Prmt6529np-14.np.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 member ID card.
For Georgia State Health Benefit Plan (SHBP)
ANTIINFECTIVES
Antiparkinson Drugs
Hypolipoproteinemics
Antivirals
CARDIOVASCULAR MEDICATIONS
ACE Inhibitors + HCT Combos
Antipsychotic Drugs
Cephalosporins
Nitrates
Angiotensin II Receptor Antagonists +
Antivertigo & Antiemetics
Macrolides
HCT Combos
Other Antihypertensives
Oral Antifungals
Anxiolytics
Penicillins
Anti-Arrhythmic Drugs
Beta-Adrenergic Antagonists
Class II Narcotics
Quinolones
Other Cardiovascular Drugs
Tetracyclines
AUTONOMIC & CNS MEDICATIONS
Anticonvulsants
Topical Antibacterials
Class III Narcotics
Topical Antifungals
Calcium Antagonists
clotrimazole/betamethasone dipropionate amlodipine CNS Stimulants
Urinary Antiinfectives
Diuretics
Other Antiinfective Drugs
Antidementia Drugs
Endothelin Receptor Antagonists
ANTINEOPLASTIC/IMMUNO-
HMG-CoA Reductase Inhibitors
Antidepressants
Drugs to Prevent & Treat Headaches
SUPPRESSANT DRUGS
HMG-CoA Combinations
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 Express-Scripts.com/GeorgiaSHBP.
*Diabetic Free Meter Program: 800-243-7290 • Brochure Code (Order Code): 133SGA002
2014 Express Scripts
All Rights Reserved
PRMT6529NP-14 (09/04/13)
Topical Anti-Inflammatory Drugs
Other Endocrine Drugs
Drugs to Treat Multiple Sclerosis
EAR-NOSE MEDICATIONS
Drugs Affecting The Ear
NUTRITION & BLOOD MODIFIERS
Antiplatelet Drugs
Drugs Affecting The Nose
GASTROINTESTINAL MEDICATIONS
Non-Narcotic Analgesics
Antispasmodics/Drugs Affecting GI
Motility
Blood Detoxicants
Sedative/Hypnotics
H. Pylori Drugs
Oral and Inj. Anticoagulants
ENDOCRINE MEDICATIONS
Proton Pump Inhibitors
Selective Serotonin Reuptake Inhibitors Amylin Analogues
Androgen Drugs
Therapeutic Vitamins & Minerals
Other GI Drugs
Tertiary Amines
Dipeptidyl Peptidase-IV Inhibitors &
Combos
Other Autonomic/CNS Drugs
Thrombin Inhibitors
Other Drugs For ADHD
Glucocorticoids
OBSTETRICAL & GYNECOLOGICAL
MEDICATIONS
DERMATOLOGICAL MEDICATIONS
Contraceptives
NOTE: The following contraceptives represent some of the contraceptives that Antiacne Drugs
are available at a Zero Dollar [ZD] Glucose Elevating Drugs
coinsurance for females age 50 and Growth Hormones
NOTE: Coverage based on benefit design. IMMUNOLOGICALS
NOTE: Coverage based on benefit design. LOESTRIN 24 FE [ZD] Incretin Mimetics
Erythroid Stimulants
Insulins
Interferons
Antipsoriasis & Antieczema Drugs
MUSCULOSKELETAL MEDICATIONS
Corticosteroid Drugs
Insulin Sensitizers
CNS Muscle Relaxants
Oral Hypoglycemics
Estrogen Drugs
Miscellaneous Dermatologicals
Drugs to Prevent & Treat Gout
Sodium-Glucose Co-Transporter 2
Non-Steroidal Anti-Inflammatory Agents VIVELLE-DOT [QLL]
Inhibitors
Estrogen/Progestin Combinations
Thyroid Supplements
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 Express-Scripts.com/GeorgiaSHBP.
*Diabetic Free Meter Program: 800-243-7290 • Brochure Code (Order Code): 133SGA002
2014 Express Scripts
All Rights Reserved
PRMT6529NP-14 (09/04/13)
Antihistamine/Antitussives
Nonpreferred Medications With Preferred Alternatives
Prenatal Vitamins
The following is a list of nonpreferred brand-name medications with preferred alternatives NOTE: All oral prescription generic that are on the preferred drug list. Column 1 lists nonpreferred medications. Column 2 prenatal vitamins are preferred drugs. Antitussive & Expectorants
lists preferred alternatives that can be prescribed.
Progestin Drugs
Nonpreferred Medications Preferred Alternative(s)
Beta-2 Adrenergics
ACCU-CHEK
Vaginal Antiinfectives
METERS*/STRIPS [ST]
ADVAIR DISKUS/HFA
[PA] [QLL] [ST]
ALVESCO [QLL] [ST]
ASMANEX [QLL], PULMICORT FLEXHALER [QLL], QVAR [QLL] APIDRA [ST]
OPHTHALMIC MEDICATIONS
AUVI-Q [QLL] [ST]
AVINZA [QLL] [ST]
morphine sulfate ext-release [QLL], oxymorphone ext-release [QLL], Antibacterial Drugs
NUCYNTA ER [QLL], OPANA ER [QLL], OXYCONTIN [QLL] BECONASE AQ [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], Leukotriene Modifiers
BETASERON [PA] [QLL] [ST] AVONEX [PA] [QLL], EXTAVIA [PA] [QLL] [ST], REBIF [PA] [QLL]
BREEZE, CONTOUR
Other Drugs For Asthma
METERS*/STRIPS [ST]
BREO ELLIPTA [PA] [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]
Antiglaucoma Drugs
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], UROLOGICAL MEDICATIONS
NUCYNTA ER [QLL], OPANA ER [QLL], OXYCONTIN [QLL] KAZANO [QLL] [ST]
JANUMET [QLL], JANUMET XR [QLL], KOMBIGLYZE XR [QLL] Anticholinergic Antispasmodics
LEVITRA [PA] [QLL] [ST]
MAXAIR AUTOHALER
[QLL] [ST]
MICARDIS/MICARDIS
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, Corticosteroid Drugs
HCT [ST]
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, BENICAR/HCT NESINA [QLL] [ST]
NOVOLIN [ST]
NOVOLOG [ST]
Other Ophthalmic Drugs
NUTROPIN/NUTROPIN
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] AQ [PA] [ST]
Drugs Used For BPH
OMNARIS [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], OMNITROPE [PA] [ST]
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] PEGINTRON [PA] [QLL] [ST] PEGASYS [PA] [QLL]
Erectile Dysfunction Agents
PROVENTIL HFA [QLL] [ST]
NOTE: Coverage based on benefit design. RHINOCORT AQUA
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], [QLL] [ST]
SAIZEN [PA] [ST]
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] SIMPONI [PA] [ST]
STAXYN [PA] [QLL] [ST]
DIABETIC SUPPLIES
STELARA [PA] [ST]
TESTIM [PA] [ST]
TEVETEN/TEVETEN
candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, Meters* & Strips
HCT [ST]
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, BENICAR/HCT TEV-TROPIN [PA] [ST]
GENOTROPIN [PA], HUMATROPE [PA], NORDITROPIN [PA] RESPIRATORY MEDICATIONS
TRADJENTA [QLL] [ST]
TRUETEST, TRUETRACK
Antihistamines
METERS*/STRIPS [ST]
VERAMYST [QLL] [ST]
flunisolide [QLL], fluticasone [QLL], triamcinolone acetonide [QLL], Miscellaneous Supplies
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 all strengths.
The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths of the drug.
• Tier 2 products are preferred brand-name products and are The symbol [ZD] next to a drug name indicates a contraceptive that it is available for Zero Dollar coinsurance for females age 50 and under.
For the member: Generic medications contain the same active ingredients as their corresponding brand-name
• Tier 3 products are nonpreferred brand-name products and medications, although they may look different in color or shape. They have been FDA-approved under strictstandards.
are listed in BOLD, ITALIC UPPER CASE letters.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
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 Express-Scripts.com/GeorgiaSHBP.
*Diabetic Free Meter Program: 800-243-7290 • Brochure Code (Order Code): 133SGA002
2014 Express Scripts
All Rights Reserved
PRMT6529NP-14 (09/04/13)

Source: http://empoweredgaaction.org/files/2014_Drug_List.pdf