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Prmt6529anp-14.anp.130904

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the preferred drug list (formulary) that is at the core of your prescription-drugbenefit plan. The list is not all-inclusive and does not guarantee coverage. In addition tousing this list, you are encouraged to ask your doctor to prescribe generic drugs wheneverappropriate.
2014 Express Scripts
National Preferred Formulary

PLEASE NOTE: Preferred brand-name drugs may move to nonpreferred status if a generic
version becomes available during the year. For specific questions about your coverage,

(Preferred Drug List)
please call the Express Scripts phone number printed on your ID card.
For Georgia State Health Benefit Plan (SHBP)
A
L
G
N
BYDUREON [INJ] [PA] [QLL] dorzolamide/timolol C
H
E
O
M
I
F
J
B
D
K
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at
2014 Express Scripts Holding Company
All Rights Reserved
PRMT6529ANP-14 (09/04/13)
P
Nonpreferred Medications With Preferred Alternatives
The following is a list of nonpreferred brand-name medications with preferred alternatives that are on the preferred drug list. Column 1 lists nonpreferred medications. Column 2 lists preferred alternatives that can be prescribed.
Nonpreferred Medications Preferred Alternative(s)
S
ACCU-CHEK
METERS/STRIPS [ST]
ADVAIR DISKUS/HFA
[PA] [QLL] [ST]
ALVESCO [QLL] [ST]
ASMANEX [QLL], PULMICORT FLEXHALER [QLL], QVAR [QLL] APIDRA [ST]
U
AUVI-Q [QLL] [ST]
AVINZA [QLL] [ST]
morphine sulfate ext-release [QLL], oxymorphone ext-release [QLL], NUCYNTA ER [QLL], OPANA ER [QLL], OXYCONTIN [QLL] BECONASE AQ [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], 80 MG, 105 MG, 115 MG V
BETASERON [PA] [QLL] [ST] AVONEX [PA] [QLL], EXTAVIA [PA] [QLL] [ST], REBIF [PA] [QLL]
BREEZE, CONTOUR
METERS/STRIPS [ST]
BREO ELLIPTA [ST]
CIMZIA [PA] [ST]
EDARBI/EDARBYCLOR [ST]
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, BENICAR/HCT EXALGO [QLL] [ST]
morphine sulfate ext-release [QLL], oxymorphone ext-release [QLL], NUCYNTA ER [QLL], OPANA ER [QLL], OXYCONTIN [QLL] FLOVENT DISKUS/HFA
ASMANEX [QLL], PULMICORT FLEXHALER [QLL], QVAR [QLL] [QLL] [ST]
FORTESTA [PA] [ST]
FREESTYLE, PRECISION
METERS/STRIPS [ST]
JENTADUETO [QLL] [ST]
JANUMET [QLL], JANUMET XR [QLL], KOMBIGLYZE XR [QLL] KADIAN [QLL] [ST]
morphine sulfate ext-release [QLL], oxymorphone ext-release [QLL], NUCYNTA ER [QLL], OPANA ER [QLL], OXYCONTIN [QLL] KAZANO [QLL] [ST]
JANUMET [QLL], JANUMET XR [QLL], KOMBIGLYZE XR [QLL] LEVITRA [PA] [QLL] [ST]
MAXAIR AUTOHALER
T
[QLL] [ST]
MICARDIS/MICARDIS
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, HCT [ST]
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, BENICAR/HCT NESINA [QLL] [ST]
NOVOLIN [ST]
NOVOLOG [ST]
NUTROPIN/NUTROPIN
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] W
AQ [PA] [ST]
OMNARIS [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], Q
OMNITROPE [PA] [ST]
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] PEGINTRON [PA] [QLL] [ST] PEGASYS [PA] [QLL]
X
PROVENTIL HFA [QLL] [ST]
RHINOCORT AQUA
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], [QLL] [ST]
SAIZEN [PA] [ST]
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] SIMPONI [PA] [ST]
Z
STAXYN [PA] [QLL] [ST]
R
STELARA [PA] [ST]
TESTIM [PA] [ST]
TEVETEN/TEVETEN
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, HCT [ST]
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, BENICAR/HCT TEV-TROPIN [PA] [ST]
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] TRADJENTA [QLL] [ST]
TRUETEST, TRUETRACK
METERS/STRIPS [ST]
VERAMYST [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], VICTOZA [PA] [QLL] [ST]
XELJANZ [PA] [ST]
XOPENEX HFA [QLL] [ST]
ZETONNA [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], ZIOPTAN [PA] [ST]
latanoprost [PA], travoprost [PA], LUMIGAN [PA], TRAVATAN Z [PA] • Tier 1 products are generic products and are listed in all The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [PA] next to a drug name indicates that a Prior Authorization is required for coverage.
The symbol [QLL] next to a drug name indicates that the drug has a Quantity Level Limit on some or allstrengths.
• Tier 2 products are preferred brand-name products and are The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths ofthe drug.
For the member: Generic medications contain the same active ingredients as their corresponding
brand-name medications, although they may look different in color or shape. They have been FDA-
• Tier 3 products are nonpreferred brand-name products and approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically
are listed in BOLD, ITALIC UPPER CASE letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at
2014 Express Scripts Holding Company
All Rights Reserved
PRMT6529ANP-14 (09/04/13)

Source: http://jasperga.schooldesk.net/Portals/JasperGa/District/docs/HRInfo/Open%20Enrollment/Preferred%20Rx%20List.pdf

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