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Prmtmdcnp-12.np.110715

The following is a list of the most commonly prescribed drugs. It representsan abbreviated version of the drug list (formulary) that is at the core of yourprescription-drug benefit plan. The list is not all-inclusive and does notguarantee coverage. In addition to using this list, you are encouraged to askyour doctor to prescribe generic drugs whenever appropriate.
2012 Express Scripts
Medicare

PLEASE NOTE: Not all the drugs listed are covered by all prescription-drug
benefit programs; check your benefit materials for the specific drugs

National Preferred
covered and the copayments for your prescription-drug benefit program.
Formulary
For specific questions about your coverage, please call the phone
number printed on your ID card.

ANESTHETICS
ANTINEOPLASTIC/
IMMUNOSUPPRESSANT DRUGS SEROQUEL, XR [Q]
Topical Anesthetics
Other Macrolides
Antivertigo &
Antiemetic Drugs
ANTIINFECTIVES
Other Topical Antifungals
Antiretrovirals &
Protease Inhibitors
Penicillins
Anxiolytics
AUTONOMIC & CNS
Carbamazepines
Quinolones
MEDICATIONS
Cephalosporins
Class II Narcotics
Analgesics
Sulfonamides
Clindamycins
Antidementia Drugs
Erythromycins
Tetracyclines
Oral Antifungal Drugs
Class III Narcotics
Antimania Drugs
Topical Antibacterial Drugs
Antiparkinson
Topical Antifungal-
Anticholinergic Drugs
Other Antiinfective Drugs
Corticosteroid Comb.
Drugs To Prevent &
Other Antiviral Drugs
Antipsychotic Drugs
Treat Headaches
Urinary Antiinfectives
KEY
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [P] indicates that prior authorization may apply.
The symbol [Q] indicates that quantities dispensed may be limited.
The symbol [S] indicates that step therapy may apply.
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-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case, italicized letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
NP 4T- S7950_2012_DOC7NP
All Rights Reserved
PRMTMDCNP-12 (07/15/11)
Other Antihypertensives
Topical Dermatological Drugs
Hydantoins
Other Anticonvulsants
Angiotensin II Receptor
Antagonists
EAR-NOSE-THROAT
Beta-Adrenergic
MEDICATIONS
Antagonist Drugs
Other Antidepressants
Drugs Affecting The Ear
Drugs Affecting The Nose
Calcium Antagonists
Other Cardiovascular Drugs
Other Antiparkinson Drugs
Other Vasodilating Drugs
Cardiac Glycosides
Potassium Sparing Diuretics
Drugs Affecting The Throat
& Mouth
Centrally Acting
Antihypertensives
Thiazide & Related Drugs
Other CNS/Autonomic Drugs
Endothelin Receptor
Vasodilator Antihypertensives ENDOCRINE MEDICATIONS
Antagonists
Glucocorticoid Drugs
Secondary Amines
Hmg-CoA Reductase
Inhibitors
DERMATOLOGICAL
Sedative/Hypnotic Drugs
MEDICATIONS
Glucose Elevating Drugs
Antiacne Drugs
Hypoglycemic Drugs
Selective Serotonin
Reuptake Inhibitors
Hypolipoproteinemics
Antipruritic Drugs
Insulin
Antipsoriasis &
Antieczema Drugs
Tertiary Amines
Oral Dermatological Drugs
Oral Hypoglycemics &
Scabicides
Combos
CARDIOVASCULAR
Loop Diuretics
Topical Antiinflammatory
MEDICATIONS
Drugs
Amiodarones
Nitrates
Topical Corticosteroid Drugs
Angiotensin Converting
Enzyme Inhibitors
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
NP 4T- S7950_2012_DOC7NP
All Rights Reserved
PRMTMDCNP-12 (07/15/11)
OBSTETRICAL &
Ophthalmic Topical
GYNECOLOGICAL
Antibacterial Drugs
MEDICAL (MISCELLANEOUS)
MEDICATIONS
SUPPLIES
Androgen Drugs
Other Endocrine Drugs
Diabetic Supplies
MISCELLANEOUS DRUGS
Contraceptives
Other Ophthalmic Drugs
Thyroid Supplements
MUSCULOSKELETAL
Estrogen Drugs
MEDICATIONS
CNS Muscle Relaxants
GASTROINTESTINAL
MEDICATIONS
Direct Muscle Relaxants
RESPIRATORY MEDICATIONS
Antispasmodics/
Antihistamines
Drugs Affect GI Motility
Drugs To Prevent &
Estrogen/Progestin
Treat Gout
Combinations
Antiulcer Drugs
Beta-2 Adrenergic Drugs
Irritable Bowel Drugs
Non-Steroidal
Antiinflammatory Agents
Other Antiulcer Drugs
Progestin Drugs
Other GI Drugs
Leukotriene Modifiers
Selective Estrogen
Receptor Modulator
Other Drugs For Asthma
NUTRITION, BLOOD
MODIFIERS, ELECTROLYTES
OPHTHALMIC MEDICATIONS
Antiplatelet Drugs
Antiglaucoma Drugs
Blood Detoxicants
Proton Pump Inhibitors
UROLOGICAL MEDICATIONS
Injectable Anticoagulants
Anticholinergic
Antispasmodics
Oral Anticoagulants,
Vitamin K
IMMUNOLOGICALS &
VACCINES
Ophthalmic Antiinfective/
Corticosteroids
Other Genitourinary Products
Erythroid Stimulants
Potassium Supplements
neomycin-polymyxin-dexameth AVODART Therapeutic Vitamins &
Ophthalmic Corticosteroid
Interferons
Minerals
Drugs
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
NP 4T- S7950_2012_DOC7NP
All Rights Reserved
PRMTMDCNP-12 (07/15/11)
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on theformulary.
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
lansoprazole/odt [Q] [S], omeprazole [Q], citalopram [Q], fluoxetine [Q], paroxetine/er [Q], sertraline [Q], lovastatin [Q], pravastatin [Q], lovastatin [Q], pravastatin [Q], fenofibrate, TRICOR [S], TRILIPIX [S] fenofibrate, TRICOR [S], TRILIPIX [S] lovastatin [Q], pravastatin [Q], fluoxetine [Q], fluvoxamine [Q], paroxetine/er [Q], sertraline [Q] MAXAIR AUTOHALER PROAIR HFA [Q], VENTOLIN HFA [Q] dorzolamide, ALPHAGAN P 0.1% DROPS, lansoprazole/odt [Q] [S], omeprazole [Q], fenofibrate, TRICOR [S], TRILIPIX [S] fenofibrate, TRICOR [S], TRILIPIX [S] fenofibrate, TRICOR [S], TRILIPIX [S] lovastatin [Q], pravastatin [Q], lansoprazole/odt [Q] [S], omeprazole [Q], KEY
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [P] indicates that prior authorization may apply.
The symbol [Q] indicates that quantities dispensed may be limited.
The symbol [S] indicates that step therapy may apply.
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-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case, italicized letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
NP 4T- S7950_2012_DOC7NP
All Rights Reserved
PRMTMDCNP-12 (07/15/11)

Source: http://www.covchurch.org/resources/files/2010/05/2012-Medicare-Formulary-by-therapeutic-class.pdf

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