Page 1 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. A abacavir [SP] abacavir/lamivudine [SP] abacavir/lamivudine/zidovudine [SP] ABELCET [INJ] ABILIFY MAINTENA [INJ] abiraterone acetate [SP] ABRAXANE [INJ] [SP] acamprosate delayed-release acarbose ACCU-CHEK FASTCLIX LANCETS [OTC] ACCU-CHEK MULTICLIX LANCET KIT [OTC] ACCU-CHEK MULTICLIX LANCETS [OTC] ACCU-CHEK SOFTCLIX LANCET KIT [OTC] ACCU-CHEK SOFTCLIX LANCETS [OTC] acebutolol acetaminophen/codeine acetazolamide acetazolamide ext-release acetazolamide sodium [INJ] acetic acid ear solution acetic acid irrigation solution acetic acid/hydrocortisone ear solution acetic acid/oxyquinoline vaginal acetylcysteine [INJ] acetylcysteine inhalation solution acitretin ACTEMRA [INJ] [SP] ACTHIB [INJ] ACTHREL [INJ] ACTIMMUNE [INJ] [SP] ACTIVASE [INJ] acyclovir acyclovir ointment acyclovir sodium [INJ] ADACEL [INJ] adapalene adapalene/benzoyl peroxide ADCETRIS [INJ] [SP] ADDAMEL N [INJ] adefovir ADEMPAS [SP] adenosine [INJ] ADVAIR HFA ADVATE [INJ] [SP] ADYNOVATE [INJ] [SP] AFINITOR [SP] AFINITOR DISPERZ [SP] afirmelle AFLURIA [INJ] AFLURIA QUAD [INJ] AFSTYLA [INJ] [SP] AIMOVIG [INJ] AJOVY [INJ] albendazole albumin human [INJ] albuterol albuterol ext-release albuterol nebulization solution alclometasone ALDURAZYME [INJ] [SP] ALECENSA [SP] alendronate alfentanil [INJ] ALFERON N [INJ] alfuzosin ext-release ALIMTA [INJ] ALINIA ALIQOPA [INJ] [SP] aliskiren allopurinol allopurinol sodium [INJ] almotriptan alosetron ALPHAGAN P 0.1% ALPHANATE [INJ] [SP] ALPHANINE SD [INJ] [SP] alprazolam alprazolam ext-release alprazolam orally disintegrating tablets ALPROLIX [INJ] [SP] alprostadil [INJ] ALREX altavera alyacen amabelz amantadine AMBISOME [INJ] ambrisentan [SP] amcinonide amethia amethia lo amethyst AMICAR SOLUTION amifostine [INJ] amikacin [INJ] amiloride amiloride/hydrochlorothiazide aminocaproic acid aminocaproic acid [INJ] aminophylline [INJ] AMINOSYN [INJ] amiodarone amiodarone [INJ] amitriptyline amitriptyline/chlordiazepoxide amlodipine amlodipine/atorvastatin amlodipine/benazepril amlodipine/olmesartan amlodipine/valsartan amlodipine/valsartan/hydrochlorothiazide ammonium lactate 12% topical amoxapine amoxicillin amoxicillin/potassium clavulanate amoxicillin/potassium clavulanate ext-release amphetamine sulfate amphotericin [INJ] ampicillin ampicillin sodium [INJ] ampicillin sodium/sulbactam [INJ] AMYTAL [INJ] anagrelide anastrozole ANDRODERM ANORO ELLIPTA anthralin APLISOL [INJ] APOKYN [INJ] [SP] apraclonidine eye solution aprepitant apri APRISO APTIVUS [SP] AQUASOL A [INJ] ARALAST NP [INJ] [SP] aranelle ARIKAYCE [SP] aripiprazole aripiprazole orally disintegrating tablets ARISTADA [INJ] ARISTOSPAN [INJ] armodafinil ARMONAIR RESPICLICK ARMOUR THYROID ARNUITY ELLIPTA ARRANON [INJ] [SP] arsenic trioxide [INJ] ascorbic acid [INJ] ashlyna ASMANEX HFA ASMANEX TWISTHALER aspirin/dipyridamole ext-release atazanavir [SP] atenolol atenolol/chlorthalidone ATGAM [INJ] atomoxetine atorvastatin atovaquone atovaquone/proguanil atropine [INJ] atropine sulfate eye ointment atropine sulfate eye solution aubra aubra eq AUGMENTIN 125-31.25 MG/5 ML aurovela aurovela 24 fe 2020 Express Scripts National Preferred Formulary List The 2020 National Preferred Formulary drug list is shown below. The formulary is the list of drugs included in your prescription plan. Inclusion on the list does not guarantee coverage. The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products and prescription medical supplies that appear on the list are in contracted classes. 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 prescription plans; check your benefit materials for the specific drugs covered and the copayments for your prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card. KEY [INJ] – Injectable Drug [OTC] – Over-the-counter Product [SP] – Specialty Drug Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA Generic drugs are listed in lower-case letters. Example: ibuprofen For the member: FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Page 2 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. aurovela fe AUSTEDO [SP] AVASTIN [INJ] [SP] aviane avo cream AVONEX [INJ] [SP] AVYCAZ [INJ] ayuna azacitidine [INJ] [SP] AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] AZASITE azathioprine [SP] azathioprine sodium [INJ] [SP] AZEDRA [INJ] [SP] azelaic acid azelastine eye solution azelastine nasal spray azithromycin azithromycin [INJ] aztreonam [INJ] azurette B bacitracin [INJ] bacitracin eye ointment bacitracin/polymyxin eye ointment baclofen baclofen [INJ] BAL IN OIL [INJ] balanced salt eye irrigation solution bal-care dha prenatal vitamins balsalazide BALVERSA [SP] balziva BANZEL BAQSIMI BARACLUDE SOLUTION BAVENCIO [INJ] [SP] b-complex [INJ] BD AUTOSHIELD DUO NEEDLES [OTC] BD ULTRAFINE INSULIN SYRINGES [OTC] BD ULTRAFINE PEN NEEDLES [OTC] BEBULIN [INJ] [SP] bekyree BELBUCA benazepril benazepril/hydrochlorothiazide BENDEKA [INJ] [SP] BENEFIX [INJ] [SP] BENLYSTA [INJ] [SP] BENZNIDAZOLE benzonatate benzoyl peroxide benzphetamine benztropine benztropine [INJ] BEPREVE BESPONSA [INJ] [SP] betamethasone acetate/betamethasone sodium phosphate [INJ] betamethasone dipropionate betamethasone dipropionate augmented betamethasone valerate BETASERON [INJ] [SP] betaxolol betaxolol eye solution bethanechol BETHKIS [SP] BEVESPI AEROSPHERE bexarotene [SP] BEXSERO [INJ] bicalutamide BICILLIN C-R [INJ] BICILLIN L-A [INJ] BIKTARVY [SP] bimatoprost eye solution biolon [INJ] BIOTHRAX [INJ] bisoprolol bisoprolol/hydrochlorothiazide bivalirudin [INJ] blanche bleomycin [INJ] BLINCYTO [INJ] [SP] blisovi 24 fe blisovi fe BOOSTRIX [INJ] bosentan [SP] BOSULIF [SP] BOTOX [INJ] [SP] BREO ELLIPTA BREVITAL [INJ] briellyn BRILINTA brimonidine eye solution BRINEURA [INJ] [SP] bromfenac eye solution bromocriptine brompheniramine/pseudoephedrine/ codeine brompheniramine/pseudoephedrine/ dextromethorphan budesonide ext-release budesonide nebulization suspension bumetanide bumetanide [INJ] bupivacaine [INJ] bupivacaine/dextrose [INJ] bupivacaine/epinephrine [INJ] buprenorphine buprenorphine [INJ] buprenorphine patches buprenorphine/naloxone bupropion bupropion ext-release bupropion ext-release (smoking deterrent) buspirone busulfan [INJ] butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine/ codeine butalbital/aspirin/caffeine butalbital/aspirin/caffeine/codeine butorphanol [INJ] butorphanol nasal BYDUREON [INJ] BYETTA [INJ] BYSTOLIC C cabergoline CABLIVI [INJ] [SP] CABOMETYX [SP] caffeine citrated caffeine citrated [INJ] caffeine/sodium benzoate [INJ] calcipotriene calcipotriene/betamethasone dipropionate calcitonin salmon nasal calcitriol calcitriol [INJ] calcitriol ointment calcium acetate calcium chloride [INJ] CALCIUM DISODIUM VERSENATE [INJ] calcium gluconate [INJ] calcium-pnv 28-1-250 prenatal vitamins CALDOLOR [INJ] camila camrese camrese lo candesartan candesartan/hydrochlorothiazide CAPASTAT SULFATE [INJ] capecitabine [SP] CAPRELSA [SP] captopril captopril/hydrochlorothiazide CARAC CARAFATE SUSPENSION carbachol [INJ] CARBAGLU [SP] carbamazepine carbamazepine ext-release carbidopa carbidopa/levodopa carbidopa/levodopa ext-release carbidopa/levodopa orally disintegrating tablets carbidopa/levodopa/entacapone carbinoxamine carboplatin [INJ] carmustine [INJ] carteolol eye solution carvedilol carvedilol phosphate ext-release caspofungin [INJ] CATHFLO ACTIVASE [INJ] CAVERJECT [INJ] CAYSTON [SP] caziant cefaclor cefaclor ext-release cefadroxil cefazolin [INJ] cefdinir cefditoren cefepime [INJ] cefepime/dextrose [INJ] cefixime cefotaxime [INJ] cefotetan [INJ] cefoxitin [INJ] cefoxitin/dextrose [INJ] cefpodoxime cefprozil ceftazidime [INJ] CEFTAZIDIME/DEXTROSE [INJ] ceftriaxone [INJ] ceftriaxone/dextrose [INJ] cefuroxime axetil cefuroxime sodium [INJ] celacyn celecoxib CELONTIN cephalexin CEPROTIN [INJ] [SP] CERDELGA [SP] CEREZYME [INJ] [SP] cetirizine syrup CETROTIDE [INJ] [SP] cevimeline CHANTIX chateal chateal eq CHEMET CHENODAL [SP] chloramphenicol [INJ] chlordiazepoxide chlordiazepoxide/clidinium chlorhexidine gluconate chloroprocaine hcl [INJ] chloroquine chlorothiazide chlorothiazide sodium [INJ] chlorpheniramine/phenylephrine/ dextromethorphan chlorpromazine chlorpromazine [INJ] chlorthalidone chlorzoxazone CHOLBAM [SP] cholestyramine cholestyramine light choline salicylate/magnesium salicylate chromium chloride [INJ] ciclopirox ciclopirox shampoo cidofovir [INJ] cilostazol CIMDUO [SP] cimetidine cinacalcet CINRYZE [INJ] [SP] CINVANTI [INJ] CIPRODEX ciprofloxacin ciprofloxacin ear solution ciprofloxacin ext-release ciprofloxacin eye solution ciprofloxacin lactate/dextrose [INJ] cisplatin [INJ] citalopram cladribine [INJ] clarithromycin clarithromycin ext-release clemastine CLENPIQ clindamycin hcl clindamycin palmitate clindamycin phosphate [INJ] clindamycin phosphate topical clindamycin phosphate vaginal clindamycin phosphate/benzoyl peroxide clindamycin phosphate/dextrose [INJ] clindamycin phosphate/tretinoin CLINIMIX [INJ] CLINIMIX E [INJ] clobazam clobetasol propionate clobetasol propionate shampoo clobetasol propionate/emollient clofarabine [INJ] clomiphene citrate clomipramine clonazepam clonazepam orally disintegrating tablets clonidine clonidine [INJ] clonidine ext-release clonidine patches Page 3 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. clopidogrel clorazepate clotrimazole topical clotrimazole troche clotrimazole/betamethasone dipropionate clozapine clozapine orally disintegrating tablets c-nate dha prenatal vitamins COAGADEX [INJ] [SP] COARTEM cocaine topical solution codeine sulfate colchicine/probenecid COLCRYS colesevelam hcl colestipol colistimethate [INJ] COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ [SP] complete natal dha prenatal vitamins completenate prenatal vitamins constulose COPAXONE 40 MG [INJ] [SP] copper chloride [INJ] CORIFACT [INJ] [SP] CORLANOR cortisone acetate COSENTYX [INJ] [SP] cosyntropin [INJ] COTELLIC [SP] CREON CRESEMBA CRESEMBA [INJ] CRINONE 4% CRINONE 8% [SP] CRIXIVAN [SP] CROFAB [INJ] cromolyn sodium eye solution cromolyn sodium nebulization solution cromolyn sodium oral solution crotamiton cryselle CRYSVITA [INJ] [SP] cyanocobalamin [INJ] cyclafem cyclobenzaprine cyclobenzaprine ext-release cyclopentolate eye solution cyclopentolate/tropicamide/ phenylephrine eye drops cyclophosphamide [INJ] CYCLOPHOSPHAMIDE CAPSULES cyclosporine [INJ] [SP] cyclosporine [SP] cyclosporine modified [SP] cyproheptadine CYRAMZA [INJ] [SP] cyred cyred eq CYSTADANE [SP] CYSTAGON [SP] CYSTARAN [SP] cytarabine [INJ] CYTOGAM [INJ] [SP] D dacarbazine [INJ] dactinomycin [INJ] dalfampridine ext-release [SP] DALIRESP DALVANCE [INJ] danazol dantrolene dantrolene [INJ] dapsone DAPTACEL [INJ] daptomycin [INJ] DARAPRIM [SP] darifenacin ext-release DARZALEX [INJ] [SP] dasetta daunorubicin [INJ] daysee DAYTRANA DDAVP RHINAL SOLUTION deblitane decitabine [INJ] [SP] deferasirox [SP] deferoxamine [INJ] delflex with dextrose [INJ] delyla demeclocycline DEMSER DEPEN DEPO-ESTRADIOL [INJ] DEPO-PROVERA 400 MG/ML [INJ] DESCOVY [SP] desipramine desloratadine desloratadine orally disintegrating tablets desmopressin acetate desmopressin acetate [INJ] [SP] desmopressin nasal desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine succinate ext-release dexamethasone dexamethasone sodium phosphate [INJ] dexamethasone sodium phosphate eye solution dexchlorpheniramine DEXCOM RECEIVER, SENSOR, TRANSMITTER dexmedetomidine [INJ] dexmedetomidine/nacl [INJ] dexmethylphenidate dexmethylphenidate ext-release dexrazoxane [INJ] dextran/dextrose [INJ] dextran/normal saline [INJ] dextroamphetamine dextroamphetamine ext-release dextroamphetamine/amphetamine dextroamphetamine/amphetamine ext-release dextrose/lactated ringers [INJ] dextrose/sodium chloride [INJ] dextrose/water [INJ] DIACOMIT [SP] diazepam diazepam [INJ] diazepam rectal gel diclofenac eye solution diclofenac potassium diclofenac sodium delayed-release diclofenac sodium ext-release diclofenac sodium gel diclofenac sodium topical solution diclofenac sodium/misoprostol ext-release dicloxacillin dicyclomine dicyclomine [INJ] didanosine delayed-release [SP] diethylpropion diethylpropion ext-release diflorasone diflorasone/emollient diflunisal digoxin digoxin [INJ] dihydrocodeine/acetaminophen/caffeine dihydroergotamine [INJ] dihydroergotamine nasal DILANTIN 30 MG CAPSULES DILATRATE-SR diltiazem diltiazem [INJ] diltiazem ext-release dimenhydrinate [INJ] diphenhydramine diphenhydramine [INJ] diphenoxylate/atropine DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] dipyridamole dipyridamole [INJ] disulfiram divalproex delayed-release divalproex ext-release DIVIGEL dobutamine [INJ] dobutamine/dextrose [INJ] DOCEFREZ [INJ] docetaxel [INJ] DOCETAXEL 200 MG/10 ML [INJ] dofetilide donepezil donepezil orally disintegrating tablets dopamine [INJ] dopamine/dextrose [INJ] DOPTELET [SP] dorzolamide eye solution dorzolamide/timolol eye solution dothelle dha prenatal vitamins DOVATO [SP] doxazosin doxepin doxepin cream doxercalciferol doxercalciferol [INJ] doxorubicin [INJ] doxorubicin/liposomal [INJ] doxycycline hyclate doxycycline hyclate [INJ] doxycycline hyclate delayed-release doxycycline monohydrate doxylamine succinate/vit b6 D-PENAMINE dronabinol droperidol [INJ] drospirenone-ethinyl estradiol drospirenone-ethinyl estradiol-levomefolate DROXIA DUAVEE DULERA duloxetine delayed-release DUPIXENT [INJ] [SP] dutasteride dutasteride/tamsulosin ext-release DYANAVEL XR DYMISTA E econazole EDARBI EDARBYCLOR EDURANT [SP] efavirenz [SP] EGRIFTA [INJ] [SP] ELAPRASE [INJ] [SP] electrolyte-48 solution/dextrose [INJ] eletone eletriptan ELIGARD [INJ] [SP] elinest ELIQUIS ELITEK [INJ] elite-ob prenatal vitamins ELMIRON ELOCTATE [INJ] [SP] ELZONRIS [INJ] [SP] EMCYT EMGALITY [INJ] emoquette EMTRIVA [SP] emulsion sb EMVERM enalapril enalapril/hydrochlorothiazide enalaprilat [INJ] ENBREL [INJ] [SP] ENGERIX-B [INJ] enoxaparin [INJ] [SP] enpresse enskyce ENSTILAR entacapone entecavir ENTRESTO ENTYVIO [INJ] [SP] EOVIST [INJ] EPCLUSA [SP] ephedrine [INJ] EPIDIOLEX [SP] EPIDUO FORTE epinastine eye solution epinephrine auto-injector (by Mylan) [INJ] epinephrine vial, ampule, syringe [INJ] epinephrine-dextrose [INJ] epinephrine-nacl [INJ] EPIPEN, EPIPEN JR [INJ] epirubicin [INJ] EPIVIR HBV SOLUTION eplerenone epoprostenol [INJ] [SP] epoprostenol diluent [INJ] [SP] eprosartan eptifibatide [INJ] ERAXIS [INJ] ERBITUX [INJ] [SP] ergocalciferol ergoloid mesylates ergotamine tartrate/caffeine ergotamine tartrate/caffeine suppositories ERIVEDGE [SP] ERLEADA [SP] erlotinib [SP] errin Page 4 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. ertapenem [INJ] ERYTHROCIN [INJ] erythromycin erythromycin delayed-release erythromycin ethylsuccinate erythromycin eye ointment erythromycin stearate erythromycin topical erythromycin/benzoyl peroxide ESBRIET [SP] escitalopram esmolol [INJ] esmolol-nacl [INJ] esomeprazole magnesium delayed-release esomeprazole sodium [INJ] estarylla estazolam esterified estrogens/methyltestosterone estradiol estradiol cream estradiol patches estradiol vaginal estradiol valerate [INJ] estradiol/norethindrone acetate ESTRING estropipate eszopiclone ethacrynate [INJ] ethacrynic acid ethambutol ETHAMOLIN [INJ] ethosuximide ethyl alcohol [INJ] ethyl chloride spray ethynodiol-ethinyl estradiol etidronate etodolac etodolac ext-release etomidate [INJ] ETOPOPHOS [INJ] etoposide etoposide [INJ] EUFLEXXA [INJ] [SP] exemestane EXTRANEAL ICODEXTRIN DIALYSIS SOLUTION [INJ] EYLEA [INJ] [SP] ezetimibe ezetimibe/simvastatin F FABRAZYME [INJ] [SP] falmina famciclovir famotidine famotidine [INJ] famotidine/nacl [INJ] FARXIGA FASENRA [INJ] [SP] FASLODEX [INJ] fayosim febuxostat FEIBA NF [INJ] [SP] felbamate felodipine ext-release femynor fenofibrate fenofibrate micronized fenofibric acid fenofibric acid delayed-release fenoprofen fentanyl citrate [INJ] fentanyl citrate lozenges fentanyl citrate/nacl [INJ] fentanyl patches FERAHEME [INJ] FERRIPROX [SP] FETZIMA FINACEA FOAM finasteride FIRMAGON [INJ] [SP] FIRST-LANSOPRAZOLE FIRST-MOUTHWASH BLM FIRST-OMEPRAZOLE flavoxate flecainide FLECTOR FLOLAN [INJ] [SP] FLOLAN DILUENT [INJ] [SP] FLOVENT DISKUS FLOVENT HFA floxuridine [INJ] FLUAD [INJ] FLUARIX QUAD [INJ] FLUBLOK QUAD [INJ] FLUCELVAX QUAD [INJ] fluconazole fluconazole/dextrose [INJ] fluconazole/normal saline [INJ] flucytosine fludarabine [INJ] fludrocortisone acetate FLULAVAL QUAD [INJ] flumazenil [INJ] flunisolide nasal spray fluocinolone fluocinolone acetonide oil ear solution fluocinonide fluocinonide/emollient fluorescein [INJ] fluorescein eye strips fluorometholone eye suspension fluorouracil fluorouracil [INJ] fluoxetine fluoxetine delayed-release fluphenazine decanoate [INJ] fluphenazine hcl fluphenazine hcl [INJ] flurandrenolide flurazepam flurbiprofen flurbiprofen sodium eye solution flutamide fluticasone nasal spray fluticasone topical FLUTICASONE/SALMETEROL AEROSOL fluticasone/salmeterol powder inhaler fluvastatin fluvastatin ext-release fluvoxamine fluvoxamine ext-release FLUZONE HIGH-DOSE [INJ] FLUZONE QUAD [INJ] folic acid folic acid [INJ] folivane-ob prenatal vitamins FOLOTYN [INJ] [SP] fomepizole [INJ] fondaparinux [INJ] [SP] FORTEO [INJ] [SP] fosamprenavir [SP] fosaprepitant [INJ] fosinopril fosinopril/hydrochlorothiazide fosphenytoin [INJ] FRAGMIN [INJ] [SP] FREAMINE HBC [INJ] freamine iii [INJ] FREESTYLE FREEDOM KIT [OTC] FREESTYLE FREEDOM LITE METER [OTC] FREESTYLE INSULINX GLUCOSE SYSTEM [OTC] FREESTYLE INSULINX TEST STRIPS [OTC] FREESTYLE LIBRE FREESTYLE LITE METER [OTC] FREESTYLE LITE TEST STRIPS [OTC] FREESTYLE TEST STRIPS [OTC] frovatriptan fulvestrant [INJ] furosemide furosemide [INJ] FUZEON [INJ] [SP] fyavolv FYCOMPA G gabapentin GABLOFEN SYRINGE [INJ] galantamine galantamine ext-release GAMASTAN [INJ] [SP] GAMASTAN S-D [INJ] [SP] GAMIFANT [INJ] [SP] GAMMAGARD LIQUID [INJ] [SP] GAMMAGARD S-D [INJ] [SP] GAMUNEX-C [INJ] [SP] ganciclovir [INJ] ganirelix acetate [INJ] [SP] GARDASIL 9 [INJ] gatifloxacin eye solution gavilyte-c gavilyte-g gavilyte-n GAZYVA [INJ] [SP] GELNIQUE gemcitabine [INJ] gemfibrozil GENOTROPIN [INJ] [SP] gentamicin [INJ] gentamicin eye ointment gentamicin eye solution gentamicin topical gentamicin/normal saline [INJ] GENTAMICIN/NORMAL SALINE 100 MG/50 ML [INJ] GENVOYA [SP] gianvi GILENYA [SP] GILOTRIF [SP] GLASSIA [INJ] [SP] glatiramer [INJ] [SP] glatopa [INJ] [SP] GLEOSTINE glimepiride glipizide glipizide ext-release glipizide/metformin GLUCAGEN [INJ] GLUCAGON [INJ] glyburide glyburide micronized glyburide/metformin glycine irrigation solution glycolax GLYCOPHOS [INJ] glycopyrrolate glycopyrrolate [INJ] glycopyrrolate-water [INJ] GLYXAMBI GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT [INJ] [SP] granisetron granisetron [INJ] GRASTEK griseofulvin microsize griseofulvin ultramicrosize guaifenesin/codeine guaifenesin/phenylephrine guanfacine guanfacine ext-release guanidine H hailey hailey 24 fe HALAVEN [INJ] [SP] halcinonide halobetasol haloperidol haloperidol decanoate [INJ] haloperidol lactate haloperidol lactate [INJ] HARVONI [SP] HAVRIX [INJ] heather HELIXATE FS [INJ] [SP] HEMABATE [INJ] hemenatal ob + dha prenatal vitamins hemenatal ob prenatal vitamins HEMLIBRA [INJ] [SP] HEMOFIL-M [INJ] [SP] HEPAGAM B [INJ] heparin lock flush [INJ] heparin sodium [INJ] heparin sodium/dextrose [INJ] heparin sodium/nacl [INJ] HEPATAMINE [INJ] HERCEPTIN [INJ] [SP] hetastarch/normal saline [INJ] HEXTEND LACTATED ELECTROLYTE [INJ] HIBERIX [INJ] HIZENTRA [INJ] [SP] homatropine eye solution hpr emollient foam hpr plus hpr plus hydrogel HUMALOG [INJ] HUMATE-P [INJ] [SP] HUMIRA [INJ] [SP] HUMULIN [INJ] HUMULIN R 500 UNITS [INJ] HYCAMTIN CAPSULES [SP] hydralazine hydralazine [INJ] hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/chlorpheniramine polistirex ext-release hydrocodone/homatropine hydrocodone/ibuprofen Page 5 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. hydrocortisone hydrocortisone acetate suppositories hydrocortisone butyrate hydrocortisone butyrate/emollient hydrocortisone enema hydrocortisone sodium succinate [INJ] hydrocortisone topical hydrocortisone valerate hydrocortisone/iodoquinol hydrocortisone/iodoquinol/aloe hydrocortisone/lidocaine hydrocortisone/pramoxine hydromorphone hydromorphone [INJ] hydromorphone ext-release hydromorphone suppositories hydromorphone/nacl [INJ] hydroquinone hydroquinone microspheres hydroxocobalamin [INJ] hydroxychloroquine hydroxyprogesterone [INJ] hydroxyprogesterone [INJ] [SP] hydroxyurea hydroxyzine hcl hydroxyzine hcl [INJ] hydroxyzine pamoate hyophen hyoscyamine hyoscyamine ext-release hyoscyamine orally disintegrating tablets HYPERHEP B S-D [INJ] HYPERRAB [INJ] HYPERRAB S-D [INJ] HYPERRHO S-D [INJ] HYPERTET S-D [INJ] hypochlorous acid/sodium chloride HYSINGLA ER I ibandronate ibandronate [INJ] [SP] IBRANCE [SP] ibuprofen ibuprofen lysine [INJ] ibutilide [INJ] icatibant [INJ] [SP] ICLUSIG [SP] idarubicin [INJ] IDHIFA [SP] ifosfamide [INJ] ifosfamide/mesna [INJ] ILARIS [INJ] [SP] ILEVRO imatinib [SP] IMBRUVICA [SP] IMFINZI [INJ] [SP] imipenem/cilastatin [INJ] imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT [INJ] IMOVAX RABIES VACCINE [INJ] IMPAVIDO INBRIJA [SP] incassia INCRELEX [INJ] [SP] INCRUSE ELLIPTA indapamide indomethacin indomethacin ext-release indomethacin sodium [INJ] INFANRIX [INJ] infed [INJ] INFUMORPH [INJ] INFUVITE [INJ] INLYTA [SP] INTELENCE [SP] intralipid 20% [INJ] INTRON A [INJ] [SP] introvale INVANZ ADD-VANTAGE [INJ] INVELTYS INVIRASE [SP] INVOKAMET INVOKAMET XR INVOKANA iodine/potassium iodide iodine/sodium iodide IODOPEN [INJ] IONOSOL/DEXTROSE [INJ] IPOL [INJ] ipratropium bromide nasal spray ipratropium bromide nebulization solution ipratropium/albuterol sulfate nebulization solution irbesartan irbesartan/hydrochlorothiazide IRESSA [SP] irinotecan [INJ] ISENTRESS [SP] isibloom ISOLYTE [INJ] isoniazid isoniazid [INJ] isoproterenol [INJ] isosorbide dinitrate isosorbide dinitrate ext-release isosorbide mononitrate isosorbide mononitrate ext-release isotretinoin isoxsuprine isradipine ISTODAX [INJ] [SP] itraconazole ivermectin IXEMPRA [INJ] [SP] IXIARO [INJ] IXINITY [INJ] [SP] J JAKAFI [SP] JANUMET JANUMET XR JANUVIA JARDIANCE jasmiel jencycla JENTADUETO JENTADUETO XR JETREA [INJ] [SP] jevantique lo JEVTANA [INJ] [SP] jinteli JIVI [INJ] [SP] jolessa jolivette juleber JULUCA [SP] junel junel fe JUXTAPID [SP] K KADCYLA [INJ] [SP] kaitlib fe KALETRA TABLETS [SP] kalliga KALYDECO [SP] KANJINTI [INJ] [SP] KANUMA [INJ] [SP] kariva kelnor KEPIVANCE [INJ] [SP] ketamine [INJ] ketamine-nacl [INJ] ketoconazole ketoconazole shampoo ketoconazole topical ketoconazole/skin cleanser kit ketoprofen ketoprofen ext-release ketorolac ketorolac [INJ] ketorolac eye solution KEYTRUDA [INJ] [SP] kimidess KINEVAC [INJ] KITABIS PAK [SP] KOGENATE FS [INJ] [SP] KOVALTRY [INJ] [SP] K-PHOS ORIGINAL KRYSTEXXA [INJ] [SP] kurvelo KUVAN [SP] KYLEENA [SP] KYMRIAH [INJ] [SP] KYPROLIS [INJ] [SP] L labetalol labetalol [INJ] lactulose lamivudine [SP] lamivudine hbv lamivudine/zidovudine [SP] lamotrigine lamotrigine ext-release lamotrigine orally disintegrating tablets LANOXIN PEDIATRIC [INJ] lansoprazole delayed-release lansoprazole delayed-release +amoxicillin+clarithromycin lansoprazole orally disintegrating tablets lanthanum LANTUS [INJ] larin larin fe larissia latanoprost eye solution LATUDA layolis fe l-cysteine [INJ] leena leflunomide LENVIMA [SP] lessina letrozole leucovorin leucovorin [INJ] LEUKERAN LEUKINE [INJ] [SP] leuprolide [INJ] [SP] levalbuterol nebulization solution LEVEMIR [INJ] levetiracetam levetiracetam [INJ] levetiracetam ext-release levetiracetam-nacl [INJ] levobunolol eye solution levocarnitine levocetirizine levofloxacin levofloxacin [INJ] levofloxacin eye solution levofloxacin/dextrose [INJ] LEVOLEUCOVORIN [INJ] levonest levonorgestrel-ethinyl estradiol levora levorphanol levothyroxine sodium levothyroxine sodium [INJ] LEVSIN [INJ] LEXISCAN [INJ] LEXIVA SUSPENSION [SP] LIBTAYO [INJ] [SP] lidocaine [INJ] lidocaine jelly lidocaine patches lidocaine topical lidocaine viscous lidocaine/dextrose [INJ] lidocaine/epinephrine [INJ] lidocaine/glycerin lidocaine/hydrocortisone lidocaine/prilocaine lillow lincomycin [INJ] lindane shampoo linezolid linezolid [INJ] linezolid/nacl [INJ] LINZESS LIORESAL [INJ] liothyronine liothyronine [INJ] LIPOFEN lisinopril lisinopril/hydrochlorothiazide lithium carbonate lithium carbonate ext-release lithium citrate LIVALO LO LOESTRIN FE LOKELMA LONSURF [SP] loperamide lopinavir/ritonavir [SP] lopreeza lorazepam lorazepam [INJ] LORBRENA [SP] loryna losartan losartan/hydrochlorothiazide LOTEMAX LOTEMAX SM loteprednol etabonate eye solution lovastatin Page 6 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. low-ogestrel loxapine lo-zumandimine LUMIGAN LUMIZYME [INJ] [SP] LUPANETA PACK [INJ] [SP] LUPRON DEPOT 3.75 MG, 11.25 MG [INJ] [SP] LUPRON DEPOT-PED [INJ] [SP] LUTATHERA [INJ] [SP] lutera luxamend LUXTURNA [INJ] [SP] LYNPARZA [SP] LYSODREN lyza M m.v.i. adult [INJ] M.V.I. PEDIATRIC [INJ] M.V.I.-12 [INJ] mafenide magnesium chloride [INJ] magnesium sulfate [INJ] MAGNESIUM/DEXTROSE 1 GM/100 ML [INJ] malathion manganese chloride [INJ] manganese sulfate [INJ] mannitol [INJ] maprotiline marlissa MARQIBO [INJ] [SP] MATULANE [SP] MAYZENT [SP] mb hydrogel meclizine meclofenamate medroxyprogesterone medroxyprogesterone (contraceptive) [INJ] mefenamic acid mefloquine megestrol MEKINIST [SP] melodetta 24 fe meloxicam melphalan melphalan [INJ] memantine memantine ext-release MENACTRA [INJ] MENOPUR [INJ] [SP] mepivacaine [INJ] MEPSEVII [INJ] [SP] mercaptopurine meropenem [INJ] MEROPENEM/NACL [INJ] mesalamine delayed-release mesalamine enema mesalamine kit mesalamine suppositories mesna [INJ] MESNEX TABLETS metaproterenol metaxalone metformin metformin ext-release methadone methadone [INJ] methamphetamine methazolamide methenamine hippurate methenamine mandelate methenamine/sodium phosphate/ methylene blue/hyoscyamine methimazole METHITEST methocarbamol methocarbamol [INJ] methotrexate methotrexate [INJ] methoxsalen methyclothiazide methyldopa methyldopa/hydrochlorothiazide methyldopate [INJ] methylergonovine methylergonovine [INJ] methylphenidate methylphenidate ext-release methylprednisolone methylprednisolone acetate [INJ] methylprednisolone sodium succinate [INJ] methyltestosterone metipranolol eye solution metoclopramide metoclopramide [INJ] metoclopramide orally disintegrating tablets metolazone metoprolol succinate ext-release metoprolol tartrate metoprolol tartrate [INJ] metoprolol/hydrochlorothiazide metronidazole metronidazole topical metronidazole vaginal metronidazole/nacl [INJ] mexiletine MIACALCIN [INJ] mibelas 24 fe miconazole vaginal microgestin microgestin fe midazolam midazolam [INJ] midazolam/nacl [INJ] midodrine mifepristone miglitol miglustat [SP] mili milrinone [INJ] milrinone/dextrose [INJ] mimvey mimvey lo MINIMED INFUSION SET MINIMED RESERVOIR MINOCIN [INJ] minocycline minocycline ext-release minoxidil MIRENA [SP] mirtazapine mirtazapine orally disintegrating tablets MIRVASO misoprostol MITIGARE mitomycin [INJ] mitoxantrone [INJ] [SP] M-M-R II [INJ] m-natal prenatal vitamins modafinil moderiba [SP] moexipril molindone mometasone mometasone nasal spray mono-linyah mononessa MONONINE [INJ] [SP] MONOVISC [INJ] [SP] montelukast morphine sulfate morphine sulfate [INJ] morphine sulfate ext-release morphine sulfate suppositories morphine sulfate/nacl [INJ] MOVANTIK moxifloxacin MOXIFLOXACIN [INJ] moxifloxacin eye solution MOZOBIL [INJ] [SP] MULTI-LANCET DEVICE [OTC] MULTITRACE-4 [INJ] MULTITRACE-5 [INJ] mupirocin MUSE MUSTARGEN [INJ] MVASI [INJ] [SP] MYALEPT [INJ] [SP] MYCAMINE [INJ] mycophenolate mofetil [SP] mycophenolate mofetil hcl [INJ] [SP] mycophenolic acid delayed-release [SP] MYDAYIS MYLERAN MYLOTARG [INJ] [SP] mynatal advance prenatal vitamins mynatal plus prenatal vitamins mynatal prenatal vitamins mynatal ultracaplet prenatal vitamins mynatal-z prenatal vitamins mynate 90 plus prenatal vitamins MYOBLOC [INJ] [SP] MYRBETRIQ myzilra N nabumetone nadolol nadolol/bendroflumethiazide nafcillin [INJ] nafcillin/dextrose [INJ] naftifine NAGLAZYME [INJ] [SP] nalbuphine [INJ] naloxone [INJ] naltrexone NAMZARIC nandrolone [INJ] naproxen naproxen delayed-release naproxen sodium naproxen sodium ext-release naratriptan NARCAN NASAL SPRAY NASCOBAL NATACYN nateglinide NATPARA [INJ] [SP] NATRECOR [INJ] NAYZILAM NEBUPENT necon neomycin neomycin/bacitracin/polymyxin eye ointment neomycin/bacitracin/polymyxin/ hydrocortisone eye ointment neomycin/polymyxin irrigation solution neomycin/polymyxin/dexamethasone eye ointment neomycin/polymyxin/dexamethasone eye suspension neomycin/polymyxin/gramicidin eye solution neomycin/polymyxin/hydrocortisone ear solution neomycin/polymyxin/hydrocortisone ear suspension neomycin/polymyxin/hydrocortisone eye suspension neostigmine [INJ] NEPHRAMINE [INJ] NERLYNX [SP] NEULASTA [INJ] [SP] NEUT [INJ] nevirapine [SP] nevirapine ext-release [SP] newgen prenatal vitamins NEXAVAR [SP] NEXIUM PACKETS NEXPLANON [INJ] [SP] NEXTERONE [INJ] niacin niacin ext-release nicardipine nicardipine [INJ] nifedipine ext-release nikki nilutamide nimodipine NINLARO [SP] nisoldipine ext-release nitisinone [SP] nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohydrate/macrocrystal nitroglycerin [INJ] nitroglycerin ext-release nitroglycerin ointment nitroglycerin patches nitroglycerin spray nitroglycerin/dextrose [INJ] nitroprusside sodium [INJ] NITYR [SP] nivatopic plus NIVESTYM [INJ] [SP] nizatidine nora-be NORDITROPIN [INJ] [SP] norepinephrine [INJ] norepinephrine/dextrose [INJ] norepinephrine/nacl [INJ] norethindrone norethindrone acetate norethindrone acetate-ethinyl estradiol norethindrone acetate-ethinyl estradiol + iron norgestimate-ethinyl estradiol Page 7 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. norlyda norlyroc NORMOSOL-M AND DEXTROSE [INJ] NORMOSOL-R AND DEXTROSE [INJ] NORMOSOL-R PH 7.4 [INJ] nortrel nortriptyline NORVIR CAPSULES [SP] NORVIR PACKETS [SP] NORVIR SOLUTION [SP] NOVAREL [INJ] [SP] NOVOEIGHT [INJ] [SP] NOVOFINE AUTOSHIELD NEEDLES [OTC] NOVOFINE NEEDLES [OTC] NOVOSEVEN RT [INJ] [SP] NOVOTWIST NEEDLES [OTC] NOXAFIL [INJ] NOXAFIL SUSPENSION NPLATE [INJ] [SP] NUBEQA [SP] NUCALA [INJ] [SP] NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX [INJ] [SP] nutrilyte [INJ] NUVARING nystatin nystatin topical nystatin/triamcinolone O OBIZUR [INJ] [SP] obstetrix dha prenatal vitamins OCALIVA [SP] ocella OCREVUS [INJ] [SP] octreotide [INJ] [SP] ODACTRA ODEFSEY [SP] ODOMZO [SP] OFEV [SP] OFIRMEV [INJ] ofloxacin ofloxacin ear solution ofloxacin eye solution ogestrel olanzapine olanzapine [INJ] olanzapine orally disintegrating tablets olanzapine/fluoxetine olmesartan olmesartan/amlodipine/ hydrochlorothiazide olmesartan/hydrochlorothiazide olopatadine eye solution olopatadine nasal spray omega-3 ethyl esters omeprazole delayed-release omeprazole/sodium bicarbonate OMNIPAQUE [INJ] OMNIPOD OMNIPOD DASH ONCASPAR [INJ] ondansetron ondansetron [INJ] ondansetron orally disintegrating tablets ONETOUCH DELICA LANCETS [OTC] ONETOUCH DELICA PLUS LANCETS [OTC] ONETOUCH ULTRA 2 SYSTEM [OTC] ONETOUCH ULTRA TEST STRIPS [OTC] ONETOUCH ULTRAMINI METER [OTC] ONETOUCH ULTRASOFT LANCETS [OTC] ONETOUCH VERIO FLEX [OTC] ONETOUCH VERIO IQ METER [OTC] ONETOUCH VERIO METER SYSTEM [OTC] ONETOUCH VERIO TEST STRIPS [OTC] ONEXTON ONIVYDE [INJ] [SP] OPDIVO [INJ] [SP] opium tincture opium/belladonna alkaloids suppositories OPSUMIT [SP] ORACEA ORALAIR [SP] ORBACTIV [INJ] ORILISSA ORKAMBI [SP] orphenadrine [INJ] orphenadrine ext-release orphenadrine/aspirin/caffeine orsythia ORTHOVISC [INJ] [SP] oseltamivir OTEZLA [SP] OTOVEL OTREXUP [INJ] OVIDREL [INJ] [SP] oxacillin [INJ] oxacillin/dextrose [INJ] oxaliplatin [INJ] oxandrolone oxaprozin oxcarbazepine OXERVATE [SP] oxiconazole oxybutynin oxybutynin ext-release oxycodone oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen OXYCONTIN oxymorphone oxymorphone ext-release oxytocin [INJ] OZEMPIC [INJ] OZURDEX [INJ] [SP] P paclitaxel [INJ] paliperidone ext-release palonosetron [INJ] PALYNZIQ [INJ] [SP] pamidronate [INJ] pantoprazole [INJ] pantoprazole delayed-release papaverine [INJ] PARADIGM INFUSION SETS PARADIGM RESERVOIRS PARADIGM SILHOUETTE SETS paregoric paricalcitol paricalcitol [INJ] paromomycin paroxetine hcl paroxetine hcl ext-release paroxetine mesylate PAZEO PEDIARIX [INJ] PEDITRACE [INJ] PEDVAXHIB [INJ] peg 3350/electrolytes powder for 4000 ml solution PEGANONE PEGASYS [INJ] [SP] peg-prep kit penicillamine penicillin g potassium [INJ] penicillin g procaine [INJ] penicillin g sodium [INJ] PENICILLIN GK/DEXTROSE [INJ] penicillin v potassium PENTACEL [INJ] PENTACEL ACTHIB COMPONENT [INJ] pentamidine [INJ] PENTASA pentobarbital [INJ] pentoxifylline ext-release PERFOROMIST perindopril PERJETA [INJ] [SP] permethrin perphenazine perphenazine/amitriptyline phenazopyridine phendimetrazine phendimetrazine ext-release phenelzine phenobarbital phenobarbital sodium [INJ] phenobarbital/hyoscyamine/atropine/ scopolamine phenoxybenzamine phentermine phentolamine [INJ] phenylbutyrate phenylephrine [INJ] phenylephrine eye solution phenylephrine/chlorpheniramine phenylephrine/dextrose [INJ] phenylephrine/nacl [INJ] phenytoin phenytoin sodium [INJ] phenytoin sodium extended philith PHOSLYRA phosphasal PHOSPHOLINE IODIDE PHOTOFRIN [INJ] physostigmine [INJ] phytonadione phytonadione [INJ] PHYTONADIONE 1 MG/0.5 ML SYRINGE [INJ] PICATO pilocarpine pilocarpine eye solution pimecrolimus pimozide pimtrea pindolol pioglitazone pioglitazone/glimepiride pioglitazone/metformin piperacillin/tazobactam [INJ] pirmella piroxicam PLASMA-LYTE [INJ] plasmanate [INJ] PLEGRIDY [INJ] [SP] plenamine [INJ] PNEUMOVAX 23 [INJ] pnv 29-1 prenatal vitamins pnv ob+dha prenatal vitamins pnv-dha + docusate prenatal vitamins pnv-dha prenatal vitamins pnv-ferrous fumarate-docu-fa prenatal vitamins pnv-omega prenatal vitamins pnv-select prenatal vitamins pnv-vp-u prenatal vitamins podofilox POLOCAINE [INJ] polyethylene glycol 3350 POLYFIN QR INFUSION SET polymyxin [INJ] polymyxin/trimethoprim eye solution POMALYST [SP] portia posaconazole POSACONAZOLE SUSPENSION potassium acetate [INJ] potassium bicarbonate/citric acid effervescent tablets potassium chloride [INJ] potassium chloride ext-release potassium chloride oral solution potassium chloride powder packets for solution potassium chloride/dextrose [INJ] potassium chloride/dextrose/nacl [INJ] potassium chloride/lactated ringers/ dextrose [INJ] potassium chloride/nacl [INJ] potassium chloride/water [INJ] potassium citrate ext-release potassium citrate/citric acid potassium iodide/iodine solution potassium phosphate [INJ] POTELIGEO [INJ] [SP] pr natal 400 ec prenatal vitamins pr natal 400 prenatal vitamins pr natal 430 ec prenatal vitamins pr natal 430 prenatal vitamins PRALUENT (NDCs starting with 00024) [INJ] pramipexole pramipexole ext-release prasugrel pravastatin praziquantel prazosin PRECISION XTRA B-KETONE STRIPS [OTC] PRECISION XTRA MONITOR [OTC] PRECISION XTRA TEST STRIPS [OTC] prednicarbate prednisolone prednisolone acetate eye suspension prednisolone sodium phosphate prednisolone sodium phosphate disintegrating tablets prednisolone sodium phosphate eye solution prednisone pregabalin PREMARIN [INJ] PREMARIN CREAM PREMARIN TABLETS premasol [INJ] PREMASOL 6% [INJ] PREMPHASE Page 8 (continued) © 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners. #1702 NP-A COMP1702A-20 (11/01/19) Go to express-scripts.com/2020drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com. PREMPRO prena1 chew prenatal vitamins prena1 pearl prenatal vitamins prena1 true prenatal vitamins prenaissance plus prenatal vitamins prenaissance prenatal vitamins prenatabs fa prenatal vitamins prenatabs rx prenatal vitamins prenatal low iron prenatal vitamins prenatal plus iron prenatal vitamins prenatal plus prenatal vitamins prenatal-u prenatal vitamins preplus prenatal vitamins PREPOPIK pretab 29-1 prenatal vitamins previfem PREVNAR 13 [INJ] PREVYMIS PREVYMIS [INJ] PREZISTA [