Express Scripts 2020 National Preferred Formulary List - Express Scripts

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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 For the member: FDA-approved generic medications meet strict standards and [INJ] – Injectable Drug contain the same active ingredients as their corresponding brand-name medications, [OTC] – Over-the-counter Product although they may have a different appearance. [SP] – Specialty Drug For the physician: Please prescribe preferred products and allow generic Brand-name drugs are listed in CAPITAL letters. Example: ABILIFY MAINTENA substitutions when medically appropriate. Generic drugs are listed in lower-case letters. Example: ibuprofen A adenosine [INJ] amabelz anthralin ADVAIR HFA amantadine APLISOL [INJ] abacavir [SP] ADVATE [INJ] [SP] AMBISOME [INJ] APOKYN [INJ] [SP] abacavir/lamivudine [SP] ADYNOVATE [INJ] [SP] ambrisentan [SP] apraclonidine eye solution abacavir/lamivudine/zidovudine [SP] AFINITOR [SP] amcinonide aprepitant ABELCET [INJ] AFINITOR DISPERZ [SP] amethia apri ABILIFY MAINTENA [INJ] afirmelle amethia lo APRISO abiraterone acetate [SP] AFLURIA [INJ] amethyst APTIVUS [SP] ABRAXANE [INJ] [SP] AFLURIA QUAD [INJ] AMICAR SOLUTION AQUASOL A [INJ] acamprosate delayed-release AFSTYLA [INJ] [SP] amifostine [INJ] ARALAST NP [INJ] [SP] acarbose AIMOVIG [INJ] amikacin [INJ] aranelle ACCU-CHEK FASTCLIX LANCETS [OTC] AJOVY [INJ] amiloride ARIKAYCE [SP] ACCU-CHEK MULTICLIX LANCET KIT [OTC] albendazole amiloride/hydrochlorothiazide aripiprazole ACCU-CHEK MULTICLIX LANCETS [OTC] albumin human [INJ] aminocaproic acid aripiprazole orally disintegrating tablets ACCU-CHEK SOFTCLIX LANCET KIT [OTC] albuterol aminocaproic acid [INJ] ARISTADA [INJ] ACCU-CHEK SOFTCLIX LANCETS [OTC] albuterol ext-release aminophylline [INJ] ARISTOSPAN [INJ] acebutolol albuterol nebulization solution AMINOSYN [INJ] armodafinil acetaminophen/codeine alclometasone amiodarone ARMONAIR RESPICLICK acetazolamide ALDURAZYME [INJ] [SP] amiodarone [INJ] ARMOUR THYROID acetazolamide ext-release ALECENSA [SP] amitriptyline ARNUITY ELLIPTA acetazolamide sodium [INJ] alendronate amitriptyline/chlordiazepoxide ARRANON [INJ] [SP] acetic acid ear solution alfentanil [INJ] amlodipine arsenic trioxide [INJ] acetic acid irrigation solution ALFERON N [INJ] amlodipine/atorvastatin ascorbic acid [INJ] acetic acid/hydrocortisone ear solution alfuzosin ext-release amlodipine/benazepril ashlyna acetic acid/oxyquinoline vaginal ALIMTA [INJ] amlodipine/olmesartan ASMANEX HFA acetylcysteine [INJ] ALINIA amlodipine/valsartan ASMANEX TWISTHALER acetylcysteine inhalation solution ALIQOPA [INJ] [SP] amlodipine/valsartan/hydrochlorothiazide aspirin/dipyridamole ext-release acitretin aliskiren ammonium lactate 12% topical atazanavir [SP] ACTEMRA [INJ] [SP] allopurinol amoxapine atenolol ACTHIB [INJ] allopurinol sodium [INJ] amoxicillin atenolol/chlorthalidone ACTHREL [INJ] almotriptan amoxicillin/potassium clavulanate ATGAM [INJ] ACTIMMUNE [INJ] [SP] alosetron amoxicillin/potassium clavulanate atomoxetine ACTIVASE [INJ] ALPHAGAN P 0.1% ext-release atorvastatin acyclovir ALPHANATE [INJ] [SP] amphetamine sulfate atovaquone acyclovir ointment ALPHANINE SD [INJ] [SP] amphotericin [INJ] atovaquone/proguanil acyclovir sodium [INJ] alprazolam ampicillin atropine [INJ] ADACEL [INJ] alprazolam ext-release ampicillin sodium [INJ] atropine sulfate eye ointment adapalene alprazolam orally disintegrating tablets ampicillin sodium/sulbactam [INJ] atropine sulfate eye solution adapalene/benzoyl peroxide ALPROLIX [INJ] [SP] AMYTAL [INJ] aubra ADCETRIS [INJ] [SP] alprostadil [INJ] anagrelide aubra eq ADDAMEL N [INJ] ALREX anastrozole AUGMENTIN 125-31.25 MG/5 ML adefovir altavera ANDRODERM aurovela ADEMPAS [SP] alyacen ANORO ELLIPTA aurovela 24 fe (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 1 COMP1702A-20 (11/01/19) aurovela fe BEXSERO [INJ] calcitriol CETROTIDE [INJ] [SP] AUSTEDO [SP] bicalutamide calcitriol [INJ] cevimeline AVASTIN [INJ] [SP] BICILLIN C-R [INJ] calcitriol ointment CHANTIX aviane BICILLIN L-A [INJ] calcium acetate chateal avo cream BIKTARVY [SP] calcium chloride [INJ] chateal eq AVONEX [INJ] [SP] bimatoprost eye solution CALCIUM DISODIUM VERSENATE [INJ] CHEMET AVYCAZ [INJ] biolon [INJ] calcium gluconate [INJ] CHENODAL [SP] ayuna BIOTHRAX [INJ] calcium-pnv 28-1-250 prenatal vitamins chloramphenicol [INJ] azacitidine [INJ] [SP] bisoprolol CALDOLOR [INJ] chlordiazepoxide AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] bisoprolol/hydrochlorothiazide camila chlordiazepoxide/clidinium AZASITE bivalirudin [INJ] camrese chlorhexidine gluconate azathioprine [SP] blanche camrese lo chloroprocaine hcl [INJ] azathioprine sodium [INJ] [SP] bleomycin [INJ] candesartan chloroquine AZEDRA [INJ] [SP] BLINCYTO [INJ] [SP] candesartan/hydrochlorothiazide chlorothiazide azelaic acid blisovi 24 fe CAPASTAT SULFATE [INJ] chlorothiazide sodium [INJ] azelastine eye solution blisovi fe capecitabine [SP] chlorpheniramine/phenylephrine/ azelastine nasal spray BOOSTRIX [INJ] CAPRELSA [SP] dextromethorphan azithromycin bosentan [SP] captopril chlorpromazine azithromycin [INJ] BOSULIF [SP] captopril/hydrochlorothiazide chlorpromazine [INJ] aztreonam [INJ] BOTOX [INJ] [SP] CARAC chlorthalidone azurette BREO ELLIPTA CARAFATE SUSPENSION chlorzoxazone BREVITAL [INJ] carbachol [INJ] CHOLBAM [SP] B briellyn CARBAGLU [SP] cholestyramine BRILINTA carbamazepine cholestyramine light bacitracin [INJ] brimonidine eye solution carbamazepine ext-release choline salicylate/magnesium salicylate bacitracin eye ointment BRINEURA [INJ] [SP] carbidopa chromium chloride [INJ] bacitracin/polymyxin eye ointment bromfenac eye solution carbidopa/levodopa ciclopirox baclofen bromocriptine carbidopa/levodopa ext-release ciclopirox shampoo baclofen [INJ] brompheniramine/pseudoephedrine/ carbidopa/levodopa orally cidofovir [INJ] BAL IN OIL [INJ] codeine disintegrating tablets cilostazol balanced salt eye irrigation solution brompheniramine/pseudoephedrine/ carbidopa/levodopa/entacapone CIMDUO [SP] bal-care dha prenatal vitamins dextromethorphan carbinoxamine cimetidine balsalazide budesonide ext-release carboplatin [INJ] cinacalcet BALVERSA [SP] budesonide nebulization suspension carmustine [INJ] CINRYZE [INJ] [SP] balziva bumetanide carteolol eye solution CINVANTI [INJ] BANZEL bumetanide [INJ] carvedilol CIPRODEX BAQSIMI bupivacaine [INJ] carvedilol phosphate ext-release ciprofloxacin BARACLUDE SOLUTION bupivacaine/dextrose [INJ] caspofungin [INJ] ciprofloxacin ear solution BAVENCIO [INJ] [SP] bupivacaine/epinephrine [INJ] CATHFLO ACTIVASE [INJ] ciprofloxacin ext-release b-complex [INJ] buprenorphine CAVERJECT [INJ] ciprofloxacin eye solution BD AUTOSHIELD DUO NEEDLES [OTC] buprenorphine [INJ] CAYSTON [SP] ciprofloxacin lactate/dextrose [INJ] BD ULTRAFINE INSULIN SYRINGES [OTC] buprenorphine patches caziant cisplatin [INJ] BD ULTRAFINE PEN NEEDLES [OTC] buprenorphine/naloxone cefaclor citalopram BEBULIN [INJ] [SP] bupropion cefaclor ext-release cladribine [INJ] bekyree bupropion ext-release cefadroxil clarithromycin BELBUCA bupropion ext-release (smoking deterrent)cefazolin [INJ] clarithromycin ext-release benazepril buspirone cefdinir clemastine benazepril/hydrochlorothiazide busulfan [INJ] cefditoren CLENPIQ BENDEKA [INJ] [SP] butalbital/acetaminophen cefepime [INJ] clindamycin hcl BENEFIX [INJ] [SP] butalbital/acetaminophen/caffeine cefepime/dextrose [INJ] clindamycin palmitate BENLYSTA [INJ] [SP] butalbital/acetaminophen/caffeine/ cefixime clindamycin phosphate [INJ] BENZNIDAZOLE codeine cefotaxime [INJ] clindamycin phosphate topical benzonatate butalbital/aspirin/caffeine cefotetan [INJ] clindamycin phosphate vaginal benzoyl peroxide butalbital/aspirin/caffeine/codeine cefoxitin [INJ] clindamycin phosphate/benzoyl peroxide benzphetamine butorphanol [INJ] cefoxitin/dextrose [INJ] clindamycin phosphate/dextrose [INJ] benztropine butorphanol nasal cefpodoxime clindamycin phosphate/tretinoin benztropine [INJ] BYDUREON [INJ] cefprozil CLINIMIX [INJ] BEPREVE BYETTA [INJ] ceftazidime [INJ] CLINIMIX E [INJ] BESPONSA [INJ] [SP] BYSTOLIC CEFTAZIDIME/DEXTROSE [INJ] clobazam betamethasone acetate/betamethasone ceftriaxone [INJ] clobetasol propionate sodium phosphate [INJ] C ceftriaxone/dextrose [INJ] clobetasol propionate shampoo betamethasone dipropionate cefuroxime axetil clobetasol propionate/emollient betamethasone dipropionate augmented cabergoline cefuroxime sodium [INJ] clofarabine [INJ] betamethasone valerate CABLIVI [INJ] [SP] celacyn clomiphene citrate BETASERON [INJ] [SP] CABOMETYX [SP] celecoxib clomipramine betaxolol caffeine citrated CELONTIN clonazepam betaxolol eye solution caffeine citrated [INJ] cephalexin clonazepam orally disintegrating tablets bethanechol caffeine/sodium benzoate [INJ] CEPROTIN [INJ] [SP] clonidine BETHKIS [SP] calcipotriene CERDELGA [SP] clonidine [INJ] BEVESPI AEROSPHERE calcipotriene/betamethasone dipropionate CEREZYME [INJ] [SP] clonidine ext-release bexarotene [SP] calcitonin salmon nasal cetirizine syrup clonidine patches (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 2 COMP1702A-20 (11/01/19) clopidogrel dalfampridine ext-release [SP] diclofenac sodium/misoprostol ext-release DYANAVEL XR clorazepate DALIRESP dicloxacillin DYMISTA clotrimazole topical DALVANCE [INJ] dicyclomine clotrimazole troche danazol dicyclomine [INJ] E clotrimazole/betamethasone dipropionate dantrolene didanosine delayed-release [SP] clozapine dantrolene [INJ] diethylpropion econazole clozapine orally disintegrating tablets dapsone diethylpropion ext-release EDARBI c-nate dha prenatal vitamins DAPTACEL [INJ] diflorasone EDARBYCLOR COAGADEX [INJ] [SP] daptomycin [INJ] diflorasone/emollient EDURANT [SP] COARTEM DARAPRIM [SP] diflunisal efavirenz [SP] cocaine topical solution darifenacin ext-release digoxin EGRIFTA [INJ] [SP] codeine sulfate DARZALEX [INJ] [SP] digoxin [INJ] ELAPRASE [INJ] [SP] colchicine/probenecid dasetta dihydrocodeine/acetaminophen/caffeine electrolyte-48 solution/dextrose [INJ] COLCRYS daunorubicin [INJ] dihydroergotamine [INJ] eletone colesevelam hcl daysee dihydroergotamine nasal eletriptan colestipol DAYTRANA DILANTIN 30 MG CAPSULES ELIGARD [INJ] [SP] colistimethate [INJ] DDAVP RHINAL SOLUTION DILATRATE-SR elinest COMBIGAN deblitane diltiazem ELIQUIS COMBIPATCH decitabine [INJ] [SP] diltiazem [INJ] ELITEK [INJ] COMBIVENT RESPIMAT deferasirox [SP] diltiazem ext-release elite-ob prenatal vitamins COMETRIQ [SP] deferoxamine [INJ] dimenhydrinate [INJ] ELMIRON complete natal dha prenatal vitamins delflex with dextrose [INJ] diphenhydramine ELOCTATE [INJ] [SP] completenate prenatal vitamins delyla diphenhydramine [INJ] ELZONRIS [INJ] [SP] constulose demeclocycline diphenoxylate/atropine EMCYT COPAXONE 40 MG [INJ] [SP] DEMSER DIPHTHERIA-TETANUS TOXOIDS-PED [INJ] EMGALITY [INJ] copper chloride [INJ] DEPEN dipyridamole emoquette CORIFACT [INJ] [SP] DEPO-ESTRADIOL [INJ] dipyridamole [INJ] EMTRIVA [SP] CORLANOR DEPO-PROVERA 400 MG/ML [INJ] disulfiram emulsion sb cortisone acetate DESCOVY [SP] divalproex delayed-release EMVERM COSENTYX [INJ] [SP] desipramine divalproex ext-release enalapril cosyntropin [INJ] desloratadine DIVIGEL enalapril/hydrochlorothiazide COTELLIC [SP] desloratadine orally disintegrating tablets dobutamine [INJ] enalaprilat [INJ] CREON desmopressin acetate dobutamine/dextrose [INJ] ENBREL [INJ] [SP] CRESEMBA desmopressin acetate [INJ] [SP] DOCEFREZ [INJ] ENGERIX-B [INJ] CRESEMBA [INJ] desmopressin nasal docetaxel [INJ] enoxaparin [INJ] [SP] CRINONE 4% desogestrel-ethinyl estradiol DOCETAXEL 200 MG/10 ML [INJ] enpresse CRINONE 8% [SP] desonide dofetilide enskyce CRIXIVAN [SP] desoximetasone donepezil ENSTILAR CROFAB [INJ] desvenlafaxine succinate ext-release donepezil orally disintegrating tablets entacapone cromolyn sodium eye solution dexamethasone dopamine [INJ] entecavir cromolyn sodium nebulization solution dexamethasone sodium phosphate [INJ] dopamine/dextrose [INJ] ENTRESTO cromolyn sodium oral solution dexamethasone sodium phosphate DOPTELET [SP] ENTYVIO [INJ] [SP] crotamiton eye solution dorzolamide eye solution EOVIST [INJ] cryselle dexchlorpheniramine dorzolamide/timolol eye solution EPCLUSA [SP] CRYSVITA [INJ] [SP] DEXCOM RECEIVER, SENSOR, dothelle dha prenatal vitamins ephedrine [INJ] cyanocobalamin [INJ] TRANSMITTER DOVATO [SP] EPIDIOLEX [SP] cyclafem dexmedetomidine [INJ] doxazosin EPIDUO FORTE cyclobenzaprine dexmedetomidine/nacl [INJ] doxepin epinastine eye solution cyclobenzaprine ext-release dexmethylphenidate doxepin cream epinephrine auto-injector (by Mylan) [INJ] cyclopentolate eye solution dexmethylphenidate ext-release doxercalciferol epinephrine vial, ampule, syringe [INJ] cyclopentolate/tropicamide/ dexrazoxane [INJ] doxercalciferol [INJ] epinephrine-dextrose [INJ] phenylephrine eye drops dextran/dextrose [INJ] doxorubicin [INJ] epinephrine-nacl [INJ] cyclophosphamide [INJ] dextran/normal saline [INJ] doxorubicin/liposomal [INJ] EPIPEN, EPIPEN JR [INJ] CYCLOPHOSPHAMIDE CAPSULES dextroamphetamine doxycycline hyclate epirubicin [INJ] cyclosporine [INJ] [SP] dextroamphetamine ext-release doxycycline hyclate [INJ] EPIVIR HBV SOLUTION cyclosporine [SP] dextroamphetamine/amphetamine doxycycline hyclate delayed-release eplerenone cyclosporine modified [SP] dextroamphetamine/amphetamine doxycycline monohydrate epoprostenol [INJ] [SP] cyproheptadine ext-release doxylamine succinate/vit b6 epoprostenol diluent [INJ] [SP] CYRAMZA [INJ] [SP] dextrose/lactated ringers [INJ] D-PENAMINE eprosartan cyred dextrose/sodium chloride [INJ] dronabinol eptifibatide [INJ] cyred eq dextrose/water [INJ] droperidol [INJ] ERAXIS [INJ] CYSTADANE [SP] DIACOMIT [SP] drospirenone-ethinyl estradiol ERBITUX [INJ] [SP] CYSTAGON [SP] diazepam drospirenone-ethinyl ergocalciferol CYSTARAN [SP] diazepam [INJ] estradiol-levomefolate ergoloid mesylates cytarabine [INJ] diazepam rectal gel DROXIA ergotamine tartrate/caffeine CYTOGAM [INJ] [SP] diclofenac eye solution DUAVEE ergotamine tartrate/caffeine diclofenac potassium DULERA suppositories D diclofenac sodium delayed-release duloxetine delayed-release ERIVEDGE [SP] diclofenac sodium ext-release DUPIXENT [INJ] [SP] ERLEADA [SP] dacarbazine [INJ] diclofenac sodium gel dutasteride erlotinib [SP] dactinomycin [INJ] diclofenac sodium topical solution dutasteride/tamsulosin ext-release errin (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 3 COMP1702A-20 (11/01/19) ertapenem [INJ] fenoprofen fosamprenavir [SP] glyburide micronized ERYTHROCIN [INJ] fentanyl citrate [INJ] fosaprepitant [INJ] glyburide/metformin erythromycin fentanyl citrate lozenges fosinopril glycine irrigation solution erythromycin delayed-release fentanyl citrate/nacl [INJ] fosinopril/hydrochlorothiazide glycolax erythromycin ethylsuccinate fentanyl patches fosphenytoin [INJ] GLYCOPHOS [INJ] erythromycin eye ointment FERAHEME [INJ] FRAGMIN [INJ] [SP] glycopyrrolate erythromycin stearate FERRIPROX [SP] FREAMINE HBC [INJ] glycopyrrolate [INJ] erythromycin topical FETZIMA freamine iii [INJ] glycopyrrolate-water [INJ] erythromycin/benzoyl peroxide FINACEA FOAM FREESTYLE FREEDOM KIT [OTC] GLYXAMBI ESBRIET [SP] finasteride FREESTYLE FREEDOM LITE METER [OTC] GONAL-F, GONAL-F RFF, escitalopram FIRMAGON [INJ] [SP] FREESTYLE INSULINX GLUCOSE GONAL-F RFF REDI-JECT [INJ] [SP] esmolol [INJ] FIRST-LANSOPRAZOLE SYSTEM [OTC] granisetron esmolol-nacl [INJ] FIRST-MOUTHWASH BLM FREESTYLE INSULINX TEST STRIPS [OTC] granisetron [INJ] esomeprazole magnesium delayed-release FIRST-OMEPRAZOLE FREESTYLE LIBRE GRASTEK esomeprazole sodium [INJ] flavoxate FREESTYLE LITE METER [OTC] griseofulvin microsize estarylla flecainide FREESTYLE LITE TEST STRIPS [OTC] griseofulvin ultramicrosize estazolam FLECTOR FREESTYLE TEST STRIPS [OTC] guaifenesin/codeine esterified estrogens/methyltestosterone FLOLAN [INJ] [SP] frovatriptan guaifenesin/phenylephrine estradiol FLOLAN DILUENT [INJ] [SP] fulvestrant [INJ] guanfacine estradiol cream FLOVENT DISKUS furosemide guanfacine ext-release estradiol patches FLOVENT HFA furosemide [INJ] guanidine estradiol vaginal floxuridine [INJ] FUZEON [INJ] [SP] estradiol valerate [INJ] FLUAD [INJ] fyavolv H estradiol/norethindrone acetate FLUARIX QUAD [INJ] FYCOMPA ESTRING FLUBLOK QUAD [INJ] hailey estropipate FLUCELVAX QUAD [INJ] G hailey 24 fe eszopiclone fluconazole HALAVEN [INJ] [SP] ethacrynate [INJ] fluconazole/dextrose [INJ] gabapentin halcinonide ethacrynic acid fluconazole/normal saline [INJ] GABLOFEN SYRINGE [INJ] halobetasol ethambutol flucytosine galantamine haloperidol ETHAMOLIN [INJ] fludarabine [INJ] galantamine ext-release haloperidol decanoate [INJ] ethosuximide fludrocortisone acetate GAMASTAN [INJ] [SP] haloperidol lactate ethyl alcohol [INJ] FLULAVAL QUAD [INJ] GAMASTAN S-D [INJ] [SP] haloperidol lactate [INJ] ethyl chloride spray flumazenil [INJ] GAMIFANT [INJ] [SP] HARVONI [SP] ethynodiol-ethinyl estradiol flunisolide nasal spray GAMMAGARD LIQUID [INJ] [SP] HAVRIX [INJ] etidronate fluocinolone GAMMAGARD S-D [INJ] [SP] heather etodolac fluocinolone acetonide oil ear solution GAMUNEX-C [INJ] [SP] HELIXATE FS [INJ] [SP] etodolac ext-release fluocinonide ganciclovir [INJ] HEMABATE [INJ] etomidate [INJ] fluocinonide/emollient ganirelix acetate [INJ] [SP] hemenatal ob + dha prenatal vitamins ETOPOPHOS [INJ] fluorescein [INJ] GARDASIL 9 [INJ] hemenatal ob prenatal vitamins etoposide fluorescein eye strips gatifloxacin eye solution HEMLIBRA [INJ] [SP] etoposide [INJ] fluorometholone eye suspension gavilyte-c HEMOFIL-M [INJ] [SP] EUFLEXXA [INJ] [SP] fluorouracil gavilyte-g HEPAGAM B [INJ] exemestane fluorouracil [INJ] gavilyte-n heparin lock flush [INJ] EXTRANEAL ICODEXTRIN DIALYSIS fluoxetine GAZYVA [INJ] [SP] heparin sodium [INJ] SOLUTION [INJ] fluoxetine delayed-release GELNIQUE heparin sodium/dextrose [INJ] EYLEA [INJ] [SP] fluphenazine decanoate [INJ] gemcitabine [INJ] heparin sodium/nacl [INJ] ezetimibe fluphenazine hcl gemfibrozil HEPATAMINE [INJ] ezetimibe/simvastatin fluphenazine hcl [INJ] GENOTROPIN [INJ] [SP] HERCEPTIN [INJ] [SP] flurandrenolide gentamicin [INJ] hetastarch/normal saline [INJ] F flurazepam gentamicin eye ointment HEXTEND LACTATED ELECTROLYTE [INJ] flurbiprofen gentamicin eye solution HIBERIX [INJ] FABRAZYME [INJ] [SP] flurbiprofen sodium eye solution gentamicin topical HIZENTRA [INJ] [SP] falmina flutamide gentamicin/normal saline [INJ] homatropine eye solution famciclovir fluticasone nasal spray GENTAMICIN/NORMAL SALINE hpr emollient foam famotidine fluticasone topical 100 MG/50 ML [INJ] hpr plus famotidine [INJ] FLUTICASONE/SALMETEROL AEROSOL GENVOYA [SP] hpr plus hydrogel famotidine/nacl [INJ] fluticasone/salmeterol powder inhaler gianvi HUMALOG [INJ] FARXIGA fluvastatin GILENYA [SP] HUMATE-P [INJ] [SP] FASENRA [INJ] [SP] fluvastatin ext-release GILOTRIF [SP] HUMIRA [INJ] [SP] FASLODEX [INJ] fluvoxamine GLASSIA [INJ] [SP] HUMULIN [INJ] fayosim fluvoxamine ext-release glatiramer [INJ] [SP] HUMULIN R 500 UNITS [INJ] febuxostat FLUZONE HIGH-DOSE [INJ] glatopa [INJ] [SP] HYCAMTIN CAPSULES [SP] FEIBA NF [INJ] [SP] FLUZONE QUAD [INJ] GLEOSTINE hydralazine felbamate folic acid glimepiride hydralazine [INJ] felodipine ext-release folic acid [INJ] glipizide hydrochlorothiazide femynor folivane-ob prenatal vitamins glipizide ext-release hydrocodone/acetaminophen fenofibrate FOLOTYN [INJ] [SP] glipizide/metformin hydrocodone/chlorpheniramine polistirex fenofibrate micronized fomepizole [INJ] GLUCAGEN [INJ] ext-release fenofibric acid fondaparinux [INJ] [SP] GLUCAGON [INJ] hydrocodone/homatropine fenofibric acid delayed-release FORTEO [INJ] [SP] glyburide hydrocodone/ibuprofen (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 4 COMP1702A-20 (11/01/19) hydrocortisone indomethacin ext-release junel fe leucovorin [INJ] hydrocortisone acetate suppositories indomethacin sodium [INJ] JUXTAPID [SP] LEUKERAN hydrocortisone butyrate INFANRIX [INJ] LEUKINE [INJ] [SP] hydrocortisone butyrate/emollient infed [INJ] K leuprolide [INJ] [SP] hydrocortisone enema INFUMORPH [INJ] levalbuterol nebulization solution hydrocortisone sodium succinate [INJ] INFUVITE [INJ] KADCYLA [INJ] [SP] LEVEMIR [INJ] hydrocortisone topical INLYTA [SP] kaitlib fe levetiracetam hydrocortisone valerate INTELENCE [SP] KALETRA TABLETS [SP] levetiracetam [INJ] hydrocortisone/iodoquinol intralipid 20% [INJ] kalliga levetiracetam ext-release hydrocortisone/iodoquinol/aloe INTRON A [INJ] [SP] KALYDECO [SP] levetiracetam-nacl [INJ] hydrocortisone/lidocaine introvale KANJINTI [INJ] [SP] levobunolol eye solution hydrocortisone/pramoxine INVANZ ADD-VANTAGE [INJ] KANUMA [INJ] [SP] levocarnitine hydromorphone INVELTYS kariva levocetirizine hydromorphone [INJ] INVIRASE [SP] kelnor levofloxacin hydromorphone ext-release INVOKAMET KEPIVANCE [INJ] [SP] levofloxacin [INJ] hydromorphone suppositories INVOKAMET XR ketamine [INJ] levofloxacin eye solution hydromorphone/nacl [INJ] INVOKANA ketamine-nacl [INJ] levofloxacin/dextrose [INJ] hydroquinone iodine/potassium iodide ketoconazole LEVOLEUCOVORIN [INJ] hydroquinone microspheres iodine/sodium iodide ketoconazole shampoo levonest hydroxocobalamin [INJ] IODOPEN [INJ] ketoconazole topical levonorgestrel-ethinyl estradiol hydroxychloroquine IONOSOL/DEXTROSE [INJ] ketoconazole/skin cleanser kit levora hydroxyprogesterone [INJ] IPOL [INJ] ketoprofen levorphanol hydroxyprogesterone [INJ] [SP] ipratropium bromide nasal spray ketoprofen ext-release levothyroxine sodium hydroxyurea ipratropium bromide nebulization solution ketorolac levothyroxine sodium [INJ] hydroxyzine hcl ipratropium/albuterol sulfate nebulization ketorolac [INJ] LEVSIN [INJ] hydroxyzine hcl [INJ] solution ketorolac eye solution LEXISCAN [INJ] hydroxyzine pamoate irbesartan KEYTRUDA [INJ] [SP] LEXIVA SUSPENSION [SP] hyophen irbesartan/hydrochlorothiazide kimidess LIBTAYO [INJ] [SP] hyoscyamine IRESSA [SP] KINEVAC [INJ] lidocaine [INJ] hyoscyamine ext-release irinotecan [INJ] KITABIS PAK [SP] lidocaine jelly hyoscyamine orally disintegrating tablets ISENTRESS [SP] KOGENATE FS [INJ] [SP] lidocaine patches HYPERHEP B S-D [INJ] isibloom KOVALTRY [INJ] [SP] lidocaine topical HYPERRAB [INJ] ISOLYTE [INJ] K-PHOS ORIGINAL lidocaine viscous HYPERRAB S-D [INJ] isoniazid KRYSTEXXA [INJ] [SP] lidocaine/dextrose [INJ] HYPERRHO S-D [INJ] isoniazid [INJ] kurvelo lidocaine/epinephrine [INJ] HYPERTET S-D [INJ] isoproterenol [INJ] KUVAN [SP] lidocaine/glycerin hypochlorous acid/sodium chloride isosorbide dinitrate KYLEENA [SP] lidocaine/hydrocortisone HYSINGLA ER isosorbide dinitrate ext-release KYMRIAH [INJ] [SP] lidocaine/prilocaine isosorbide mononitrate KYPROLIS [INJ] [SP] lillow I isosorbide mononitrate ext-release lincomycin [INJ] isotretinoin L lindane shampoo ibandronate isoxsuprine linezolid ibandronate [INJ] [SP] isradipine labetalol linezolid [INJ] IBRANCE [SP] ISTODAX [INJ] [SP] labetalol [INJ] linezolid/nacl [INJ] ibuprofen itraconazole lactulose LINZESS ibuprofen lysine [INJ] ivermectin lamivudine [SP] LIORESAL [INJ] ibutilide [INJ] IXEMPRA [INJ] [SP] lamivudine hbv liothyronine icatibant [INJ] [SP] IXIARO [INJ] lamivudine/zidovudine [SP] liothyronine [INJ] ICLUSIG [SP] IXINITY [INJ] [SP] lamotrigine LIPOFEN idarubicin [INJ] lamotrigine ext-release lisinopril IDHIFA [SP] J lamotrigine orally disintegrating tablets lisinopril/hydrochlorothiazide ifosfamide [INJ] LANOXIN PEDIATRIC [INJ] lithium carbonate ifosfamide/mesna [INJ] JAKAFI [SP] lansoprazole delayed-release lithium carbonate ext-release ILARIS [INJ] [SP] JANUMET lansoprazole delayed-release lithium citrate ILEVRO JANUMET XR +amoxicillin+clarithromycin LIVALO imatinib [SP] JANUVIA lansoprazole orally disintegrating tablets LO LOESTRIN FE IMBRUVICA [SP] JARDIANCE lanthanum LOKELMA IMFINZI [INJ] [SP] jasmiel LANTUS [INJ] LONSURF [SP] imipenem/cilastatin [INJ] jencycla larin loperamide imipramine hcl JENTADUETO larin fe lopinavir/ritonavir [SP] imipramine pamoate JENTADUETO XR larissia lopreeza imiquimod JETREA [INJ] [SP] latanoprost eye solution lorazepam IMOGAM RABIES-HT [INJ] jevantique lo LATUDA lorazepam [INJ] IMOVAX RABIES VACCINE [INJ] JEVTANA [INJ] [SP] layolis fe LORBRENA [SP] IMPAVIDO jinteli l-cysteine [INJ] loryna INBRIJA [SP] JIVI [INJ] [SP] leena losartan incassia jolessa leflunomide losartan/hydrochlorothiazide INCRELEX [INJ] [SP] jolivette LENVIMA [SP] LOTEMAX INCRUSE ELLIPTA juleber lessina LOTEMAX SM indapamide JULUCA [SP] letrozole loteprednol etabonate eye solution indomethacin junel leucovorin lovastatin (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 5 COMP1702A-20 (11/01/19) low-ogestrel methazolamide M-M-R II [INJ] NATPARA [INJ] [SP] loxapine methenamine hippurate m-natal prenatal vitamins NATRECOR [INJ] lo-zumandimine methenamine mandelate modafinil NAYZILAM LUMIGAN methenamine/sodium phosphate/ moderiba [SP] NEBUPENT LUMIZYME [INJ] [SP] methylene blue/hyoscyamine moexipril necon LUPANETA PACK [INJ] [SP] methimazole molindone neomycin LUPRON DEPOT 3.75 MG, 11.25 MG METHITEST mometasone neomycin/bacitracin/polymyxin [INJ] [SP] methocarbamol mometasone nasal spray eye ointment LUPRON DEPOT-PED [INJ] [SP] methocarbamol [INJ] mono-linyah neomycin/bacitracin/polymyxin/ LUTATHERA [INJ] [SP] methotrexate mononessa hydrocortisone eye ointment lutera methotrexate [INJ] MONONINE [INJ] [SP] neomycin/polymyxin irrigation solution luxamend methoxsalen MONOVISC [INJ] [SP] neomycin/polymyxin/dexamethasone LUXTURNA [INJ] [SP] methyclothiazide montelukast eye ointment LYNPARZA [SP] methyldopa morphine sulfate neomycin/polymyxin/dexamethasone LYSODREN methyldopa/hydrochlorothiazide morphine sulfate [INJ] eye suspension lyza methyldopate [INJ] morphine sulfate ext-release neomycin/polymyxin/gramicidin methylergonovine morphine sulfate suppositories eye solution M methylergonovine [INJ] morphine sulfate/nacl [INJ] neomycin/polymyxin/hydrocortisone methylphenidate MOVANTIK ear solution m.v.i. adult [INJ] methylphenidate ext-release moxifloxacin neomycin/polymyxin/hydrocortisone M.V.I. PEDIATRIC [INJ] methylprednisolone MOXIFLOXACIN [INJ] ear suspension M.V.I.-12 [INJ] methylprednisolone acetate [INJ] moxifloxacin eye solution neomycin/polymyxin/hydrocortisone mafenide methylprednisolone sodium MOZOBIL [INJ] [SP] eye suspension magnesium chloride [INJ] succinate [INJ] MULTI-LANCET DEVICE [OTC] neostigmine [INJ] magnesium sulfate [INJ] methyltestosterone MULTITRACE-4 [INJ] NEPHRAMINE [INJ] MAGNESIUM/DEXTROSE metipranolol eye solution MULTITRACE-5 [INJ] NERLYNX [SP] 1 GM/100 ML [INJ] metoclopramide mupirocin NEULASTA [INJ] [SP] malathion metoclopramide [INJ] MUSE NEUT [INJ] manganese chloride [INJ] metoclopramide orally MUSTARGEN [INJ] nevirapine [SP] manganese sulfate [INJ] disintegrating tablets MVASI [INJ] [SP] nevirapine ext-release [SP] mannitol [INJ] metolazone MYALEPT [INJ] [SP] newgen prenatal vitamins maprotiline metoprolol succinate ext-release MYCAMINE [INJ] NEXAVAR [SP] marlissa metoprolol tartrate mycophenolate mofetil [SP] NEXIUM PACKETS MARQIBO [INJ] [SP] metoprolol tartrate [INJ] mycophenolate mofetil hcl [INJ] [SP] NEXPLANON [INJ] [SP] MATULANE [SP] metoprolol/hydrochlorothiazide mycophenolic acid delayed-release [SP] NEXTERONE [INJ] MAYZENT [SP] metronidazole MYDAYIS niacin mb hydrogel metronidazole topical MYLERAN niacin ext-release meclizine metronidazole vaginal MYLOTARG [INJ] [SP] nicardipine meclofenamate metronidazole/nacl [INJ] mynatal advance prenatal vitamins nicardipine [INJ] medroxyprogesterone mexiletine mynatal plus prenatal vitamins nifedipine ext-release medroxyprogesterone (contraceptive) [INJ] MIACALCIN [INJ] mynatal prenatal vitamins nikki mefenamic acid mibelas 24 fe mynatal ultracaplet prenatal vitamins nilutamide mefloquine miconazole vaginal mynatal-z prenatal vitamins nimodipine megestrol microgestin mynate 90 plus prenatal vitamins NINLARO [SP] MEKINIST [SP] microgestin fe MYOBLOC [INJ] [SP] nisoldipine ext-release melodetta 24 fe midazolam MYRBETRIQ nitisinone [SP] meloxicam midazolam [INJ] myzilra nitrofurantoin melphalan midazolam/nacl [INJ] nitrofurantoin macrocrystal melphalan [INJ] midodrine N nitrofurantoin monohydrate/macrocrystal memantine mifepristone nitroglycerin [INJ] memantine ext-release miglitol nabumetone nitroglycerin ext-release MENACTRA [INJ] miglustat [SP] nadolol nitroglycerin ointment MENOPUR [INJ] [SP] mili nadolol/bendroflumethiazide nitroglycerin patches mepivacaine [INJ] milrinone [INJ] nafcillin [INJ] nitroglycerin spray MEPSEVII [INJ] [SP] milrinone/dextrose [INJ] nafcillin/dextrose [INJ] nitroglycerin/dextrose [INJ] mercaptopurine mimvey naftifine nitroprusside sodium [INJ] meropenem [INJ] mimvey lo NAGLAZYME [INJ] [SP] NITYR [SP] MEROPENEM/NACL [INJ] MINIMED INFUSION SET nalbuphine [INJ] nivatopic plus mesalamine delayed-release MINIMED RESERVOIR naloxone [INJ] NIVESTYM [INJ] [SP] mesalamine enema MINOCIN [INJ] naltrexone nizatidine mesalamine kit minocycline NAMZARIC nora-be mesalamine suppositories minocycline ext-release nandrolone [INJ] NORDITROPIN [INJ] [SP] mesna [INJ] minoxidil naproxen norepinephrine [INJ] MESNEX TABLETS MIRENA [SP] naproxen delayed-release norepinephrine/dextrose [INJ] metaproterenol mirtazapine naproxen sodium norepinephrine/nacl [INJ] metaxalone mirtazapine orally disintegrating tablets naproxen sodium ext-release norethindrone metformin MIRVASO naratriptan norethindrone acetate metformin ext-release misoprostol NARCAN NASAL SPRAY norethindrone acetate-ethinyl estradiol methadone MITIGARE NASCOBAL norethindrone acetate-ethinyl estradiol methadone [INJ] mitomycin [INJ] NATACYN + iron methamphetamine mitoxantrone [INJ] [SP] nateglinide norgestimate-ethinyl estradiol (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 6 COMP1702A-20 (11/01/19) norlyda ONETOUCH ULTRA TEST STRIPS [OTC] PEDITRACE [INJ] plenamine [INJ] norlyroc ONETOUCH ULTRAMINI METER [OTC] PEDVAXHIB [INJ] PNEUMOVAX 23 [INJ] NORMOSOL-M AND DEXTROSE [INJ] ONETOUCH ULTRASOFT LANCETS [OTC] peg 3350/electrolytes powder for 4000 ml pnv 29-1 prenatal vitamins NORMOSOL-R AND DEXTROSE [INJ] ONETOUCH VERIO FLEX [OTC] solution pnv ob+dha prenatal vitamins NORMOSOL-R PH 7.4 [INJ] ONETOUCH VERIO IQ METER [OTC] PEGANONE pnv-dha + docusate prenatal vitamins nortrel ONETOUCH VERIO METER SYSTEM [OTC] PEGASYS [INJ] [SP] pnv-dha prenatal vitamins nortriptyline ONETOUCH VERIO TEST STRIPS [OTC] peg-prep kit pnv-ferrous fumarate-docu-fa NORVIR CAPSULES [SP] ONEXTON penicillamine prenatal vitamins NORVIR PACKETS [SP] ONIVYDE [INJ] [SP] penicillin g potassium [INJ] pnv-omega prenatal vitamins NORVIR SOLUTION [SP] OPDIVO [INJ] [SP] penicillin g procaine [INJ] pnv-select prenatal vitamins NOVAREL [INJ] [SP] opium tincture penicillin g sodium [INJ] pnv-vp-u prenatal vitamins NOVOEIGHT [INJ] [SP] opium/belladonna alkaloids suppositories PENICILLIN GK/DEXTROSE [INJ] podofilox NOVOFINE AUTOSHIELD NEEDLES [OTC] OPSUMIT [SP] penicillin v potassium POLOCAINE [INJ] NOVOFINE NEEDLES [OTC] ORACEA PENTACEL [INJ] polyethylene glycol 3350 NOVOSEVEN RT [INJ] [SP] ORALAIR [SP] PENTACEL ACTHIB COMPONENT [INJ] POLYFIN QR INFUSION SET NOVOTWIST NEEDLES [OTC] ORBACTIV [INJ] pentamidine [INJ] polymyxin [INJ] NOXAFIL [INJ] ORILISSA PENTASA polymyxin/trimethoprim eye solution NOXAFIL SUSPENSION ORKAMBI [SP] pentobarbital [INJ] POMALYST [SP] NPLATE [INJ] [SP] orphenadrine [INJ] pentoxifylline ext-release portia NUBEQA [SP] orphenadrine ext-release PERFOROMIST posaconazole NUCALA [INJ] [SP] orphenadrine/aspirin/caffeine perindopril POSACONAZOLE SUSPENSION NUCYNTA orsythia PERJETA [INJ] [SP] potassium acetate [INJ] NUCYNTA ER ORTHOVISC [INJ] [SP] permethrin potassium bicarbonate/citric acid NUEDEXTA oseltamivir perphenazine effervescent tablets NULOJIX [INJ] [SP] OTEZLA [SP] perphenazine/amitriptyline potassium chloride [INJ] nutrilyte [INJ] OTOVEL phenazopyridine potassium chloride ext-release NUVARING OTREXUP [INJ] phendimetrazine potassium chloride oral solution nystatin OVIDREL [INJ] [SP] phendimetrazine ext-release potassium chloride powder packets for nystatin topical oxacillin [INJ] phenelzine solution nystatin/triamcinolone oxacillin/dextrose [INJ] phenobarbital potassium chloride/dextrose [INJ] oxaliplatin [INJ] phenobarbital sodium [INJ] potassium chloride/dextrose/nacl [INJ] O oxandrolone phenobarbital/hyoscyamine/atropine/ potassium chloride/lactated ringers/ oxaprozin scopolamine dextrose [INJ] OBIZUR [INJ] [SP] oxcarbazepine phenoxybenzamine potassium chloride/nacl [INJ] obstetrix dha prenatal vitamins OXERVATE [SP] phentermine potassium chloride/water [INJ] OCALIVA [SP] oxiconazole phentolamine [INJ] potassium citrate ext-release ocella oxybutynin phenylbutyrate potassium citrate/citric acid OCREVUS [INJ] [SP] oxybutynin ext-release phenylephrine [INJ] potassium iodide/iodine solution octreotide [INJ] [SP] oxycodone phenylephrine eye solution potassium phosphate [INJ] ODACTRA oxycodone/acetaminophen phenylephrine/chlorpheniramine POTELIGEO [INJ] [SP] ODEFSEY [SP] oxycodone/aspirin phenylephrine/dextrose [INJ] pr natal 400 ec prenatal vitamins ODOMZO [SP] oxycodone/ibuprofen phenylephrine/nacl [INJ] pr natal 400 prenatal vitamins OFEV [SP] OXYCONTIN phenytoin pr natal 430 ec prenatal vitamins OFIRMEV [INJ] oxymorphone phenytoin sodium [INJ] pr natal 430 prenatal vitamins ofloxacin oxymorphone ext-release phenytoin sodium extended PRALUENT (NDCs starting ofloxacin ear solution oxytocin [INJ] philith with 00024) [INJ] ofloxacin eye solution OZEMPIC [INJ] PHOSLYRA pramipexole ogestrel OZURDEX [INJ] [SP] phosphasal pramipexole ext-release olanzapine PHOSPHOLINE IODIDE prasugrel olanzapine [INJ] P PHOTOFRIN [INJ] pravastatin olanzapine orally disintegrating tablets physostigmine [INJ] praziquantel olanzapine/fluoxetine paclitaxel [INJ] phytonadione prazosin olmesartan paliperidone ext-release phytonadione [INJ] PRECISION XTRA B-KETONE STRIPS [OTC] olmesartan/amlodipine/ palonosetron [INJ] PHYTONADIONE 1 MG/0.5 ML PRECISION XTRA MONITOR [OTC] hydrochlorothiazide PALYNZIQ [INJ] [SP] SYRINGE [INJ] PRECISION XTRA TEST STRIPS [OTC] olmesartan/hydrochlorothiazide pamidronate [INJ] PICATO prednicarbate olopatadine eye solution pantoprazole [INJ] pilocarpine prednisolone olopatadine nasal spray pantoprazole delayed-release pilocarpine eye solution prednisolone acetate eye suspension omega-3 ethyl esters papaverine [INJ] pimecrolimus prednisolone sodium phosphate omeprazole delayed-release PARADIGM INFUSION SETS pimozide prednisolone sodium phosphate omeprazole/sodium bicarbonate PARADIGM RESERVOIRS pimtrea disintegrating tablets OMNIPAQUE [INJ] PARADIGM SILHOUETTE SETS pindolol prednisolone sodium phosphate OMNIPOD paregoric pioglitazone eye solution OMNIPOD DASH paricalcitol pioglitazone/glimepiride prednisone ONCASPAR [INJ] paricalcitol [INJ] pioglitazone/metformin pregabalin ondansetron paromomycin piperacillin/tazobactam [INJ] PREMARIN [INJ] ondansetron [INJ] paroxetine hcl pirmella PREMARIN CREAM ondansetron orally disintegrating tablets paroxetine hcl ext-release piroxicam PREMARIN TABLETS ONETOUCH DELICA LANCETS [OTC] paroxetine mesylate PLASMA-LYTE [INJ] premasol [INJ] ONETOUCH DELICA PLUS LANCETS [OTC] PAZEO plasmanate [INJ] PREMASOL 6% [INJ] ONETOUCH ULTRA 2 SYSTEM [OTC] PEDIARIX [INJ] PLEGRIDY [INJ] [SP] PREMPHASE (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 7 COMP1702A-20 (11/01/19) PREMPRO pseudoephedrine/chlorpheniramine/ REVLIMID [SP] sildenafil [INJ] [SP] prena1 chew prenatal vitamins methscopolamine ext-release REYATAZ PACKETS [SP] sildenafil [SP] prena1 pearl prenatal vitamins pseudoephedrine/codeine/guaifenesin R-GENE 10 [INJ] SILHOUETTE INFUSION SETS prena1 true prenatal vitamins PULMICORT FLEXHALER RHOPRESSA silodosin prenaissance plus prenatal vitamins PULMOZYME [SP] RIASTAP [INJ] [SP] silver nitrate prenaissance prenatal vitamins PURIXAN [SP] ribavirin [SP] silver sulfadiazine prenatabs fa prenatal vitamins PYLERA ribavirin nebulization solution simliya prenatabs rx prenatal vitamins pyrazinamide RIDAURA simpesse prenatal low iron prenatal vitamins pyridostigmine rifabutin SIMPONI 100 MG (for ulcerative prenatal plus iron prenatal vitamins pyridostigmine [INJ] rifampin colitis only) [INJ] [SP] prenatal plus prenatal vitamins pyridostigmine ext-release rifampin [INJ] SIMULECT [INJ] [SP] prenatal-u prenatal vitamins pyridoxine [INJ] riluzole simvastatin preplus prenatal vitamins rimantadine sirolimus [SP] PREPOPIK Q ringers irrigation solution SIRTURO pretab 29-1 prenatal vitamins ringers lactated irrigation solution SKYLA [SP] previfem QBREXZA ringers solution [INJ] SKYRIZI [INJ] [SP] PREVNAR 13 [INJ] QNASL ringers solution lactated [INJ] sodium acetate [INJ] PREVYMIS QUADRACEL DTAP-IPV [INJ] RINVOQ ER [SP] sodium benzoate/ PREVYMIS [INJ] quasense risedronate sodium phenylacetate [INJ] PREZISTA [SP] QUDEXY XR risedronate delayed-release sodium bicarbonate [INJ] PRIALT [INJ] [SP] quetiapine RISPERDAL CONSTA [INJ] sodium bicarbonate/dextrose [INJ] PRIFTIN quetiapine ext-release risperidone sodium chloride [INJ] PRIMAQUINE QUICK RELEASE TEFLON CANNULA risperidone orally disintegrating tablets sodium chloride 0.45 % [INJ] primaquine phosphate QUILLICHEW ER ritonavir [SP] sodium chloride 0.9 % [INJ] primidone QUILLIVANT XR RITUXAN [INJ] [SP] sodium chloride 3 % [INJ] PRIVIGEN [INJ] [SP] quinapril RITUXAN HYCELA [INJ] [SP] sodium chloride 5 % [INJ] PROAIR HFA quinapril/hydrochlorothiazide rivastigmine sodium chloride irrigation solution PROAIR RESPICLICK quinidine gluconate [INJ] rivastigmine patches sodium chloride nebulization solution probenecid quinidine gluconate ext-release rivelsa sodium chloride, bacteriostatic [INJ] procainamide [INJ] quinidine sulfate rizatriptan sodium ferric gluconate complex [INJ] PROCALAMINE [INJ] quinine sulfate rizatriptan orally disintegrating tablets sodium fluoride dental cream, gel prochlorperazine edisylate [INJ] QVAR REDIHALER ropinirole sodium lactate [INJ] prochlorperazine maleate ropinirole ext-release sodium phosphate [INJ] prochlorperazine maleate suppositories R ropivacaine/nacl [INJ] sodium polystyrene sulfonate PROCRIT [INJ] [SP] rosuvastatin sodium polystyrene sulfonate rectal PROFILNINE SD [INJ] [SP] RABAVERT [INJ] ROTATEQ sodium thiosulfate [INJ] progesterone in oil [INJ] [SP] rabeprazole delayed-release ROZLYTREK [SP] SOF-SET MICRO INFUSION SET progesterone micronized RADICAVA [INJ] [SP] RUBRACA [SP] SOF-SET ULTIMATE QR SET PROGLYCEM RAGWITEK RUCONEST [INJ] [SP] SOFT TOUCH LANCETS [OTC] PROGRAF [INJ] [SP] rajani RUZURGI [SP] solifenacin PROGRAF PACKET [SP] raloxifene RYDAPT [SP] SOLIQUA [INJ] PROLASTIN C [INJ] [SP] ramelteon SOLIRIS [INJ] [SP] PROLENSA ramipril S SOLU-CORTEF [INJ] PROLEUKIN [INJ] [SP] ranitidine SOMATULINE DEPOT [INJ] [SP] PROMACTA [SP] ranitidine [INJ] salicylic acid shampoo SOMAVERT [INJ] [SP] promethazine ranolazine ext-release salicylic acid topical sonafine promethazine [INJ] RAPIVAB [INJ] salsalate SOOLANTRA promethazine suppositories rasagiline SAMSCA [SP] sotalol promethazine/codeine RASUVO [INJ] SANDIMMUNE SOLUTION [SP] SOTALOL [INJ] promethazine/dextromethorphan RAVICTI [SP] SANTYL SOTRADECOL [INJ] promethazine/phenylephrine REBIF [INJ] [SP] SAVELLA SOTYLIZE promethazine/phenylephrine/codeine reclipsen scopolamine patches sp antipruritic propafenone RECOMBIVAX HB [INJ] secobarbital sp scar propafenone ext-release RECTIV SEGLUROMET spinosad proparacaine eye solution REGRANEX selegiline SPINRAZA [INJ] [SP] proparacaine/fluorescein eye solution RELISTOR [INJ] selenium [INJ] spironolactone propofol [INJ] RELISTOR TABLETS selenium sulfide spironolactone/hydrochlorothiazide propranolol REMICADE [INJ] [SP] selenium sulfide shampoo sprintec propranolol [INJ] remifentanil [INJ] SELZENTRY [SP] SPRYCEL [SP] propranolol ext-release REMODULIN [INJ] [SP] se-natal 19 prenatal vitamins sronyx propranolol/hydrochlorothiazide RENACIDIN SENSORCAINE-EPI 0.75%-0.0005% [INJ] STAMARIL [INJ] propylthiouracil repaglinide SEREVENT DISKUS stavudine [SP] PROQUAD [INJ] repaglinide/metformin hcl SEROSTIM [INJ] [SP] STEGLATRO PROSOL [INJ] REPATHA (NDCs starting sertraline STELARA SC [INJ] [SP] protamine [INJ] with 55513) [INJ] setlakin STIMATE [SP] PROTOPAM [INJ] RESCRIPTOR [SP] sevelamer carbonate STIVARGA [SP] protriptyline RESECTISOL sevelamer hcl STRENSIQ [INJ] [SP] PROVENGE [INJ] [SP] RESTASIS sharobel STREPTOMYCIN SULFATE [INJ] pruclair RETACRIT [INJ] [SP] SHINGRIX [INJ] SUBLOCADE [INJ] [SP] prumyx RETROVIR [INJ] [SP] SIGNIFOR [INJ] [SP] SUBOXONE SL FILM prutect REVCOVI [INJ] [SP] sildenafil SUCRAID [SP] (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 8 COMP1702A-20 (11/01/19) sucralfate TEMODAR [INJ] [SP] trandolapril TYPHIM VI [INJ] sufentanil [INJ] temozolomide [SP] trandolapril/verapamil ext-release TYSABRI [INJ] [SP] sulfacetamide eye ointment temsirolimus [INJ] [SP] tranexamic acid TYVASO [SP] sulfacetamide eye solution TENIPOSIDE [INJ] tranexamic acid [INJ] sulfacetamide sodium shampoo tenofovir disoproxil fumarate [SP] tranylcypromine U sulfacetamide sodium topical terazosin travasol [INJ] sulfacetamide sodium/sulfur terbinafine TRAVATAN Z UCERIS FOAM sulfacetamide sodium/sulfur/urea terbutaline trazodone UDENYCA [INJ] [SP] sulfacetamide/prednisolone eye solution terbutaline [INJ] TREANDA [INJ] [SP] UNITUXIN [INJ] [SP] sulfadiazine terconazole vaginal TRELEGY ELLIPTA UPTRAVI [SP] sulfamethoxazole/trimethoprim testosterone TREMFYA [INJ] [SP] ur n-c sulfamethoxazole/trimethoprim [INJ] testosterone cypionate [INJ] treprostinil diluent [INJ] [SP] urea SULFAMYLON CREAM testosterone enanthate [INJ] treprostinil sodium [INJ] [SP] uretron d-s sulfasalazine testosterone propionate [INJ] TRESIBA [INJ] urimar-t sulfasalazine delayed-release TETANUS DIPHTHERIA TOXOIDS [INJ] tretinoin urin d.s. sulindac tetrabenazine [SP] tretinoin microspheres uro-458 sumatriptan tetracaine [INJ] tretinoin topical urogesic sumatriptan [INJ] tetracaine eye solution tretinoin/emollient uro-mp sumatriptan nasal tetracycline TRETTEN [INJ] [SP] ursodiol sumatriptan/naproxen sodium THALOMID [SP] tri femynor uryl SUNOSI theophylline triamcinolone [INJ] ustell SUPREP theophylline ext-release triamcinolone dental paste utira-c SURE-T INFUSION SET theophylline/dextrose [INJ] triamcinolone topical UVADEX [INJ] SUTENT [SP] THERACYS [INJ] triamterene syeda thiamine [INJ] triamterene/hydrochlorothiazide V SYLATRON [INJ] [SP] thioridazine triazolam SYLVANT [INJ] [SP] thiotepa [INJ] trientine valacyclovir SYMBICORT thiothixene tri-estarylla VALCHLOR [SP] SYMDEKO [SP] THROMBATE III [INJ] trifluoperazine valganciclovir SYMFI [SP] THYMOGLOBULIN [INJ] [SP] trifluridine eye solution valproate sodium [INJ] SYMFI LO [SP] THYROGEN [INJ] [SP] trihexyphenidyl valproic acid SYMJEPI [INJ] thyroid tri-legest fe valrubicin [SP] SYMLINPEN [INJ] tiagabine tri-linyah valsartan SYMPROIC TIBSOVO [SP] tri-lo-estarylla valsartan/hydrochlorothiazide SYNAGIS [INJ] [SP] TICE BCG [INJ] tri-lo-marzia VALSTAR [SP] SYNAREL tigecycline [INJ] tri-lo-mili vancomycin SYNERCID [INJ] tilia fe tri-lo-sprintec vancomycin [INJ] SYNJARDY timolol maleate trilyte with flavor packets VANCOMYCIN/DEXTROSE [INJ] SYNJARDY XR timolol maleate eye solution trimethobenzamide VANCOMYCIN-NS [INJ] SYNRIBO [INJ] [SP] tinidazole trimethoprim VANTAS [SP] TIVICAY [SP] tri-mili vardenafil T tizanidine trimipramine vardenafil orally disintegrating tablets tl g-fol os TRIMO-SAN VARIVAX [INJ] TACLONEX SUSPENSION TOBI PODHALER [SP] trinatal rx 1 prenatal vitamins VARIZIG [INJ] tacrolimus [SP] TOBRADEX OINTMENT trinate prenatal vitamins VARUBI tacrolimus topical TOBRADEX ST trinessa VASCEPA tadalafil tobramycin [INJ] trinessa lo vasopressin/nacl [INJ] tadalafil [SP] tobramycin eye solution tri-previfem VAXCHORA VACCINE TAFINLAR [SP] tobramycin nebulization solution [SP] TRIPTODUR [INJ] [SP] VECTIBIX [INJ] [SP] TAGRISSO [SP] tobramycin/dexamethasone TRISENOX [INJ] VELCADE [INJ] [SP] TALZENNA [SP] eye suspension tri-sprintec velivet tamoxifen tobramycin/nacl [INJ] TRIUMEQ [SP] VELPHORO tamsulosin ext-release tolazamide triveen-duo dha prenatal vitamins VEMLIDY TARGRETIN GEL [SP] tolbutamide trivora VENCLEXTA [SP] tarina fe tolcapone tri-vylibra venlafaxine taron-c dha prenatal vitamins tolmetin TROGARZO [INJ] [SP] venlafaxine ext-release taron-prex dha prenatal vitamins tolterodine TROPHAMINE [INJ] VENOFER [INJ] TASIGNA [SP] tolterodine ext-release tropicamide eye solution VENTOLIN HFA TAYTULLA topiramate trospium verapamil tazarotene topotecan [INJ] [SP] trospium ext-release verapamil [INJ] TAZORAC 0.05% CREAM toremifene TRULANCE verapamil ext-release TAZORAC GEL torsemide TRULICITY [INJ] veripred TECENTRIQ [INJ] [SP] TOUJEO [INJ] TRUMENBA [INJ] VERZENIO [SP] TECFIDERA [SP] TOVIAZ trust natal dha prenatal vitamins VGO TECHLITE BLOOD LANCETS [OTC] TPN ELECTROLYTES [INJ] TRUVADA [SP] VIBATIV [INJ] TEFLARO [INJ] TRACE ELEMENTS-4 [INJ] TUBERSOL [INJ] VIBERZI TEKTURNA HCT TRACLEER SUSPENSION [SP] tulana VIDEX SOLUTION [SP] telmisartan TRADJENTA TWINRIX [INJ] vienva telmisartan/amlodipine tramadol tydemy vigabatrin [SP] telmisartan/hydrochlorothiazide tramadol ext-release TYKERB [SP] VIIBRYD TEMIXYS [SP] tramadol/acetaminophen TYMLOS [INJ] [SP] vilamit mb (continued) 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 9 COMP1702A-20 (11/01/19) vilevev mb voriconazole XIFAXAN ZEMAIRA [INJ] [SP] VIMIZIM [INJ] [SP] voriconazole [INJ] XIGDUO XR zenchent VIMPAT VOSEVI [SP] XIIDRA ZENPEP VIMPAT [INJ] VOTRIENT [SP] XOFIGO [INJ] [SP] ZEPATIER [SP] vinate care prenatal vitamins vp-ch plus prenatal vitamins XOLAIR [INJ] [SP] ZERBAXA [INJ] vinate ii prenatal vitamins vp-ch-pnv prenatal vitamins XOSPATA [SP] ZEVALIN [INJ] vinate one prenatal vitamins vp-ggr-b6 prenatal vitamins XTANDI [SP] zidovudine [SP] vinate-m prenatal vitamins vyfemla xulane patches zileuton ext-release vinblastine [INJ] vylibra XULTOPHY [INJ] zinc chloride [INJ] vincristine [INJ] VYNDAMAX [SP] XURIDEN [SP] zinc sulfate [INJ] vinorelbine [INJ] VYNDAQEL [SP] XYREM [SP] zingiber prenatal vitamins VIOKACE VYVANSE ziprasidone viorele VYXEOS LIPOSOME [INJ] [SP] Y ZOLADEX [INJ] [SP] VIRACEPT [SP] zoledronic acid [INJ] [SP] VIREAD 150 MG, 200 MG, 250 MG W YERVOY [INJ] [SP] zoledronic acid/mannitol [INJ] [SP] TABLETS [SP] YESCARTA [INJ] [SP] ZOLGENSMA [INJ] [SP] VIREAD POWDER [SP] warfarin YF-VAX [INJ] ZOLINZA [SP] virt nate prenatal vitamins water for injection, bacteriostatic [INJ] YONDELIS [INJ] [SP] zolmitriptan virt-advance prenatal vitamins water for injection, sterile [INJ] YONSA [SP] zolmitriptan orally disintegrating tablets virt-c dha prenatal vitamins water for irrigation; sterile YUPELRI zolpidem virt-nate dha prenatal vitamins wera yuvafem zolpidem ext-release virt-pn dha prenatal vitamins WILATE [INJ] [SP] ZOMIG NASAL virt-pn plus prenatal vitamins wixela inhub Z zonisamide virt-select prenatal vitamins wymzya fe ZORTRESS [SP] virt-vite gt prenatal vitamins zafirlukast ZOSYN GALAXY BAGS [INJ] VISTOGARD [SP] X zaleplon zovia VISUDYNE [INJ] [SP] ZALTRAP [INJ] [SP] ZTLIDO VITRAKVI [SP] XALKORI [SP] ZANOSAR [INJ] ZUBSOLV VIVITROL [INJ] [SP] XARELTO zarah ZULRESSO [INJ] [SP] VIVOTIF XELJANZ [SP] ZARXIO [INJ] [SP] zumandimine VIZIMPRO [SP] XELJANZ XR [SP] zatean-pn dha prenatal vitamins ZYDELIG [SP] VOLUVEN [INJ] XERMELO [SP] zatean-pn plus prenatal vitamins ZYKADIA [SP] VONVENDI [INJ] [SP] XGEVA [INJ] [SP] ZEJULA [SP] ZYLET VORAXAZE [INJ] XIAFLEX [INJ] [SP] ZELBORAF [SP] ZYTIGA 500 MG [SP] 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. © 2019 Express Scripts. All Rights Reserved. #1702 NP-A All trademarks are the property of their respective owners. Page 10 COMP1702A-20 (11/01/19) 2020 National Preferred Formulary 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’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. 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 plan. For specific questions about your coverage, please call the number on your member ID card. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans. Drug Class Excluded Medications Preferred Alternatives ANTIINFECTIVES DOXYCYCLINE HYCLATE DR 80 MG doxycycline hyclate dr Antibiotics Antifungal Agents (Oral) TOLSURA itraconazole Antivirals (Oral) SITAVIG acyclovir oral or cream, famciclovir, valacyclovir AUTONOMIC & CENTRAL NERVOUS SYSTEM LUCEMYRA clonidine Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Anticonvulsants TOPIRAMATE ER CAPSULES topiramate tablets, QUDEXY XR Anti-Migraine Therapy ONZETRA XSAIL sumatriptan nasal spray, ZOMIG NASAL SPRAY amantadine capsules, amantadine tablets, GOCOVRI ER, OSMOLEX ER Antiparkinsonism Agents amantadine oral solution XADAGO rasagiline, selegiline EMFLAZA prednisone solution, prednisone tablets Duchenne Muscular Dystrophy (DMD) Agents EXONDYS 51 No alternatives recommended hydromorphone ER, morphine sulfate ER, oxymorphone ER, Long-Acting Opioid Oral Analgesics EMBEDA, OXYCODONE ER HYSINGLA ER, NUCYNTA ER, OXYCONTIN AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, Multiple Sclerosis (Beta Interferons) EXTAVIA PLEGRIDY, REBIF, REBIF REBIDOSE Multiple Sclerosis (Oral) AUBAGIO GILENYA, MAYZENT, TECFIDERA APADAZ, BENZHYDROCODONE/ACETAMINOPHEN hydrocodone/acetaminophen Narcotic Analgesics & Combinations BUTRANS buprenorphine patches, BELBUCA Narcotic Antagonists EVZIO naloxone syringes, NARCAN NASAL SPRAY Neuropathic Agents LYRICA CR gabapentin, pregabalin Tardive Dyskinesia Therapy INGREZZA AUSTEDO ABSTRAL, FENTANYL CITRATE BUCCAL TABLETS, Transmucosal Fentanyl Analgesics fentanyl citrate lozenges FENTORA, LAZANDA, SUBSYS olanzapine/fluoxetine, bupropion, desvenlafaxine er, Miscellaneous Antidepressants SPRAVATO duloxetine, escitalopram, mirtazapine, sertraline CARDIOVASCULAR EPANED enalapril ACE Inhibitors QBRELIS lisinopril Anticoagulants PRADAXA, SAVAYSA ELIQUIS, XARELTO KAPSPARGO SPRINKLE metoprolol succinate Beta Blockers & Combinations metoprolol tartrate/hydrochlorothiazide, DUTOPROL, METOPROLOL SUCCINATE/HCTZ ER metoprolol succinate ER plus hydrochlorothiazide Calcium Channel Blockers KATERZIA amlodipine atorvastatin, fluvastatin er, lovastatin, pravastatin, HMG & Cholesterol Inhibitor Combinations ALTOPREV, EZALLOR SPRINKLE rosuvastatin, simvastatin, LIVALO Continued © 2019 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 11 DL44109Q-SD-20 (11/15/2019) Drug Class Excluded Medications Preferred Alternatives CARDIOVASCULAR (continued) PRALUENT (NDCs starting with 72733), PRALUENT (NDCs starting with 00024), PCSK9 Inhibitors REPATHA (NDCs starting with 72511) REPATHA (NDCs starting with 55513) DERMATOLOGICAL MINOLIRA minocycline ER Oral Agents for Acne Rosacea Agents (Oral) DOXYCYCLINE 40 MG CAPSULES ORACEA Rosacea Agents (Topical) RHOFADE MIRVASO clindamycin/benzoyl peroxide, clindamycin/tretinoin, Topical Acne/Antibiotic Combinations AKTIPAK, VELTIN erythromycin/benzoyl peroxide, ONEXTON diclofenac 3% gel, fluorouracil 2% solution, FLUOROURACIL 0.5% CREAM, Topical Agents for Actinic Keratosis fluorouracil 5% cream, imiquimod 5% cream, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA CARAC, PICATO Topical Antifungals LULICONAZOLE ciclopirox, econazole, ketoconazole, naftifine, oxiconazole betamethasone valerate, fluocinolone acetonide, CLOCORTOLONE triamcinolone acetonide Topical Corticosteroids desonide 0.05% cream/lotion/ointment, TOPICORT SPRAY, VERDESO FOAM desoximetasone 0.25% cream/ointment ALCORTIN A hydrocortisone, mupirocin Miscellaneous Topical Dermatological Agents LIDOCAINE/TETRACAINE lidocaine cream, lidocaine/prilocaine cream BAYER (BREEZE, CONTOUR) FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE NATIONAL MEDICAL (ADVOCATE) FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE OMNIS HEALTH (EMBRACE, VICTORY) FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, DIABETES ROCHE (ACCU-CHEK) FREESTYLE LITE Blood Glucose Meters & Test Strips TRIVIDIA (TRUETEST, TRUETRACK) ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, UNISTRIP VERIO FLEX ALL OTHER METERS & TEST STRIPS ONETOUCH TEST STRIPS: ULTRA, VERIO THAT ARE NOT LISTED AS PREFERRED PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS ALOGLIPTIN, NESINA, ONGLYZA JANUVIA, TRADJENTA Dipeptidyl Peptidase-4 Inhibitors & Combinations ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR ALOGLIPTIN/PIOGLITAZONE pioglitazone plus JANUVIA or TRADJENTA Glucagon-Like Peptide-1 Agonists ADLYXIN, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY NOVOLIN, RELION NOVOLIN HUMULIN Insulins ADMELOG, APIDRA, FIASP, INSULIN LISPRO, NOVOLOG HUMALOG EAR/NOSE BECONASE AQ, OMNARIS, ZETONNA budesonide, flunisolide, fluticasone, mometasone, QNASL Nasal Steroids ciprofloxacin ear solution, ofloxacin ear solution, Otic Fluoroquinolone Antibiotics CETRAXAL CIPRODEX, OTOVEL ENDOCRINE (OTHER) CLIMARA PRO COMBIPATCH Combination Patches estradiol patches, estradiol tablets, yuvafem, Estrogen and Estrogen Modifiers for Vaginal Symptoms FEMRING ESTRING, PREMARIN CREAM, PREMARIN TABLETS HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, Growth Hormones GENOTROPIN, NORDITROPIN FLEXPRO SAIZEN, SAIZENPREP, ZOMACTON Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT Topical Estrogen Gels ESTROGEL DIVIGEL GASTROINTESTINAL AKYNZEO CAPSULES granisetron, ondansetron, aprepitant, VARUBI TABLETS Antiemetics (Oral) EMEND POWDER PACKETS aprepitant, VARUBI TABLETS Corticosteroids (Rectal Formulations) CORTIFOAM hydrocortisone enema, UCERIS FOAM Continued © 2019 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 12 DL44109Q-SD-20 (11/15/2019) Drug Class Excluded Medications Preferred Alternatives GASTROINTESTINAL (continued) balsalazide disodium, mesalamine delayed release, DIPENTUM Inflammatory Bowel Agents sulfasalazine, APRISO, PENTASA Irritable Bowel Agents ZELNORM LINZESS, TRULANCE Pancreatic Enzymes PANCREAZE, PERTZYE CREON, ZENPEP ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, esomeprazole, lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors PROTONIX SUSPENSION, RABEPRAZOLE DR SPRINKLE rabeprazole, NEXIUM PACKETS HEMATOLOGICAL aspirin plus omeprazole, esomeprazole, lansoprazole, ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR Antiplatelet Agents pantoprazole or rabeprazole Chelating Agents JADENU, JADENU SPRINKLE deferasirox Erythropoiesis-Stimulating Agents ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, JIVI, Factor VIII Recombinant Products NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE KOGENATE FS, KOVALTRY, NOVOEIGHT Granulocyte Colony Stimulating Factors GRANIX, NEUPOGEN NIVESTYM, ZARXIO Thrombocytopenia Agents MULPLETA DOPTELET HEPATITIS LEDIPASVIR/SOFOSBUVIR, MAVYRET, EPCLUSA, HARVONI, VOSEVI, ZEPATIER Hepatitis C SOFOSBUVIR/VELPATASVIR, SOVALDI ATRIPLA, DELSTRIGO, SYMTUZA BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, TRIUMEQ HIV COMPLERA ODEFSEY Antiretrovirals PIFELTRO efavirenz, EDURANT Note: Current patients established on therapy are allowed to continue therapy. PREZCOBIX atazanavir, ritonavir, KALETRA TABLETS, PREZISTA STRIBILD BIKTARVY, GENVOYA MUSCULOSKELETAL & RHEUMATOLOGY COLCHICINE COLCRYS, MITIGARE Gout Therapy ZURAMPIC allopurinol, probenecid fenoprofen calcium tablets, diclofenac, ibuprofen, FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES indomethacin, meloxicam, nabumetone, naproxen nabumetone, diclofenac, ibuprofen, indomethacin, RELAFEN DS Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) meloxicam, naproxen, piroxicam diclofenac sodium, etodolac, ibuprofen, indomethacin, TIVORBEX, VIVLODEX, ZORVOLEX meloxicam, nabumetone, naproxen, piroxicam ZIPSOR diclofenac potassium, diclofenac sodium DICLOFENAC EPOLAMINE PATCHES FLECTOR PATCHES Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) PENNSAID diclofenac sodium topical, FLECTOR PATCHES OBSTETRICAL & GYNECOLOGICAL CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL Human Chorionic Gonadotropin Ovulatory Stimulants (Follitropins) FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT Vaginal Progesterones ENDOMETRIN CRINONE 8% GEL ONCOLOGY KISQALI, KISQALI FEMARA CO-PACK, PIQRAY IBRANCE, VERZENIO Breast Cancer Agents DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, Multiple Myeloma Agents XPOVIO THALOMID, VELCADE Myelofibrosis Agents INREBIC JAKAFI OPHTHALMIC betaxolol drops, levobunolol drops, timolol drops, TIMOPTIC OCUDOSE Antiglaucoma Drugs (Beta-Adrenergic Blockers) ALPHAGAN P 0.1%, COMBIGAN Antiglaucoma Drugs (Ophthalmic Prostaglandins) XELPROS, ZIOPTAN bimatoprost drops, latanoprost drops, LUMIGAN, TRAVATAN Z Continued © 2019 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 13 DL44109Q-SD-20 (11/15/2019) Drug Class Excluded Medications Preferred Alternatives OPHTHALMIC (continued) azelastine drops, cromolyn drops, olopatadine drops, ALOCRIL, ALOMIDE Ophthalmic Anti-Allergic ALREX, BEPREVE, PAZEO dexamethasone drops, fluorometholone drops, Ophthalmic Anti-Inflammatory FML FORTE, FML S.O.P., MAXIDEX, PRED MILD prednisolone drops, INVELTYS, LOTEMAX Ophthalmic Non-Steroidal Anti-Inflammatory Drugs bromfenac drops, diclofenac drops, ketorolac drops, ACUVAIL, NEVANAC (NSAIDs) ILEVRO, PROLENSA DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, OSTEOARTHRITIS HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, EUFLEXXA, MONOVISC, ORTHOVISC Hyaluronic Acid Derivatives SYNVISC-ONE, TRIVISC, VISCO-3 OSTEOPOROSIS alendronate, ibandronate, risedronate, zoledronic acid, EVENITY, PROLIA Bone Modifiers FORTEO, TYMLOS RENAL DISEASE lanthanum, sevelamer carbonate, sevelamer hcl, FOSRENOL POWDER PACKETS Phosphate Binders PHOSLYRA, VELPHORO RESPIRATORY AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX) epinephrine auto-injector (by Mylan), EPIPEN, EPIPEN JR Epinephrine Auto-Injector Systems Immunological Agents for Asthma CINQAIR FASENRA, NUCALA Long-Acting Beta Agonist Inhalers STRIVERDI RESPIMAT SEREVENT DISKUS Long-Acting Muscarinic Antagonist Inhalers SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, TUDORZA PRESSAIR INCRUSE ELLIPTA Long-Acting Muscarinic Antagonist/ STIOLTO RESPIMAT ANORO ELLIPTA, BEVESPI AEROSPHERE Long-Acting Beta-Agonist Combination Inhalers ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, Pulmonary Anti-Inflammatory Inhalers ALVESCO FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR REDIHALER ALBUTEROL SULFATE HFA, LEVALBUTEROL HFA, Short-Acting Beta2-Agonist Inhalers PROAIR HFA/RESPICLICK, VENTOLIN HFA PROVENTIL HFA, XOPENEX HFA WEIGHT LOSS QSYMIA benzphetamine, diethylpropion, phentermine Weight Loss Agents SIKLOS DROXIA MISCELLANEOUS AGENTS NOCTIVA desmopressin tablets Hereditary Angioedema BERINERT RUCONEST Immunosuppressant Agents XATMEP methotrexate Metabolic Agents ORFADIN nitisinone, NITYR Polyneuropathy of Hereditary ONPATTRO No alternatives recommended Transthyretin-Mediated Amyloidosis Potassium Binders VELTASSA LOKELMA Indication Based Management Drug Class Nonpreferred Medications Preferred Alternatives All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, INFLAMMATORY CONDITIONS‡ medications is required prior to initiating therapy with a RINVOQ ER, SIMPONI 100 MG (FOR ULCERATIVE COLITIS Nonpreferred medication. A formulary exception may be ONLY), SKYRIZI, STELARA SC, TREMFYA, XELJANZ, XELJANZ XR granted for patients already established on therapy with a Nonpreferred medication. ‡ Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches. Continued © 2019 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 14 DL44109Q-SD-20 (11/15/2019) Excluded Medications/Products at a Glance ABILIFY^ EFFEXOR XR^ MAXALT^, MAXALT MLT^ SINGULAIR^ ABSTRAL ELIDEL^ MAXIDEX SITAVIG ACIPHEX^ EMBEDA METOPROLOL SUCCINATE/HCTZ ER SODIUM HYALURONATE ACIPHEX SPRINKLE EMEND CAPSULES^, TRIFOLD PACK^ MICARDIS^, MICARDIS HCT^ SOFOSBUVIR/VELPATASVIR ACUVAIL EMEND POWDER PACKETS MINASTRIN 24 FE^ SOVALDI ADCIRCA^ EMFLAZA MINOLIRA SPIRIVA HANDIHALER, SPIRIVA RESPIMAT ADDERALL^ ENDOMETRIN MIRCERA SPRAVATO ADLYXIN EPANED MULPLETA STIOLTO RESPIMAT ADMELOG EPINEPHRINE AUTO-INJECTOR (BY IMPAX) NALFON CAPSULES STRATTERA^ AKTIPAK EPOGEN NAMENDA XR^ STRIBILD AKYNZEO CAPSULES ESTROGEL NASONEX^ STRIVERDI RESPIMAT ALBUTEROL SULFATE HFA EVENITY NATIONAL MEDICAL (ADVOCATE) SUBSYS ALCORTIN A EVZIO NESINA SUPARTZ FX ALOCRIL EXFORGE^, EXFORGE HCT^ NEUPOGEN SYMTUZA ALOGLIPTIN EXJADE^ NEURONTIN^ SYNVISC, SYNVISC-ONE ALOGLIPTIN/METFORMIN EXONDYS 51 NEVANAC TESTIM^ ALOGLIPTIN/PIOGLITAZONE EXTAVIA NOCTIVA TIKOSYN^ ALOMIDE EZALLOR SPRINKLE NORCO^ TIMOPTIC OCUDOSE ALTOPREV FEMRING NORVASC^ TIVORBEX ALVESCO FENOPROFEN CAPSULES NOVOLIN TOBI SOLUTION^ AMBIEN^, AMBIEN CR^ FENORTHO NOVOLOG TOLSURA AMPYRA^ FENTANYL CITRATE BUCCAL TABLETS NUTROPIN AQ NUSPIN TOPAMAX^ AMRIX^ FENTORA NUVIGIL^ TOPICORT SPRAY ANDROGEL 1%^ FIASP NUWIQ TOPIRAMATE ER CAPSULES ANUSOL-HC^ FLUOROURACIL 0.5% CREAM OMNARIS TRIBENZOR^ APADAZ FML FORTE, FML S.O.P. OMNIS HEALTH (EMBRACE, VICTORY) TRICOR^ APIDRA FOCALIN^, FOCALIN XR^ OMNITROPE TRILEPTAL^ ARANESP FOLLISTIM AQ ONGLYZA TRIVIDIA (TRUETEST, TRUETRACK) ARIMIDEX^ FOSRENOL CHEWABLE TABLETS^ ONPATTRO TRIVISC ASACOL HD^ FOSRENOL POWDER PACKETS ONZETRA XSAIL TUDORZA PRESSAIR ASPIRIN/OMEPRAZOLE DR GANIRELIX ACETATE^ ORFADIN UNISTRIP ATACAND^, ATACAND HCT^ GEL-ONE ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ UROXATRAL^ ATRIPLA GELSYN-3 OSMOLEX ER VAGIFEM^ AUBAGIO GENVISC 850 OXYCODONE ER VALIUM^ AUVI-Q GLEEVEC^ PANCREAZE VALTREX^ AVALIDE^, AVAPRO^ GLUCOPHAGE^, GLUCOPHAGE XR^ PATADAY^ VELTASSA AVODART^ GLUMETZA^ PENNSAID VELTIN AZOR^ GOCOVRI ER PERTZYE VERDESO FOAM BARACLUDE TABLETS^ GRANIX PIFELTRO VIAGRA^ BAYER (BREEZE, CONTOUR) HUMATROPE PIQRAY VICTOZA BECONASE AQ HYALGAN PLAQUENIL^ VISCO-3 BENICAR^, BENICAR HCT^ HYMOVIS PLAVIX^ VIVELLE-DOT^ BENZHYDROCODONE/ACETAMINOPHEN IMIQUIMOD 3.75% CREAM PUMP PRADAXA VIVLODEX BERINERT IMITREX^ PRALUENT (NDCs starting with 72733) VYTORIN^ BRISDELLE^ INDERAL LA^ PRAVACHOL^ WELLBUTRIN SR^ BUPAP^ INGREZZA PRED MILD XADAGO BUTRANS INREBIC PREGNYL XALATAN^ CELEBREX^ INSULIN LISPRO PREVACID^, PREVACID SOLUTAB^ XANAX^, XANAX XR^ CELEXA^ INTUNIV^ PREZCOBIX XATMEP CETRAXAL ISTALOL^ PRILOSEC SUSPENSION XELPROS CHORIONIC GONADOTROPIN JADENU, JADENU SPRINKLE PRISTIQ^ XENAZINE^ CIALIS^ KAPSPARGO SPRINKLE PROLIA XOPENEX HFA CINQAIR KATERZIA PROTONIX^ XPOVIO CLIMARA PRO KAZANO PROTONIX SUSPENSION XYNTHA, XYNTHA SOLOFUSE CLOCORTOLONE KEPPRA^, KEPPRA XR^ PROVENTIL HFA YASMIN^ COLCHICINE KISQALI, KISQALI FEMARA CO-PACK PROVIGIL^ YOSPRALA DR COMPLERA KOMBIGLYZE XR PROZAC^ ZAVESCA^ COREG^ LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ PULMICORT RESPULES^ ZEGERID^ CORTIFOAM LAZANDA QBRELIS ZELNORM COSOPT^ LEDIPASVIR/SOFOSBUVIR QSYMIA ZETIA^ COZAAR^, HYZAAR^ LEVALBUTEROL HFA RABEPRAZOLE DR SPRINKLE ZETONNA CRESTOR^ LEXAPRO^ RAPAFLO^ ZIOPTAN CUPRIMINE^ LIBRAX^ RECOMBINATE ZIPSOR CYMBALTA^ LIDOCAINE/TETRACAINE RELAFEN DS ZOCOR^ CYTOMEL^ LIDODERM^ RELION NOVOLIN ZOLOFT^ DELSTRIGO LIPITOR^ RENAGEL^ ZOMACTON DELZICOL^ LOESTRIN^, LOESTRIN FE^ REPATHA (NDCs starting with 72511) ZOMIG TABLETS^, ZOMIG ZMT^ DETROL^, DETROL LA^ LOTREL^ RHOFADE ZONEGRAN^ DICLOFENAC EPOLAMINE PATCHES LOVENOX^ ROCHE (ACCU-CHEK) ZORVOLEX DIOVAN^, DIOVAN HCT^ LUCEMYRA SAIZEN, SAIZENPREP ZURAMPIC DIPENTUM LULICONAZOLE SANDOSTATIN LAR DEPOT ZYCLARA DOXYCYCLINE 40 MG CAPSULES LUNESTA^ SAVAYSA ZYFLO CR^ DOXYCYCLINE HYCLATE DR 80 MG LYRICA^ SEROQUEL^, SEROQUEL XR^ ZYTIGA 250 MG^ DUROLANE LYRICA CR SIGNIFOR LAR DUTOPROL MAVYRET SIKLOS ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. 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. As new generic medications become available, additional multisource brand products may become excluded. © 2019 Express Scripts. All Rights Reserved. 204612 All trademarks are the property of their respective owners. Page 15 DL44109Q-SD-20 (11/15/2019)