RELPAX Triptans AMERGE (NARATRIPTAN) IMITREX (SUMATRIPTAN) MAXALT (RIZATRIPTAN) ZOMIG (ZOLMITRIPTAN) OVERACTIVE BLADDER Anticholinergic DETROL, DETROL LA (TOLTERODINE) DITROPAN XL GELNIQUE Anticholinergic DITROPAN (OXYBUTYNIN) ENABLEX OXYTROL TOVIAZ TROSEC VESICARE Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Drugs NOT on Tier 1 Preferred drugs on Tier 1 PAIN AND INFLAMMATION COX-2 Inhibitors (pain and inflammation) CELEBREX Nonsteroidal Anti-Inflammatory Agents(NSAIDS)and Opiate Agonists ANAPROX (NAPROXEN SODIUM) NSAIDs ARTHROTEC DAYPRO DICLOFENAC DIFLUNISAL DURAGESIC (FENTANYL) FLURBIPROFEN HYDROMORPH CONTIN CAMBIA ETODOLAC NABUMETONE RELAFEN ULTRADOL VIMOVO Opiate Agonists JURNISTA NUCYNTA CR/NUCYNTA IR/NUCYNTA ER OXYCONTIN (OXYCODONE CR) OXYNEO TARGIN TRAMACET (TRAMADOL/ACETAMINOPHEN) ULTRAM INDOMETHACIN MEFENAMIC ACID MOBICOX (MELOXICAM) NAPROSYN (NAPROXEN) PERCOCET (OXYCODONE/ ACETAMINOPHEN) PERCOCET-DEMI PHENYLBUTAZONE PIROXICAM RALIVIA SULINDAC TENOXICAM TIAPROFENIC ACID TORADOL (KETOROLAC) TYLENOL WITH CODEINE 2, 3, OR 4 (ACETAMINOPHEN WITH CODEINE 2, 3, OR 4) VOLTAREN (DICLOFENAC) PARKINSON'S DISEASE (AND RESTLESS LEGS SYNDROME) AZILECT NEUPRO COMTAN MIRAPEX (PRAMIPEXOLE) PROLOPA REQUIP (ROPINIROLE) SELEGILINE SINEMET (LEVODOPA/CARBIDOPA) Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Drugs NOT on Tier 1 Preferred drugs on Tier 1 RESPIRATORY CONDITIONS Nasal Corticosteroid AVAMYS BECLOMETHASONE DRYMIRA FLONASE (FLUTICASONE) NASACORT NASONEX (MOMETASONE) OMNARIS RHINALAR (FLUNISOLIDE) RHINOCORT TURBUHALER Anti-Asthma/COPD Drugs ACCOLATE ANORO ELLIPTA CHOLEDYL (OXTRIPHYLLINE) PHYLLOCONTIN (AMINOPHYLLINE) SINGULAIR (MONTELUKAST) THEO-DUR UNIPHYL XOLAIR Nasal Corticosteroid BUDESONIDE RHINOCORT AQ Anti-Asthma /COPD Drugs ADVAIR AIROMIR ATROVENT BRICANYL COMBIVENT CROMOLYN DUOVENT FLOVENT FORADIL ORCIPRENALIN OXEZE PULMICORT QVAR SEREVENT SPIRIVA SYMBICORT ULTIBRO BREEZHALER VENTOLIN (SALBUTAMOL) SKIN CONDITIONS Corticosteroid Topical Drugs CLOBEX SPRAY DERMOTIC OIL EAR DROPS LUXIQ OLUX-E SILKIS VERDESO Corticosteroid Topical Drugs BETAMETHASONE CLOBEX LOTION/SHAMPOO (CLOBETASOL) DIODEX DERMOVATE (CLOBETASOL) DESONIDE CREAM, LOTION Oral Acne Drugs Oral Acne Drugs ACCUTANE ALESSE (AVIANE) APPRILON MINOCIN (MINOCYCLINE) CLARUS TRI-CYCLEN DIANE-35 (CYESTRA-35) EPURIS Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014. Express Scripts Canada Topical Acne Drugs Topical Acne Drugs ACZONE SOLUGEL 8% CLINDETS DALACIN-T, CLINDASOL DIFFERIN, DIFFERIN XP BENZAMYCIN TACTUO BENZACLIN, CLINDOXYL TAZORAC BIACNA RETIN-A, STIEVA-A, VITAMIN A ACID Topical Rosacea Drugs ONRELTEA Topical Rosacea Drugs FINACEA METRO GEL/CREAM/LOTION NORITATE 1% CR Information in this document is current at the time of posting but may be subject to change without notice. Updated June 23, 2014.
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