Prmt22782-12.ahp.120701.rev

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan.
The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.
PLEASE NOTE: The symbol * next to a drug signifies that it is subject to nonformulary status
2012 Express Scripts
when a generic is available throughout the year. Not all the drugs listed are covered by all
prescription-drug benefit programs; check your benefit materials for the specific drugs
High Performance Formulary
covered and the copayments for your prescription-drug benefit program. For specific
questions about your coverage, please call the phone number printed on your ID card.
A
G
C
E
H
O
M
I
P
F
J
N
K
B
D
FREESTYLE FREEDOM L
LANTUS VIALS ONLY [INJ] neomycin/polymyxin/hc THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2012 Express Scripts, Inc.
#617 HP-A W ST
All Rights Reserved
PRMT22782-12 (07/01/12 rev)
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 the formulary.
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
Q
R
U
ciprofloxacin/er, levofloxacin, ofloxacin V
ciprofloxacin/er, levofloxacin, ofloxacin ciprofloxacin/er, levofloxacin, ofloxacin S
W
X
ciprofloxacin/er, levofloxacin, ofloxacin Z
T
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths of the 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-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 letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2012 Express Scripts, Inc.
#617 HP-A W ST
All Rights Reserved
PRMT22782-12 (07/01/12 rev)

Source: http://www.averett.edu/facstaff/forms/hr/pdf/2012%20HPF%20Formulary.pdf