2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary The symbol [INJ] next to a drug name indicates that the drug is available in injectable form. The symbol [G] next to a drug name indicates that the drug may be available in a generic form. The symbol [LA] next to a drug name indicates that the drug has been noted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at specialty designated pharmacies able to appropriately handle the drugs. The symbol [PAR] in the Restrictions column indicates that prior authorization may apply. The symbol [QLL] in the Restrictions column indicates that quantities dispensed may be limited. The symbol [ST] in the Restrictions column indicates that step therapy may apply. General Drug Table Drug Generic Tier Restrictions ANESTHETICS LOCAL ANESTHETICS bupivacaine hcl injection [INJ] bupivacaine hcl-epinephrine [INJ] bupivacaine-dextrose [INJ] CARBOCAINE [INJ] chloroprocaine hcl [INJ] droperidol injection [INJ] INAPSINE [INJ] mepivacaine droperidol lidocaine hcl 0.5% vial, -1% abboject, -1% ampul, -1% syringe, 1% vial, -1.5% ampul, -2% abboject, -2% ampul, -2% luer-jet, 2% min-i-jet, -2% syringe, -2% vial, -20% vial, -4% ampul [INJ] lidocaine hcl in 7.5% dextrose [INJ] lidocaine hcl-epinephrine [INJ] MARCAINE [INJ] MARCAINE SPINAL [INJ] MARCAINE WITH EPINEPHRINE [INJ][G] MARCAINE-EPINEPHRINE [INJ] S7950_2011_DOC7aPC 1 1 1 3 1 1 3 1 bupivacaine bupivacaine hcl/dextrose-h2o bupivacaine hydrochloride/epi 1 1 3 3 3 bupivacaine hydrochloride/epi 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug NAROPIN [INJ] NESACAINE [INJ] NESACAINE-MPF [INJ] NOVOCAIN [INJ] POLOCAINE [INJ] SENSORCAINE [INJ] SENSORCAINE WITH DEXTROSE [INJ] SENSORCAINE WITH EPINEPHRINE [INJ] SENSORCAINE-MPF [INJ][G] SENSORCAINE-MPF EPINEPHRINE [INJ][G] XYLOCAINE 2% VIAL, -0.5% VIAL, 1% VIAL [INJ][G] XYLOCAINE IV [INJ] XYLOCAINE IV FOR CARDIAC [INJ] XYLOCAINE WITH EPINEPHRINE [INJ] XYLOCAINE-MPF [INJ][G] XYLOCAINE-MPF WITH EPINEPHRINE [INJ][G] Generic ropivacaine chloroprocaine chloroprocaine procaine mepivacaine bupivacaine bupivacaine hcl/dextrose-h2o Tier 3 3 3 3 3 3 3 bupivacaine hydrochloride/epi 3 bupivacaine bupivacaine hydrochloride/epi 3 3 lidocaine 3 lidocaine lidocaine lidocaine hydrochloride/epi 3 3 3 lidocaine lidocaine hydrochloride/epi 3 3 lidocaine lidocaine/prilocaine lidocaine 3 3 3 1 Restrictions TOPICAL ANESTHETICS ANESTACON EMLA [G] LIDAMANTLE lidocaine hcl cream, -jelly with prefilled applicator, -lotion, ointment, -solution non-oral lidocaine hcl viscous lidocaine-prilocaine LIDODERM SYNERA XYLOCAINE JEL, -SOLUTION NONORAL [G] S7950_2011_DOC7aPC lidocaine lidocaine/tetracaine lidocaine 1 1 2 3 3 [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions ANTIINFECTIVES AMEBICIDES paromomycin sulfate 1 AMINOGLYCOSIDES amikacin sulfate injection [INJ] gentamicin 100 mg/ns 100 ml, -60 mg/ns 50 ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -90 mg/ns 100 ml pb, -gentamicin 100 mg/100 ml, -gentamicin 60 mg/50 ml, gentamicin 80 mg/50 ml [INJ] GENTAMICIN 60 MG/NS 100 ML PB, -80 MG/NS 100 ML PB, GENTAMICIN 100 MG/50 ML, GENTAMICIN 60 MG/100 ML, GENTAMICIN 80 MG/100 ML [INJ] gentamicin sulfate injection [INJ] ISO GENTAMICIN 120 MG/100 ML, GENTAMICIN 120 MG/50 ML, GENTAMICIN 40 MG/100 ML, GENTAMICIN 40 MG/50 ML [INJ] kanamycin sulfate [INJ] NEBCIN IN DEXTROSE [INJ] NEO-FRADIN 1 1 gentamicin/sodium chloride 3 gentamicin/sodium chloride 1 2 tobramycin neomycin neomycin sulfate tablet tobramycin sulfate in ns [INJ] tobramycin sulfate injection [INJ] 1 3 2 1 1 1 ANTHELMINTICS ALBENZA BILTRICIDE albendazole praziquantel mebendazole tablet chewable STROMECTOL S7950_2011_DOC7aPC ivermectin 2 3 1 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ANTIINFECTIVES SPECIALIZED INDICATIONS DAPSONE FLAGYL [G] FLAGYL ER metro iv [INJ] Generic dapsone metronidazole metronidazole metronidazole capsule, -tablet metronidazole injection [INJ] metryl Tier Restrictions 2 3 3 1 1 1 1 ANTIRETROVIRALS AND PROTEASE INH APTIVUS ATRIPLA COMBIVIR CRIXIVAN tipranavir/vitamin e tpgs emtricitabine/tenofovir/efavir lamivudine/zidovudine indinavir didanosine EMTRIVA emtricitabine EPIVIR lamivudine EPZICOM abacavir sulfate/lamivudine FUZEON [INJ] enfuvirtide INTELENCE etravirine INVIRASE saquinavir mesylate ISENTRESS raltegravir potassium KALETRA 100-25 MG TABLET ritonavir/lopinavir KALETRA 200-50 MG TABLET, ritonavir/lopinavir SOLUTION LEXIVA SUSPENSION ORAL fosamprenavir calcium LEXIVA TABLET fosamprenavir calcium NORVIR CAPSULE, -TABLET ritonavir NORVIR SOLUTION ritonavir PREZISTA 150 MG TABLET, -300 MG darunavir ethanolate TABLET, -75 MG TABLET PREZISTA 400 MG TABLET, -600 MG darunavir ethanolate TABLET RESCRIPTOR delavirdine mesylate RETROVIR CAPSULE, -SYRUP, zidovudine TABLET [G] RETROVIR INJECTION [INJ] zidovudine REYATAZ atazanavir sulfate S7950_2011_DOC7aPC 4 4 4 2 1 2 2 4 4 4 4 4 2 4 2 4 2 4 2 4 2 3 2 4 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug SELZENTRY maraviroc Generic stavudine SUSTIVA TRIZIVIR TRUVADA VIDEX VIDEX EC [G] VIRACEPT VIRAMUNE VIREAD ZERIT [G] ZIAGEN efavirenz zidovudine/lamivudine/abacavir emtricitabine/tenofovir didanosine didanosine nelfinavir mesylate nevirapine tenofovir disproxil fumarate stavudine abacavir sulfate zidovudine Tier 4 1 2 4 4 2 3 2 2 2 3 2 1 Restrictions ANTITUBERCULOSIS DRUGS CAPASTAT SULFATE [INJ] CYCLOSERINE capreomycin cycloserine rifampin/inh/pyrazinamide cycloserine streptomycin 4 2 1 1 1 1 3 2 2 2 1 3 4 3 1 4 3 2 2 ethionamide 2 ethambutol hcl tablet isonarif isoniazid injection [INJ] isoniazid syrup, -tablet MYAMBUTOL [G] MYCOBUTIN PASER PRIFTIN ethambutol rifabutin aminosalicylic acid rifapentine pyrazinamide RIFADIN CAPSULE RIFADIN INJECTION [INJ] RIFAMATE rifampin rifampin rifampin/isoniazid rifampin capsule rifampin injection [INJ] RIFATER SEROMYCIN STREPTOMYCIN SULFATE INJECTION [INJ] TRECATOR S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic CEPHALOSPORINS CEDAX ceftibuten cefaclor cefaclor er cefadroxil cefazolin 1 gm add-van vial, -1 gm vial, -1 gm-d5w bag, -10 gm vial, 20 gm bulk vial, -500 mg vial [INJ] cefdinir cefepime [INJ] cefepime hcl [INJ] cefotaxime sodium [INJ] cefotetan [INJ] cefoxitin [INJ] cefoxitin sodium [INJ] cefpodoxime proxetil cefprozil ceftazidime [INJ] CEFTIN [G] cefuroxime axetil ceftriaxone [INJ] cefuroxime axetil cefuroxime injection [INJ] cefuroxime sod 1.5 gm vial, -sod 7.5 gm vial, -sod 750 mg vial [INJ] cefuroxime tablet cephalexin CLAFORAN [INJ][G] FORTAZ 1 GM ADD-VANTAGE VIAL, -1 GM VIAL, -2 GM VIAL, -6 GM VIAL [INJ][G] FORTAZ 2 GM ADD-VANTAGE VIAL [INJ] FORTAZ 500 MG VIAL [INJ] FORTAZ IN ISO-OSMOTIC DEXTROSE [INJ] KEFLEX [G] MAXIPIME 1 GM ADD-VANTAGE VL, -2 GM ADD-VANTAGE VL, -1 GRAM VIAL, -2 GRAM VIAL [INJ][G] S7950_2011_DOC7aPC Tier Restrictions 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 cefotaxime ceftazidime 1 1 3 3 ceftazidime 4 ceftazidime ceftazidime 2 2 cephalexin cefepime 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug MAXIPIME 500 MG VIAL [INJ] MEFOXIN [INJ][G] OMNICEF RANICLOR ROCEPHIN [INJ][G] SPECTRACEF SUPRAX TAZICEF [INJ][G] VANTIN ZINACEF [INJ][G] ZINACEF IN ISO-OSMOTIC WATER [INJ] ZINACEF ISO-OSMOTIC DEXTROSE [INJ] Generic cefepime cefoxitin cefdinir cefaclor ceftriaxone cefditoren pivoxil cefixime ceftazidime cefpodoxime cefuroxime cefuroxime Tier 2 3 3 3 3 3 2 3 3 3 3 cefuroxime 3 Restrictions CHLORAMPHENICOLS chloramphenicol sod succinate [INJ] 1 CLINDAMYCINS CLEOCIN CLEOCIN CLEOCIN CLEOCIN HCL [G] PALMITATE [G] PHOSPHATE [INJ][G] PHOSPHATE IN D5W [INJ] clindamycin hcl clindamycin palmitate clindamycin phosphate clindamycin phosphate 3 2 3 3 1 1 1 erythromycin ethylsuccinate erythromycin ethylsuccinate erythromycin ethylsuccinate erythromycin ethylsuccinate erythromycin base erythromycin lactobionate 3 3 3 3 2 2 1 clindamycin hcl capsule clindamycin palmitate hcl clindamycin phosphate injection [INJ] ERYTHROMYCINS E.E.S. 200 E.E.S. 400 [G] ERYPED 200 ERYPED 400 ERY-TAB ERYTHROCIN LACTOBIONATE [INJ] erythrocin stearate S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic erythromycin capsule enteric coated, -tablet erythromycin ethylsuccinate tablet PCE erythromycin base Tier 1 Restrictions 1 3 KETOLIDES KETEK telithromycin 3 flucytosine 4 1 3 ORAL ANTIFUNGAL DRUGS ANCOBON clotrimazole troche DIFLUCAN 100 MG TABLET, -200 MG TABLET, -50 MG TABLET [G] DIFLUCAN 150 MG TABLET [G] DIFLUCAN SUSPENSION [G] fluconazole fluconazole fluconazole fluconazole 100 mg tablet, -200 mg tablet, -50 mg tablet fluconazole 150 mg tablet fluconazole suspension GRIFULVIN V SUSPENSION ORAL GRIFULVIN V TABLET griseofulvin microsize griseofulvin microsize griseofulvin suspension oral GRIS-PEG griseofulvin ultramicrosize itraconazole capsule ketoconazole tablet LAMISIL PKT LAMISIL TABLET [G] MYCOSTATIN NOXAFIL nystatin 150,000,000 units pwd, 50,000,000 units pwd, -500,000,000 units pwd, -suspension oral, -tablet ORAVIG SPORANOX CAPSULE [G] SPORANOX SOLUTION terbinafine terbinafine nystatin posaconazole miconazole itraconazole itraconazole terbinafine hcl TERBINEX VFEND S7950_2011_DOC7aPC terbinafine/hydroxy chitosan voriconazole [PAR] 3 3 1 [QLL, 2/7] 1 1 3 2 1 2 1 1 2 3 3 4 1 [QLL, 2/7] 3 3 2 1 3 4 [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions OTHER ANTIINFECTIVE DRUGS ALINIA AZACTAM 1 GM VIAL [INJ] AZACTAM 2 GM VIAL [INJ][G] AZACTAM-ISO-OSMOT 1 GM/50 ML [INJ] AZACTAM-ISO-OSMOT 2 GM/50 ML [INJ] aztreonam 1 gm vial [INJ] aztreonam 2 gm vial [INJ] baciim [INJ] bacitracin injection [INJ] colistimethate 150 mg vial [INJ] COLY-MYCIN M PARENTERAL [INJ][G] CUBICIN [INJ] DORIBAX [INJ] INVANZ 1 GM ADD-VANTAGE VIAL [INJ] INVANZ 1 GM VIAL [INJ] LINCOCIN [INJ] lincoject [INJ] MEPRON meropenem [INJ] MERREM IV 1 GM VIAL [INJ] MERREM IV 500 MG VIAL [INJ][G] PENTAM 300 [INJ][G] pentamidine isethionate [INJ] polymyxin b sulfate injection [INJ] POLYMYXIN B SULFATE POWDER PRIMAXIN 250 MG VIAL [INJ] PRIMAXIN 500 MG VIAL [INJ] PRIMAXIN I.M. [INJ] SYNERCID [INJ] TYGACIL [INJ] VANCOCIN HCL S7950_2011_DOC7aPC nitazoxanide aztreonam aztreonam aztreonam/dextrose water 2 2 4 2 aztreonam/dextrose water 4 colistimethate, sodium 1 4 1 1 4 4 daptomycin doripenem ertapenem sodium 4 4 3 ertapenem sodium lincomycin 2 3 1 4 1 4 2 3 1 1 3 2 4 4 4 4 4 atovaquone meropenem meropenem pentamidine polymyxin b imipenem/cilastatin sodium imipenem/cilastatin sodium imipenem/cilastatin sodium quinupristin/dalfopristin tigecycline vancomycin © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug vancomycin 1 gm add-van vial, -1 gm vial, -10 gm vial, -5 gm vial, 500 mg a/v vial, -500 mg vial, -750 mg vial [INJ] VANCOMYCIN HCL 1G/200 ML BAG [INJ] VANCOMYCIN-D5W [INJ] VIBATIV [INJ] XIFAXAN 200 MG TABLET XIFAXAN 550 MG TABLET ZYVOX INJECTION [INJ] ZYVOX SUSPENSION RECONSTITUTED ORAL, -TABLET Generic Tier 1 vancomycin 3 vancomycin telavancin rifaximin rifaximin linezolid linezolid 3 4 2 4 4 4 Restrictions [PAR] OTHER ANTIVIRAL DRUGS acyclovir capsule, -suspension oral, tablet acyclovir sodium [INJ] amantadine 1 famciclovir 125 mg tablet 1 1 2 4 4 2 2 2 1 famciclovir 250 mg tablet 1 famciclovir 500 mg tablet BARACLUDE SOLUTION BARACLUDE TABLET COPEGUS [G] CYTOVENE [INJ][G] DENAVIR EPIVIR HBV entecavir entecavir ribavirin ganciclovir penciclovir lamivudine FAMVIR 125 MG TABLET [G] famciclovir 1 3 FAMVIR 250 MG TABLET [G] famciclovir 3 FAMVIR 500 MG TABLET [G] FLUMADINE [G] foscarnet sodium [INJ] FOSCAVIR [INJ] famciclovir rimantadine 3 3 1 3 4 ganciclovir S7950_2011_DOC7aPC foscarnet [QLL, 21/10] [QLL, 68/34] [QLL, 21/7] [QLL, 21/10] [QLL, 68/34] [QLL, 21/7] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ganciclovir sodium [INJ] HEPSERA REBETOL SOLUTION, -CAPSULE [G] RELENZA ribapak ribasphere 200 mg tablet ribasphere 400 mg tablet, -600 mg tablet, -capsule RIBATAB [G] Generic adefovir dipivoxil ribavirin zanamivir ribavirin Tier Restrictions 1 4 4 2 [QLL, 60/180] 4 1 4 4 1 4 ribavirin 200 mg tablet ribavirin 400 mg tablet, -600 mg tablet, -capsule rimantadine hcl TAMIFLU 30 MG GELCAP oseltamivir phosphate 1 2 TAMIFLU 45 MG GELCAP, -75 MG GELCAP TAMIFLU SUSPENSION oseltamivir phosphate 2 oseltamivir phosphate 2 TYZEKA telbivudine 2 1 valacyclovir VALCYTE VALTREX [G] valganciclovir valacyclovir 4 3 VIRAZOLE [INJ] VISTIDE [INJ] ZOVIRAX CAPSULE, -SUSPENSION ORAL, -TABLET [G] ZOVIRAX CREAM, -OINTMENT ribavirin cidofovir acyclovir 2 4 3 acyclovir 2 [QLL, 84/180] [QLL, 42/180] [QLL, 900/180] [QLL, 34/34] [QLL, 34/34] OTHER MACROLIDES azithromycin 100 mg/5 ml susp 1 azithromycin 200 mg/5 ml susp 1 azithromycin 250 mg tablet azithromycin 500 mg tablet azithromycin 600 mg tablet, -packet 1 1 1 S7950_2011_DOC7aPC [QLL, ml/5] [QLL, ml/5] [QLL, [QLL, 30 90 8/7] 4/4] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug azithromycin injection [INJ] BIAXIN [G] BIAXIN XL [G] clarithromycin clarithromycin er ZITHROMAX 100 MG/5 ML SUSP [G] Generic ZITHROMAX 200 MG/5 ML SUSP [G] azithromycin ZITHROMAX 250 MG TABLET, -250 MG Z-PAK TABLET [G] ZITHROMAX 500 MG TABLET [G] ZITHROMAX INJECTION [INJ][G] ZITHROMAX PACKET, -600 MG TABLET [G] ZITHROMAX TRI-PAK [G] ZMAX azithromycin Tier Restrictions 1 3 3 1 1 3 [QLL, 30 ml/5] 3 [QLL, 68 ml/5] 3 [QLL, 8/7] azithromycin azithromycin azithromycin 3 3 3 [QLL, 4/4] azithromycin azithromycin 3 3 ZMAX ADULT-PEDIATRIC ZMAX PEDIATRIC azithromycin azithromycin 3 3 [QLL, [QLL, ml/1] [QLL, [QLL, clarithromycin clarithromycin azithromycin 4/4] 60 60/1] 60/1] OTHER TOPICAL ANTIFUNGALS ciclopirox cream, -gel, -kit, shampoo, -suspension topical ciclopirox solution non-oral clotrimazole 1% cream, -1% solution, -af 1% cream CNL 8 1 1 1 ciclopirox/nail lacquer remov econazole nitrate cream ERTACZO EXELDERM EXTINA sertaconazole nitrate sulconazole nitrate ketoconazole ketoconazole cream, -shampoo KURIC [G] LAMISIL SOLUTION LOPROX [G] MENTAX NAFTIN NIZORAL [G] S7950_2011_DOC7aPC ketoconazole terbinafine ciclopirox butenafine naftifine ketoconazole [PAR] 3 1 3 3 3 1 3 3 3 3 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic nyamyc nystatin 100,000 unit/gm powd, cream, -ointment nystop OXISTAT oxiconazole pedi-dri PENLAC [G] VUSION XOLEGEL ciclopirox miconazole nitrate/zinc oxide ketoconazole Tier 1 1 1 3 1 3 3 3 Restrictions [PAR] PARENTERAL ANTIFUNGALS ABELCET [INJ] AMBISOME [INJ] AMPHOTEC 100 MG VIAL [INJ] AMPHOTEC 50 MG VIAL [INJ] amphotericin b injection [INJ] CANCIDAS [INJ] DIFLUCAN IN DEXTROSE [INJ] DIFLUCAN IN SALINE [INJ][G] ERAXIS (ALCOHOL DILUENT) [INJ] ERAXIS (WATER DILUENT) [INJ] fluconazole in dextrose [INJ] fluconazole in saline [INJ] MYCAMINE [INJ] VFEND IV [INJ] amphotericin b lipid complex amphotericin b liposome ampho b c-s ampho b c-s caspofungin acetate fluconazole/dextrose-water fluconazole/sodium chloride anidulafungin anidulafungin micafungin sodium voriconazole 4 4 2 3 1 4 3 3 3 3 1 1 4 4 PENICILLINS amoclan amox tr-potassium clavulanate amoxicillin amoxicillin-clavulanate er AMOXIL 125 MG/5 ML SUSPENSION amoxicillin [INJ] AMOXIL 400 MG/5 ML SUSPENSION, amoxicillin -50 MG/ML PED DROPS, -CAPSULE, -250 MG/5 ML SUSPENSION [G] ampicillin sodium [INJ] ampicillin trihydrate S7950_2011_DOC7aPC 1 1 1 1 2 2 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ampicillin-sulbactam [INJ] AUGMENTIN 125-31.25 SUSPEN, TABLET CHEWABLE AUGMENTIN 400-57 MG/5 ML, -25062.5 MG/5 ML, -TABLET [G] AUGMENTIN ES-600 AUGMENTIN XR [G] BACTOCILL BICILLIN C-R [INJ] BICILLIN L-A [INJ] dicloxacillin sodium MOXATAG NAFCILL IN DEXTROSE [INJ] nafcillin [INJ] nafcillin sodium [INJ] NALLPEN [INJ] NALLPEN IN DEXTROSE [INJ] NALLPEN-ISO-OSMOTIC DEXTROSE [INJ] oxacillin [INJ] oxacillin 1 gm add-vantage vl, -10 gm vial, -2 gm add-vantage vl, -2 gm vial [INJ] oxacillin 1 gm vial [INJ] penicillin g potassium [INJ] PENICILLIN G POTASSIUM IN D5W [INJ] penicillin g procaine [INJ] penicillin g sodium [INJ] PENICILLIN GK-ISO-OSM DEXTROSE [INJ] penicillin v potassium PFIZERPEN [INJ][G] piperacillin [INJ] piperacillin-tazobactam [INJ] PIPRACIL IN DEXTROSE [INJ] TIMENTIN [INJ] TOTACILLIN-N [INJ] UNASYN [INJ][G] ZOSYN [INJ][G] S7950_2011_DOC7aPC Generic amoxicillin clavulanate Tier 1 2 amoxicillin clavulanate 3 amoxicillin clavulanate amoxicillin clavulanate oxacillin pen g procaine/pen g benz penicillin g benzathine 3 3 3 2 2 1 3 4 4 4 4 4 4 amoxicillin nafcillin nafcillin nafcillin nafcillin Restrictions 4 4 pen g pot/dextrose-water 1 1 2 pen g pot/dextrose-water 1 1 2 penicillin g potassium piperacillin ticarcillin/k clavulanate ampicillin sodium ampicillin sodium/sulbactam na piperacillin/tazobactam sodium 1 3 1 1 2 2 3 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions PLASMODICIDES ARALEN PHOSPHATE [G] chloroquine phosphate chloroquine phosphate tablet COARTEM DARAPRIM FANSIDAR HALFAN artemether/lumefantrine pyrimethamine pyrimethamine/sulfadoxine halofantrine hydroxychloroquine sulfate tablet MALARONE atovaquone/proguanil hcl mefloquine hcl PLAQUENIL [G] PRIMAQUINE QUALAQUIN hydroxychloroquine primaquine quinine sulfate 3 1 2 2 2 2 1 2 1 3 2 2 QUINOLONES AVELOX AVELOX ABC PACK AVELOX IV [INJ] CIPRO [G] CIPRO I.V. [INJ][G] CIPRO XR ciprofloxacin [INJ] moxifloxacin moxifloxacin moxifloxacin ciprofloxacin ciprofloxacin ciprofloxacin ciprofloxacin 2 2 2 3 3 3 1 1 1 1 3 3 3 3 3 1 3 sulfamethoxazole/trimethoprim 3 ciprofloxacin er ciprofloxacin hcl tablet ciprofloxacin-d5w [INJ] FACTIVE FLOXIN I.V. [INJ] LEVAQUIN INJECTION [INJ] LEVAQUIN SOLUTION, -TABLET NOROXIN gemifloxacin ofloxacin levofloxacin levofloxacin norfloxacin ofloxacin tablet PROQUIN XR [QLL, 7/7] SULFONAMIDES BACTRIM [G] S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug BACTRIM DS [G] erythromycin-sulfisoxazole GANTRISIN SEPTRA [G] SEPTRA DS [G] sulfadiazine tablet sulfamethoxazole-trimethoprim injection [INJ] sulfamethoxazole-trimethoprim suspension oral, -tablet sulfatrim Generic sulfamethoxazole/trimethoprim sulfisoxazole acetyl sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim Tier 3 1 2 3 3 1 1 Restrictions 1 1 TETRACYCLINES ADOXA [G] ADOXA PAK [G] AVIDOXY doxycycline monohydrate doxycycline monohydrate doxycycline monohydrate demeclocycline hcl DORYX doxycycline hyclate doxycycline doxycycline hyclate 100 mg tab, capsule, -capsule enteric coated doxycycline hyclate injection [INJ] doxycycline monohydrate doxy-lemmon DYNACIN [G] MINOCIN COMBINATION PACKAGE, -KIT, -CAPSULE [G] MINOCIN INJECTION [INJ] minocycline hcl capsule, -tablet, tablet sustained release 24hr MONODOX [G] ORACEA SOLODYN [G] TERRAMYCIN [INJ] TERRAMYCIN IM [INJ] minocycline minocycline S7950_2011_DOC7aPC 1 1 1 3 3 minocycline 3 1 doxycycline monohydrate doxycycline monohydrate minocycline oxytetracycline oxytetracycline 3 3 3 3 3 1 3 3 tetracycline hcl capsule VIBRAMYCIN 50 MG CAPSULE [INJ] VIBRAMYCIN SUSPENSION, -SYRUP, -100 MG CAPSULE [G] 3 3 3 1 3 1 1 doxycycline hyclate doxycycline hyclate © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug VIBRA-TABS Generic doxycycline hyclate Tier 3 retapamulin mupirocin mupirocin calcium mupirocin neomycin/bacitracin/poly/hc 2 3 2 3 3 1 1 3 3 1 1 1 2 1 Restrictions TOPICAL ANTIBACTERIAL DRUGS ALTABAX BACTROBAN [G] BACTROBAN NASAL CENTANY CORTISPORIN CREAM, -OINTMENT gentamicin 0.1% ointment, -cream mupirocin ointment PHISOHEX SILVADENE [G] hexachlorophene silver sulfadiazine silver sulfadiazine ssd ssd af SULFAMYLON mafenide acetate thermazene TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB. clotrimazole-betamethasone LOTRISONE [G] clotrimazole/betamethasone nystatin-triamcinolone 1 3 1 URINARY ANTIINFECTIVES FURADANTIN HIPREX [G] MACROBID [G] MACRODANTIN [G] nitrofurantoin methenamine hippurate nitrofurantoin/nitrofuran mac nitrofurantoin macrocrystal methenamine hippurate methenamine mandelate MONUROL fosfomycin tromethamine nitrofurantoin capsule nitrofurantoin macrocrystal nitrofurantoin mono-macro PRIMSOL trimethoprim tablet S7950_2011_DOC7aPC trimethoprim 2 3 3 3 1 1 2 1 1 1 2 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug UROQID-ACID NO.2 utac visqid a-a Generic methenamine mandelate Tier 3 1 1 butoconazole Restrictions VAGINAL ANTIFUNGALS GYNAZOLE-1 TERAZOL 3 80 MG SUPPOSITORY [G] TERAZOL 3 CREAM [G] terconazole 3 1 1 3 terconazole 3 TERAZOL 7 [G] terconazole 3 miconazole 3 200 mg vag supp nystatin tablet terconazole 0.4% cream 1 terconazole 0.8% cream 1 terconazole 80 mg suppository ZAZOLE 0.8% VAGINAL CREAM terconazole 1 3 ZAZOLE 80 MG VAGINAL SUPP [G] ZAZOLE VAGINAL 0.4% CREAM [G] terconazole terconazole 3 3 [QLL, 3/3] [QLL, 3/3] [QLL, 20 gm/3] [QLL, 45 gm/7] [QLL, 45 gm/7] [QLL, 20 gm/3] [QLL, 3/3] [QLL, 20 gm/3] [QLL, 3/3] [QLL, 45 gm/7] ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS AFINITOR AGRYLIN [G] ALIMTA [INJ] AMEVIVE [INJ][LA] amifostine [INJ] everolimus anagrelide pemetrexed disodium alefacept ARAVA [G] leflunomide 4 3 4 4 4 1 1 3 ARIMIDEX [G] AROMASIN anastrozole exemestane 2 2 anagrelide hcl anastrozole tablet S7950_2011_DOC7aPC [PAR] [QLL, 34/34] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug AVASTIN [INJ] AZASAN bevacizumab azathioprine Generic azathioprine sodium [INJ] azathioprine tablet bicalutamide CAMPATH [INJ] CASODEX [G] CEENU CELLCEPT CAPSULE [G] CELLCEPT INJECTION [INJ] CELLCEPT TABLET, -SUSPENSION RECONSTITUTED ORAL [G] CIMZIA [INJ] alemtuzumab bicalutamide lomustine mycophenolate mofetil mycophenolate mofetil mycophenolate mofetil certolizumab pegol cyclophosphamide tablet cyclosporine capsule, -solution cyclosporine injection [INJ] cyclosporine modified DEPO-PROVERA 400 MG/ML VIAL [INJ] DROXIA ELIGARD [INJ] ELITEK [INJ] EMCYT ENBREL [INJ] ETHYOL [INJ][G] FARESTON FASLODEX [INJ] FEMARA floxuridine [INJ] medroxyprogesterone hydroxyurea leuprolide rasburicase estramustine phosphate sodium etanercept amifostine toremifene fulvestrant letrozole S7950_2011_DOC7aPC Restrictions [PAR] [PAR] [PAR] [PAR] 4 1 1 1 1 2 [PAR] [PAR] [PAR] [PAR] [PAR] imatinib mesylate altretamine adalimumab 2 2 4 2 4 4 2 4 2 1 1 1 1 4 4 4 adalimumab 4 hydroxyurea 3 flutamide fudr [INJ] gengraf GLEEVEC HEXALEN HUMIRA 20 MG/0.4 ML SYRINGE, 40 MG/0.8 ML SYRINGE [INJ] HUMIRA 40 MG/0.8 ML PEN, CROHN'S STARTER PACK, PSORIASIS STARTER PACK [INJ] HYDREA [G] Tier 2 2 1 1 1 4 3 2 3 2 4 [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR][QLL, 5/35] [PAR][QLL, 6/180] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug hydroxyurea capsule IMURAN [G] IRESSA [LA] leflunomide Generic azathioprine gefitinib leucovorin calcium injection [INJ] leucovorin calcium tablet LEUKERAN LYSODREN MATULANE MEGACE [G] MEGACE ES chlorambucil mitotane procarbazine megestrol megestrol megestrol acetate suspension oral, tablet mercaptopurine tablet MESNEX TABLET mesna methotrexate injection [INJ] methotrexate tablet mitoxantrone hcl injection [INJ] MUSTARGEN [INJ] mechlorethamine mycophenolate mofetil capsule mycophenolate mofetil tablet MYFORTIC NEORAL [G] NEXAVAR [LA] NILANDRON NOVANTRONE [INJ][G] mycophenolate sodium cyclosporine sorafenib tosylate nilutamide mitoxantrone octreotide 1,000 mcg/ml vial, -acet 100 mcg/ml amp, -acet 100 mcg/ml vl, -acet 200 mcg/ml vl, -acet 500 mcg/ml amp, -acet 500 mcg/ml vl Tier Restrictions 1 3 [PAR] 4 1 [QLL, 34/34] 1 1 2 4 4 3 2 1 1 4 1 1 4 2 1 4 2 3 4 2 4 4 [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [INJ] octreotide acet 50 mcg/ml amp, acet 50 mcg/ml vial [INJ] ORENCIA [INJ] ORTHOCLONE OKT-3 [INJ] PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE [G] PROGRAF 5 MG CAPSULE [G] PROGRAF INJECTION [INJ] S7950_2011_DOC7aPC 1 abatacept/maltose muronab-cd3 tacrolimus 4 2 3 [PAR] [PAR] [PAR] tacrolimus tacrolimus 4 2 [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug PURINETHOL [G] RAPAMUNE RAPTIVA [INJ] REMICADE [INJ] REVLIMID [LA] RHEUMATREX RITUXAN [INJ] SANDIMMUNE CAPSULE, SOLUTION [G] SANDIMMUNE INJECTION [INJ][G] SANDOSTATIN [INJ][G] SANDOSTATIN LAR 10 MG KIT, -30 MG KIT [INJ] SANDOSTATIN LAR 20 MG KIT [INJ] SIMPONI [INJ] SIMULECT [INJ] SOMATULINE DEPOT [INJ] SPRYCEL STELARA [INJ] SUTENT tacrolimus 0.5 mg capsule, -1 mg capsule tacrolimus 5 mg capsule tamoxifen citrate tablet TARCEVA TARGRETIN TASIGNA THERACYS [INJ] THIOGUANINE TRELSTAR 11.25 MG SYRINGE, 3.75 MG SYRINGE [INJ][LA] TRELSTAR 22.5 MG SYRINGE, -22.5 MG VIAL [INJ][LA] TRELSTAR DEPOT [INJ][LA] TRELSTAR LA [INJ][LA] tretinoin capsule TREXALL TYKERB TYSABRI [INJ][LA] VANTAS [INJ] S7950_2011_DOC7aPC Generic mercaptopurine sirolimus efalizumab infliximab lenalidomide methotrexate rituximab cyclosporine Tier 3 2 4 4 4 3 4 3 cyclosporine octreotide octreotide 3 4 4 [PAR] octreotide golimumab basiliximab lanreotide acetate dasatinib ustekinumab sunitinib malate 4 4 2 4 4 4 4 1 [QLL, 2/28] [PAR] [PAR] [PAR] erlotinib hcl bexarotene nilotinib hydrochloride bcg vaccine thioguanine triptorelin pamoate 4 1 4 4 4 2 2 2 triptorelin pamoate 4 triptorelin pamoate triptorelin pamoate 2 2 4 2 4 4 2 methotrexate sodium lapatinib ditosylate natalizumab histrelin ac Restrictions [PAR] [PAR] [PAR] [PAR] [PAR] [QLL, 1/28] [PAR] [PAR] [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug VELCADE [INJ] VESANOID VIDAZA [INJ] VOTRIENT ZOLADEX [INJ] ZOLINZA ZORTRESS 0.25 MG TABLET ZORTRESS 0.5 MG TABLET, -0.75 MG TABLET Generic bortezomib tretinoin azacitidine pazopanib goserelin acetate vorinostat everolimus everolimus Tier Restrictions 4 4 4 4 2 4 2 [PAR] 4 [PAR] AUTONOMIC AND CNS MEDICATIONS ANALGESICS BUPRENEX [INJ] buprenorphine PRIALT [INJ] RYBIX ODT ziconotide acetate tramadol 3 1 1 1 2 3 RYZOLT tramadol 3 buprenorphine injection [INJ] butorphanol tartrate injection [INJ] nalbuphine hcl [INJ] sufenta [INJ] sufentanil citrate injection [INJ] TALWIN INJECTION [INJ] pentazocine tramadol hcl tablet tramadol hcl tablet sustained release 24hr tramadol hcl-acetaminophen 1 1 3 1 1 1 ULTIVA [INJ] ULTRACET [G] remifentanil tramadol/apap 2 3 ULTRAM [G] tramadol 3 ULTRAM ER [G] tramadol 3 S7950_2011_DOC7aPC [QLL, 272/34][ST] [QLL, 34/34][ST] [QLL, 272/34] [QLL, 34/34] [QLL, 272/34] [QLL, 272/34][ST] [QLL, 272/34][ST] [QLL, 34/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic ANTIDEMENTIA DRUGS ARICEPT 10 MG TABLET, -5 MG TABLET ARICEPT 23 MG TABLET ARICEPT ODT COGNEX EXELON [G] donepezil 2 donepezil donepezil tacrine rivastigmine tartrate 3 2 3 2 1 1 2 3 3 1 galantamine hbr galantamine hydrobromide NAMENDA RAZADYNE [G] RAZADYNE ER [G] Tier memantine hcl galantamine galantamine rivastigmine Restrictions ANTIMANIA DRUGS ESKALITH [INJ] lithium carbonate lithium lithium carbonate capsule, -tablet, tablet sustained action lithium citrate LITHOBID [G] lithium carbonate 3 1 1 1 3 ANTIPARKINSON ANTICHOLINERGIC DRUGS benztropine mesylate injection [INJ] benztropine mesylate tablet COGENTIN [INJ][G] benztropine trihexyphenidyl hcl 1 1 3 1 ANTIPSYCHOTIC DRUGS ABILIFY DISCMELT aripiprazole 2 ABILIFY INJECTION [INJ] ABILIFY SOLUTION ABILIFY TABLET aripiprazole aripiprazole aripiprazole 2 2 2 chlorpromazine hcl injection [INJ] S7950_2011_DOC7aPC [QLL, 68/34] [QLL, 34/34] 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug chlorpromazine hcl tablet clozapine CLOZARIL [G] FANAPT 1 MG TABLET, -10 MG TABLET, -12 MG TABLET, -2 MG TABLET, -4 MG TABLET, -6 MG TABLET, -8 MG TABLET FANAPT TITRATION PACK FAZACLO fluphenazine decanoate [INJ] fluphenazine hcl elixir, -solution, tablet fluphenazine hcl injection [INJ] GEODON CAPSULE GEODON INJECTION [INJ] HALDOL [INJ] HALDOL DECANOATE 100 [INJ] HALDOL DECANOATE 50 [INJ] haloperidol decanoate [INJ] haloperidol lactate injection [INJ] Generic clozapine iloperidone iloperidone clozapine ziprasidone ziprasidone haloperidol haloperidol decanoate haloperidol decanoate Tier Restrictions 1 1 3 2 [QLL, 68/34] 2 2 1 1 1 2 INVEGA ER 1.5 MG TABLET, -ER 3 MG TABLET, -ER 9 MG TABLET INVEGA ER 6 MG TABLET paliperidone 2 3 3 3 1 1 1 1 2 paliperidone 2 INVEGA SUSTENNA 117 MG PREF SY, -156 MG PREF SY, -234 MG PREF SY [INJ] INVEGA SUSTENNA 39 MG PREF SYR, -78 MG PREF SYR [INJ] paliperidone 4 paliperidone 2 haloperidol lactate solution haloperidol tablet loxapine LOXITANE [G] MOBAN NAVANE [G] ORAP loxapine succinate molindone thiothixene pimozide perphenazine RISPERDAL CONSTA 12.5 MG SYR, 25 MG SYR [INJ] S7950_2011_DOC7aPC risperidone [QLL, 1/34] [QLL, 68/34] [QLL, 34/34] [QLL, 68/34] 1 3 2 3 2 1 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug RISPERDAL CONSTA 37.5 MG SYR, 50 MG SYR [INJ] RISPERDAL M-TAB [G] Tier 4 Restrictions risperidone 3 RISPERDAL SOLUTION [G] risperidone 3 RISPERDAL TABLET [G] risperidone 3 [QLL, 68/34] [QLL, 544 ml/34] [QLL, 68/34] [QLL, 68/34] [QLL, 68/34] [QLL, 544 ml/34] [QLL, 68/34] [QLL, 68/34] [QLL, 102/34] risperidone Generic risperidone m-tab 1 risperidone odt 1 risperidone solution 1 risperidone tablet 1 SAPHRIS asenapine 2 SEROQUEL 100 MG TABLET, -200 MG TABLET, -25 MG TABLET, -50 MG TABLET SEROQUEL 300 MG TABLET, -400 MG TABLET SEROQUEL XR 150 MG TABLET, 200 MG TABLET SEROQUEL XR 300 MG TABLET, 400 MG TABLET, -50 MG TABLET SYMBYAX quetiapine fumarate 2 quetiapine fumarate 2 quetiapine fumarate 2 quetiapine fumarate 2 olanzapine/fluoxetine hcl ZYPREXA INJECTION [INJ] ZYPREXA RELPREVV [INJ][LA] ZYPREXA TABLET olanzapine olanzapine pamoate olanzapine 3 1 1 1 2 4 2 ZYPREXA ZYDIS olanzapine 2 thioridazine hcl thiothixene trifluoperazine hcl [QLL, 68/34] [QLL, 34/34] [QLL, 68/34] [QLL, 34/34] [QLL, 34/34] ANTIVERTIGO AND ANTIEMETIC DRUGS ALOXI [INJ] S7950_2011_DOC7aPC palonosetron hcl 4 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic ANTIVERT [G] ANZEMET INJECTION [INJ] ANZEMET TABLET meclizine hcl dolasetron mesylate dolasetron mesylate CESAMET COMPAZINE INJECTION [INJ] COMPAZINE SYRUP nabilone prochlorperazine edisylate prochlorperazine edisylate compro dimenhydrinate injection [INJ] dronabinol 10 mg capsule, -5 mg capsule dronabinol 2.5 mg capsule Tier Restrictions 3 3 3 [PAR][QLL, 1/1] 4 [QLL, 30/5] 3 2 1 1 4 [PAR] EMEND 125 MG CAPSULE, -40 MG CAPSULE EMEND 80 MG CAPSULE aprepitant 1 2 aprepitant 2 EMEND INJECTION [INJ] EMEND TRIFOLD PACK aprepitant aprepitant 2 2 granisetron hcl injection [INJ] granisetron hcl tablet 1 1 granisol 1 [PAR] [PAR][QLL, 1/1] [PAR][QLL, 2/2] [PAR][QLL, 3/3] [PAR][QLL, 2/1] [PAR][QLL, 30 ml/3] KYTRIL INJECTION [INJ][G] KYTRIL TABLET [G] granisetron granisetron 4 4 MARINOL 10 MG CAPSULE, -5 MG CAPSULE [G] MARINOL 2.5 MG CAPSULE [G] dronabinol 4 dronabinol 3 1 [PAR] 1 [PAR][QLL, 1/1] [PAR][QLL, 12/5] meclizine 12.5 mg tablet, -25 mg tablet ondansetron hcl 24 mg tablet ondansetron hcl 4 mg tablet, -8 mg tablet ondansetron hcl in dextrose [INJ] ondansetron hcl injection [INJ] ondansetron hcl solution S7950_2011_DOC7aPC 1 1 1 1 [PAR][QLL, 2/1] [PAR] [PAR][QLL, 150 ml/5] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ondansetron odt Generic phenadoz prochlorperazine edisylate [INJ] prochlorperazine maleate suppository rectal, -tablet promethazine hcl suppository rectal promethegan Tier Restrictions 1 [PAR][QLL, 12/5] 1 1 1 granisetron trimethobenzamide trimethobenzamide scopolamine [INJ] ZOFRAN INJECTION [INJ][G] ZOFRAN ODT [G] 1 1 4 3 3 3 1 1 ondansetron ondansetron 3 3 ZOFRAN SOLUTION [G] ondansetron 3 ZOFRAN TABLET [G] ondansetron 3 ZUPLENZ ondansetron 3 buspirone 3 1 1 SANCUSO TIGAN CAPSULE [G] TIGAN INJECTION [INJ] TRANSDERM-SCOP trimethobenzamide hcl capsule trimethobenzamide hcl injection [QLL, 1/7] [PAR][QLL, 12/5] [PAR][QLL, 150 ml/5] [PAR][QLL, 12/5] [PAR][QLL, 12/5] ANXIOLYTICS BUSPAR buspirone hcl tablet meprobamate CARBAMAZEPINES carbamazepine suspension oral, tablet, -tablet chewable carbamazepine xr CARBATROL 1 carbamazepine epitol EQUETRO oxcarbazepine S7950_2011_DOC7aPC carbamazepine 1 3 1 3 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic carbamazepine carbamazepine carbamazepine Tier 3 2 3 oxcarbazepine 3 ACTIQ [G] fentanyl citrate 4 ALFENTA [INJ] alfentanil 3 1 3 3 TEGRETOL [G] TEGRETOL XR 100 MG TABLET TEGRETOL XR 200 MG TABLET, 400 MG TABLET [G] TRILEPTAL [G] Restrictions CLASS II NARCOTICS alfentanil hydrochloride [INJ] ASTRAMORPH-PF [INJ][G] AVINZA morphine morphine codeine phosphate injection [INJ] codeine sulfate COMBUNOX DAZIDOX DEMEROL [INJ] DILAUDID INJECTION [INJ] DILAUDID TABLET [G] DILAUDID-5 DILAUDID-HP [INJ][G] methadone fentanyl morphine morphine sulfate/naltrexone 1 1 3 3 3 3 3 3 3 1 3 3 3 3 hydromorphone 1 1 1 3 oxycodone/ibuprofen oxycodone meperidine hydromorphone hydromorphone hydromorphone hydromorphone diskets DOLOPHINE HCL [G] DURAGESIC [G] DURAMORPH [INJ][G] EMBEDA endocet endodan eth-oxydose EXALGO fentanyl fentanyl citrate injection [INJ] fentanyl citrate loz S7950_2011_DOC7aPC 1 1 4 [PAR][QLL, 120/30] [QLL, 60/30][ST] [QLL, 90/30][ST] [QLL, 60/30][ST] [PAR][QLL, 120/30] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug FENTORA hydromorphone hcl injection [INJ] hydromorphone hcl suppository rectal, -tablet INFUMORPH [INJ] KADIAN Generic fentanyl citrate Tier Restrictions 4 [PAR][QLL, 112/28] 1 1 morphine morphine 3 3 levorphanol tartrate tablet MAGNACET meperidine hcl injection [INJ] methadone hcl injection [INJ] methadone hcl solution, -tablet, tablet soluble methadone intensol methadose morphine sulfate in dextrose [INJ] morphine sulfate injection [INJ] morphine sulfate solution, suppository rectal, -tablet morphine sulfate tablet sustained action oxycodone/acetaminophen 1 3 1 1 1 1 1 1 1 1 1 MS CONTIN [G] morphine 3 NUCYNTA tapentadol hcl 3 NUMORPHAN [INJ] ONSOLIS [LA] oxymorphone fentanyl citrate 2 4 OPANA OPANA ER oxymorphone oxymorphone 3 2 OPIUM ORAMORPH SR opium morphine 3 3 oxycodone hcl oxycodone hcl-acetaminophen oxycodone hcl-ibuprofen oxycodone-acetaminophen oxycodone-aspirin S7950_2011_DOC7aPC [QLL, 90/30][ST] [QLL, 120/30] [QLL, 120/30][ST] [QLL, 205/34] [PAR][QLL, 120/30] [QLL, 90/30][ST] [QLL, 120/30][ST] 1 1 1 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug OXYCONTIN [G] Generic oxycodone PERCOCET [G] PERCODAN [G] PRIMALEV PRIMLEV ROXICET SOLUTION oxycodone/acetaminophen oxycodone/aspirin oxycodone/acetaminophen oxycodone/acetaminophen oxycodone/acetaminophen roxicet tablet ROXICODONE [G] ROXICODONE INTENSOL sublimaze [INJ] TYLOX XOLOX oxycodone oxycodone oxycodone/acetaminophen oxycodone/acetaminophen Tier Restrictions 2 [QLL, 90/30][ST] 3 3 3 3 3 1 3 3 1 3 3 CLASS III NARCOTICS acetaminophen-codeine apap-caffeine-dihydrocodeine buprenorphine hcl tablet sublingual SUBOXONE buprenorphine/naloxone 1 1 1 2 1 3 3 1 1 1 3 3 3 3 1 3 3 3 3 1 1 2 SUBUTEX [G] buprenorphine 3 CAPITAL W-CODEINE codeine phosphate/apap co-gesic DOLOREX FORTE [INJ] HYCET hydrocodone bitartrate/apap hydrocodone bitartrate/apap hydrocodone bit-ibuprofen hydrocodone-acetaminophen hydrogesic IBUDONE LORCET 10-650 [G] LORCET PLUS [G] LORTAB [G] hydrocodone hydrocodone hydrocodone hydrocodone bitartrate/ibuprof bitartrate/apap bitartrate/apap bitartrate/apap margesic h MAXIDONE [G] NORCO [G] PANLOR DC PANLOR SS [G] hydrocodone bitartrate/apap hydrocodone bitartrate/apap dihydrocodeine/apap/caffeine dihydrocodeine/apap/caffeine reprexain stagesic S7950_2011_DOC7aPC [QLL, 102/34] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug SYNALGOS-DC Generic dihydrocodeine/asa/caffeine trezix TYLENOL-CODEINE NO.3 [G] TYLENOL-CODEINE NO.4 [G] VICODIN [G] VICODIN ES [G] VICODIN HP [G] VICOPROFEN [G] VOPAC XODOL 10-300 XODOL 5-300 XODOL 7.5-300 codeine phosphate/apap codeine phosphate/apap hydrocodone bitartrate/apap hydrocodone bitartrate/apap hydrocodone bitartrate/apap hydrocodone bitartrate/ibuprof codeine phosphate/apap hydrocodone bitartrate/apap hydrocodone bitartrate/apap hydrocodone bitartrate/apap zamicet ZERLOR [G] ZYDONE dihydrocodeine/apap/caffeine hydrocodone bitartrate/apap Tier 3 1 3 3 3 3 3 3 3 3 3 3 1 3 3 Restrictions CNS STIMULANT DRUGS ADDERALL [G] ADDERALL XR amphetamine/dextroamphetamine 3 amphetamine/dextroamphetamine 3 amphetamine salt combo CAFCIT INJECTION [INJ] caffeine citrate injection [INJ] CONCERTA DAYTRANA DESOXYN [G] DEXEDRINE [G] caffeine citrated methylphenidate methylphenidate methamphetamine d-amphetamine dexmethylphenidate hcl dextroamphetamine sulfate dextroamphetamine-amphetamine FOCALIN [G] FOCALIN XR dexmethylphenidate dexmethylphenidate liquadd METADATE CD METADATE ER 10 MG TABLET SA metadate er 20 mg tablet methamphetamine hcl S7950_2011_DOC7aPC methylphenidate methylphenidate 1 3 1 2 3 3 3 1 1 1 3 3 1 2 2 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug METHYLIN 10 MG CHEWABLE TABLET, -2.5 MG CHEWABLE TAB, 5 MG CHEWABLE TABLET, SOLUTION methylin 10 mg tablet, -20 mg tablet, -5 mg tablet methylin er methylphenidate er methylphenidate hcl solution, -tablet methylphenidate sr NUVIGIL PROCENTRA PROVIGIL RITALIN [G] RITALIN LA RITALIN-SR [G] VYVANSE Generic methylphenidate Tier 3 Restrictions 1 armodafinil d-amphetamine modafinil methylphenidate methylphenidate methylphenidate lisdexamfetamine dimesylate 1 1 1 1 3 3 2 3 3 3 3 [PAR] [PAR] DRUGS TO PREVENT AND TREAT HEADACHES naratriptan 3 AXERT 12.5 MG TABLET almotriptan 1 3 AXERT 6.25 MG TABLET almotriptan 3 AMERGE [G] ascomp with codeine butalbital compound-codeine butalbital-caff-apap-codeine butorphanol tartrate aerosol spray CAFERGOT [G] D.H.E.45 [INJ][G] dihydroergotamine mesylate injection [INJ] ERGOMAR 1 1 1 ergotamine tartrate/caffeine dihydroergotamine 3 4 1 ergotamine 3 1 3 3 ergotamine-caffeine FIORICET WITH CODEINE [G] FIORINAL WITH CODEINE #3 [G] S7950_2011_DOC7aPC codeine/apap/caffeine/butalb codeine/asa/caffeine/butalb [QLL, 18/28] [QLL, 24/28] [QLL, 18/28] [QLL, 5 ml/3] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic FROVA frovatriptan IMITREX 20 MG NASAL SPRAY sumatriptan IMITREX 4 MG/0.5 ML SYRNG KIT, 6 MG/0.5 ML SYRNG KIT [INJ] IMITREX 5 MG NASAL SPRAY sumatriptan Tier Restrictions 2 [QLL, 27/28] 3 [QLL, 18 nasal sprayers/28] 3 [QLL, 8/28] sumatriptan 3 IMITREX 6 MG/0.5 ML VIAL, -4 MG/0.5 ML KIT REFILL, -6 MG/0.5 ML KIT REFILL [INJ][G] IMITREX TABLET [G] sumatriptan 3 sumatriptan 3 MAXALT rizatriptan benzoate 2 MAXALT MLT rizatriptan benzoate 2 dihydroergotamine 1 2 migergot MIGRANAL naratriptan hcl 1 RELPAX eletriptan 3 SUMATRIPTAN 20 MG NASAL SPRAY sumatriptan 3 sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml kit, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng [INJ] sumatriptan 4 mg/0.5 ml vial, -6 mg/0.5 ml vial [INJ] SUMATRIPTAN 5 MG NASAL SPRAY 1 1 sumatriptan sumatriptan succinate tablet TREXIMET S7950_2011_DOC7aPC 3 1 sumatriptan suc/naproxen sod 3 [QLL, 36 nasal sprayers/28] [QLL, 8 vials/28] [QLL, 18/28] [QLL, 27/28] [QLL, 27/28] [QLL, 16 mg/28] [QLL, 18/28] [QLL, 18/28] [QLL, 18/28] [QLL, 8/28] [QLL, 8 ml/28] [QLL, 36/28] [QLL, 18/28] [QLL, 18/28] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ZOMIG SPRAY NON-AEROSOL zolmitriptan ZOMIG TABLET zolmitriptan ZOMIG ZMT zolmitriptan Generic Tier Restrictions 2 [QLL, 18 nasal sprayers/28] 3 [QLL, 18/28] 3 [QLL, 18/28] HYDANTOINS CEREBYX [INJ] DILANTIN 100 MG CAPSULE [G] DILANTIN 30 MG CAPSULE, -30 MG KAPSEAL, -TABLET CHEWABLE DILANTIN-125 [G] fosphenytoin sodium [INJ] PEGANONE PHENYTEK [G] fosphenytoin phenytoin sodium phenytoin 3 3 2 phenytoin sodium 3 1 2 3 1 1 1 ethotoin phenytoin sodium phenytoin sodium extended phenytoin sodium injection [INJ] phenytoin suspension oral MAO INHIBITORS EMSAM MARPLAN NARDIL PARNATE selegiline isocarboxazid phenelzine tranylcypromine 2 2 2 3 1 rufinamide rufinamide felbamate 2 4 2 1 2 2 3 3 tranylcypromine sulfate OTHER ANTICONVULSANTS BANZEL 200 MG TABLET BANZEL 400 MG TABLET FELBATOL gabapentin capsule, -tablet GABITRIL KEPPRA INJECTION [INJ][G] KEPPRA SOLUTION, -TABLET [G] KEPPRA XR S7950_2011_DOC7aPC tiagabine levetiracetam levetiracetam levetiracetam [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL LAMICTAL [G] (BLUE) (GREEN) [G] (ORANGE) [G] ODT ODT (BLUE) ODT (GREEN) ODT (ORANGE) XR XR (BLUE) XR (GREEN) XR (ORANGE) lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine lamotrigine Generic lamotrigine levetiracetam injection [INJ] levetiracetam solution, -tablet LYRICA MYSOLINE [G] NEURONTIN CAPSULE, -TABLET [G] NEURONTIN SOLUTION pregabalin primidone gabapentin gabapentin primidone SABRIL [LA] TOPAMAX [G] vigabatrin topiramate topiragen topiramate capsule sprinkle, -tablet VIMPAT INJECTION [INJ] VIMPAT SOLUTION, -TABLET ZONEGRAN [G] lacosamide lacosamide zonisamide zonisamide Tier 3 3 3 3 3 3 3 3 3 3 3 3 1 1 1 2 3 3 2 1 4 3 1 1 2 2 3 1 Restrictions [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [PAR] [PAR] [PAR] [PAR] [PAR] OTHER ANTIDEPRESSANTS amitriptyline-chlordiazepoxide APLENZIN bupropion hbr 1 3 budeprion sr 1 budeprion xl 1 bupropion hcl 1 S7950_2011_DOC7aPC [QLL, 34/34][ST] [QLL, 68/34] [QLL, 34/34] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug bupropion hcl sr 100 mg tab, -100 mg tablet, -200 mg tab bupropion sr 150 mg tablet bupropion xl Generic CYMBALTA 20 MG CAPSULE, -60 MG CAPSULE CYMBALTA 30 MG CAPSULE duloxetine EFFEXOR venlafaxine EFFEXOR XR 150 MG CAPSULE, 37.5 MG CAPSULE [G] EFFEXOR XR 75 MG CAPSULE [G] venlafaxine LIMBITROL amitriptyline/chlordiazepoxide duloxetine venlafaxine maprotiline hcl mirtazapine nefazodone hcl OLEPTRO ER trazodone perphenazine-amitriptyline PRISTIQ desvenlafaxine succinate REMERON [G] SAVELLA 100 MG TABLET, -12.5 MG TABLET, -25 MG TABLET, -50 MG TABLET SAVELLA TITRATION PACK mirtazapine milnacipran hcl milnacipran hcl Tier Restrictions 1 [QLL, 68/34] 1 1 [QLL, 34/34] 2 [QLL, 68/34][ST] 2 [QLL, 34/34][ST] 3 [QLL, 102/34][ST] 2 [QLL, 34/34][ST] 2 [QLL, 102/34][ST] 3 1 1 1 3 1 2 [QLL, 34/34][ST] 3 2 [QLL, 68/34][ST] 2 trazodone hcl tablet venlafaxine hcl 1 1 venlafaxine hcl er capsule sustained release 24 hr 1 VENLAFAXINE HCL ER TAB SA venlafaxine 3 WELLBUTRIN WELLBUTRIN SR [G] bupropion bupropion 3 3 WELLBUTRIN XL [G] bupropion 3 S7950_2011_DOC7aPC [QLL, 1/34][ST] [QLL, 102/34] [QLL, 34/34] [QLL, 34/34][ST] [QLL, 68/34][ST] [QLL, 34/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions OTHER ANTIPARKINSON DRUGS APOKYN [INJ][LA] AZILECT apomorphine hcl rasagiline mesylate bromocriptine mesylate capsule, tablet carbidopa-levodopa COMTAN ELDEPRYL LODOSYN MIRAPEX [G] MIRAPEX ER PARCOPA [G] PARLODEL [G] entacapone selegiline carbidopa pramipexole pramipexole carbidopa/levodopa bromocriptine mesylate pramipexole dihydrochloride REQUIP [G] REQUIP XL ropinirole ropinirole ropinirole hcl selegiline hcl capsule, -tablet SINEMET 10-100 [G] SINEMET 25-100 [G] SINEMET 25-250 [G] SINEMET CR [G] STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 STALEVO 50 STALEVO 75 TASMAR ZELAPAR carbidopa/levodopa carbidopa/levodopa carbidopa/levodopa carbidopa/levodopa carbidopa/levodopa/entacap carbidopa/levodopa/entacap carbidopa/levodopa/entacap carbidopa/levodopa/entacap carbidopa/levodopa/entacap carbidopa/levodopa/entacap tolcapone selegiline 4 2 1 1 2 3 2 3 3 3 3 1 3 2 1 1 3 3 3 3 2 2 2 2 2 2 2 3 OTHER CNS/AUTONOMIC DRUGS ANTABUSE disulfiram atropine sulfate injection [INJ] CAMPRAL depade S7950_2011_DOC7aPC acamprosate calcium 2 1 3 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ENLON [INJ] ENLON-PLUS [INJ] flumazenil [INJ] Generic edrophonium edrophonium/atropine sulfate guanidine hcl INTUNIV MESTINON SYRUP, -TABLET SUSTAINED ACTION MESTINON TABLET [G] MYTELASE naloxone hcl injection [INJ] guanfacine pyridostigmine pyridostigmine ambenonium chloride 3 3 1 1 1 1 neostigmine bromide 2 1 3 3 3 2 4 4 4 naltrexone hcl tablet neostigmine methylsulfate [INJ] physostigmine salicylate injection [INJ] PROSTIGMIN pyridostigmine bromide REGONOL [INJ] REVIA [G] ROMAZICON [INJ] STRATTERA VIVITROL [INJ] XENAZINE [LA] XYREM [LA] Tier Restrictions 2 2 1 1 3 [ST] 2 pyridostigmine naltrexone flumazenil atomoxetine naltrexone microspheres tetrabenazine sodium oxybate [ST] [PAR] SECONDARY AMINES amoxapine desipramine hcl protriptyline 1 1 3 1 3 1 3 AMBIEN [G] zolpidem 3 AMBIEN CR zolpidem 2 NORPRAMIN [G] desipramine nortriptyline hcl capsule, -solution PAMELOR [G] nortriptyline protriptyline hcl VIVACTIL [G] SEDATIVE/HYPNOTIC DRUGS S7950_2011_DOC7aPC [QLL, 34/34][ST] [QLL, 34/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic EDLUAR zolpidem LUNESTA eszopiclone ROZEREM ramelteon SONATA 10 MG CAPSULE [G] zaleplon SONATA 5 MG CAPSULE [G] zaleplon zaleplon 10 mg capsule zaleplon 5 mg capsule zolpidem tartrate Tier Restrictions 3 [QLL, 34/34][ST] 2 [QLL, 34/34][ST] 2 [QLL, 34/34][ST] 3 [QLL, 68/34][ST] 3 [QLL, 34/34][ST] 1 [QLL, 68/34] 1 [QLL, 34/34] 1 [QLL, 34/34] SELECTIVE SEROTONIN REUPTAKE INHIBITORS CELEXA SOLUTION CELEXA TABLET [G] citalopram citalopram 3 3 citalopram citalopram hbr 1 1 fluoxetine dr fluoxetine hcl 10 mg capsule, -10 mg tablet fluoxetine hcl 20 mg capsule, -20 mg tablet, -solution fluoxetine hcl 40 mg capsule 1 1 fluvoxamine maleate 100 mg tab 1 fluvoxamine maleate 25 mg tab 1 fluvoxamine maleate 50 mg tab 1 LEXAPRO SOLUTION LEXAPRO TABLET S7950_2011_DOC7aPC [ST] [QLL, 34/34][ST] [QLL, 34/34] [QLL, 5/34] [QLL, 34/34] 1 1 escitalopram oxalate escitalopram oxalate 2 2 [QLL, 68/34] [QLL, 102/34] [QLL, 34/34] [QLL, 68/34] [ST] [QLL, 34/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug PAXIL 10 MG TABLET, -40 MG TABLET [G] PAXIL 20 MG TABLET, -30 MG TABLET [G] PAXIL CR [G] paroxetine PAXIL SUSPENSION ORAL [G] PEXEVA 10 MG TABLET, -40 MG TABLET PEXEVA 20 MG TABLET, -30 MG TABLET PROZAC 10 MG PULVULE [G] paroxetine paroxetine mesylate PROZAC 20 MG PULVULE, SOLUTION [G] PROZAC 40 MG PULVULE [G] fluoxetine Tier Restrictions 3 [QLL, 68/34][ST] 1 [QLL, 34/34] 1 [QLL, 68/34] 1 3 [QLL, 34/34][ST] 3 [QLL, 68/34][ST] 3 [QLL, 68/34][ST] 3 [ST] 3 [QLL, 34/34][ST] 3 [QLL, 68/34][ST] 3 [QLL, 34/34][ST] 3 [ST] fluoxetine 3 PROZAC WEEKLY [G] fluoxetine 3 SARAFEM 10 MG TABLET fluoxetine 1 3 SARAFEM 15 MG TABLET SARAFEM 20 MG TABLET fluoxetine fluoxetine 3 3 LUVOX CR fluvoxamine Generic paroxetine hcl 10 mg tablet, -40 mg tablet paroxetine hcl 20 mg tablet, -30 mg tablet, -tablet sustained release 24hr paroxetine hcl suspension oral paroxetine paroxetine paroxetine mesylate fluoxetine rapiflux 20 mg tablet selfemra 10 mg capsule 1 selfemra 20 mg capsule 1 sertraline hcl 100 mg tablet, -50 mg tablet sertraline hcl 25 mg tablet 1 sertraline hcl solution 1 S7950_2011_DOC7aPC 1 [QLL, 68/34][ST] [QLL, 5/34][ST] [QLL, 35/14][ST] [ST] [QLL, 140/14][ST] [QLL, 35/14] [QLL, 140/14] [QLL, 68/34] [QLL, 34/34] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ZOLOFT 100 MG TABLET, -50 MG TABLET [G] ZOLOFT 25 MG TABLET [G] ZOLOFT SOLUTION [G] Generic sertraline Tier Restrictions 3 [QLL, 68/34][ST] 3 [QLL, 34/34][ST] 3 [ST] varenicline tartrate nicotine inhaler nicotine ns bupropion 1 2 2 2 3 sertraline sertraline SMOKING CESSATION PRODUCTS buproban CHANTIX NICOTROL NICOTROL NS ZYBAN [G] SUCCINIMIDES CELONTIN methsuximide ethosuximide ZARONTIN [G] ethosuximide 2 1 3 TERTIARY AMINES amitriptyline hcl tablet ANAFRANIL [G] clomipramine clomipramine hcl capsule doxepin hcl capsule, -solution imipramine hcl tablet imipramine pamoate SURMONTIL TOFRANIL [G] TOFRANIL-PM [G] trimipramine imipramine hcl imipramine pamoate trimipramine maleate 1 3 1 1 1 1 2 3 3 1 VALPROIC ACID AND DERIVATIVES DEPACON [INJ][G] DEPAKENE [G] DEPAKOTE [G] DEPAKOTE ER [G] S7950_2011_DOC7aPC valproate sodium valproic acid divalproex divalproex 3 3 3 3 [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug DEPAKOTE SPRINKLE [G] divalproex sodium divalproex sodium er STAVZOR valproate sodium injection [INJ] valproic acid capsule, -syrup divalproex Generic valproic acid Tier Restrictions 3 [ST] 1 1 3 [ST] 1 1 CARDIOVASCULAR MEDICATIONS AMIODARONES amiodarone hcl injection [INJ] amiodarone hcl tablet CORDARONE [G] PACERONE 100 MG TABLET, -400 MG TABLET [G] amiodarone amiodarone pacerone 200 mg tablet 1 1 3 3 1 ANGIOTENSIN CONVERTING ENZYME INHIBITORS ACCUPRIL [G] ACEON [G] ALTACE [G] quinapril perindopril erbumine ramipril benazepril hcl CAPOTEN captopril captopril tablet enalapril maleate tablet enalaprilat [INJ] fosinopril sodium lisinopril tablet LOTENSIN [G] MAVIK [G] benazepril trandolapril moexipril hcl MONOPRIL fosinopril perindopril erbumine PRINIVIL [G] lisinopril quinapril hcl ramipril trandolapril UNIVASC [G] S7950_2011_DOC7aPC moexipril 3 3 3 1 3 1 1 1 1 1 3 3 1 3 1 3 1 1 1 3 [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug VASOTEC [G] ZESTRIL [G] Generic enalapril lisinopril Tier Restrictions 3 [ST] 3 [ST] ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND AVAPRO BENICAR COZAAR [G] DIOVAN candesartan cilexetil irbesartan olmesartan medoxomil losartan valsartan losartan potassium MICARDIS TEVETEN telmisartan eprosartan mesylate 3 3 2 3 2 1 3 3 [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] ANTIDYSRHYTHMIC DRUGS flecainide acetate mexiletine hcl capsule procainamide hcl injection [INJ] PRONESTYL propafenone hcl quinidine gluconate injection [INJ] quinidine gluconate tablet sustained action quinidine sulfate tablet, -tablet sustained action RYTHMOL [G] RYTHMOL SR TAMBOCOR [G] procainamide 1 1 1 3 1 1 1 1 propafenone propafenone flecainide 3 2 3 BETA-ADRENERGIC ANTAGONIST DRUGS acebutolol hcl capsule atenolol tablet betaxolol hcl tablet bisoprolol fumarate BYSTOLIC nebivolol hcl carvedilol COREG [G] COREG CR S7950_2011_DOC7aPC carvedilol carvedilol 1 1 1 1 2 1 3 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug CORGARD [G] INDERAL LA [G] INNOPRAN XL KERLONE [G] nadolol propranolol propranolol betaxolol Generic labetalol hcl injection [INJ] labetalol hcl tablet LEVATOL LOPRESSOR INJECTION [INJ][G] LOPRESSOR TABLET [G] penbutolol metoprolol tartrate metoprolol tartrate metoprolol succinate metoprolol tartrate injection [INJ] metoprolol tartrate tablet nadolol pindolol propranolol hcl cap sa, -solution, tablet propranolol hcl injection [INJ] SECTRAL [G] TENORMIN [G] acebutolol atenolol timolol maleate tablet TOPROL XL [G] TRANDATE [G] ZEBETA [G] metoprolol succinate labetalol bisoprolol Tier 3 3 3 3 1 1 3 3 3 1 1 1 1 1 1 Restrictions 1 3 3 1 3 3 3 CALCIUM ANTAGONISTS ADALAT CC [G] nifedipine afeditab cr amlodipine besylate CALAN [G] CALAN SR [G] CARDIZEM [G] CARDIZEM CD [G] CARDIZEM LA verapamil verapamil diltiazem diltiazem diltiazem cartia xt COVERA-HS DILACOR XR [G] dilt-cd diltia xt diltiazem 24hr er S7950_2011_DOC7aPC verapamil diltiazem 3 1 1 3 3 3 3 3 1 3 3 1 1 1 [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic diltiazem er diltiazem hcl injection [INJ] diltiazem hcl tablet dilt-xr diltzac er DYNACIRC CR isradipine felodipine er ISOPTIN SR [G] verapamil isradipine nicardipine hcl capsule nicardipine hcl injection [INJ] nifediac cc nifedical xl nifedipine capsule nifedipine er nimodipine NIMOTOP [INJ] NISOLDIPINE ER 17 MG TABLET, ER 25.5 MG TABLET, -ER 34 MG TABLET, -ER 8.5 MG TABLET nisoldipine er 20 mg tablet, -er 30 mg tablet, -er 40 mg tablet NORVASC [G] PROCARDIA [G] PROCARDIA XL [G] SULAR nimodipine nisoldipine 1 amlodipine nifedipine nifedipine nisoldipine taztia xt TIAZAC [G] diltiazem verapamil 360 mg cap pellet verapamil er verapamil hcl capsule 24hr sustained release pellets, -er 120 mg capsule, -er 180 mg capsule, -er 240 mg capsule, -tablet, -tablet sustained action verapamil hcl injection [INJ] VERELAN [G] VERELAN PM [G] S7950_2011_DOC7aPC Tier Restrictions 1 1 1 1 1 3 [ST] 1 3 [ST] 1 1 1 1 1 1 1 4 3 3 [ST] verapamil verapamil 3 3 3 3 1 3 1 1 1 1 3 3 [ST] [ST] [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic CARDIAC GLYCOSIDES digoxin injection [INJ] digoxin solution, -tablet LANOXIN INJECTION [INJ][G] LANOXIN PEDIATRIC [INJ] LANOXIN TABLET [G] milrinone in 5% dextrose [INJ] milrinone lactate [INJ] Tier Restrictions 1 1 3 2 3 1 1 digoxin digoxin digoxin CENTRALLY ACTING ANTIHYPERTENSIVES CATAPRES [G] CATAPRES-TTS 1 [G] CATAPRES-TTS 2 [G] CATAPRES-TTS 3 [G] clonidine clonidine clonidine clonidine clonidine clonidine hcl injection [INJ] clonidine hcl tablet DURACLON [INJ] clonidine guanabenz acetate guanfacine hcl methyldopa methyldopate hcl [INJ] TENEX [G] guanfacine 3 3 3 3 1 1 1 2 1 1 1 1 3 [QLL, [QLL, [QLL, [QLL, 5/35] 5/35] 5/35] 5/35] DRUGS FOR PHEOCHROMOCYTOMA DEMSER DIBENZYLINE PHENTOLAMINE MESYLATE INJECTION [INJ] metyrosine phenoxybenzamine phentolamine 2 2 2 ENDOTHELIN RECPTR ANTAGONIST LETAIRIS [LA] TRACLEER [LA] S7950_2011_DOC7aPC ambrisentan bosentan 4 4 [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic HMG-COA REDUCTASE INHIBITORS ADVICOR 1,000 MG-20 MG TABLET, lovastatin/niacin -1,000 MG-40 MG TABLET, -750 MG20 MG TABLET ADVICOR 500 MG-20 MG TABLET lovastatin/niacin Tier Restrictions 2 [QLL, 68/34] 2 [QLL, 34/34] [QLL, 34/34][ST] [QLL, 34/34][ST] [QLL, 34/34] [QLL, 34/34][ST] [QLL, 34/34][ST] [QLL, 68/34][ST] [QLL, 34/34][ST] [QLL, 34/34][ST] [QLL, 34/34][ST] [QLL, 34/34] [QLL, 68/34] [QLL, 68/34][ST] [QLL, 34/34][ST] [QLL, 34/34] [QLL, 68/34] [QLL, 34/34] [QLL, 34/34] ALTOPREV lovastatin 3 CADUET amlodipine/atorvast cal 3 CRESTOR 10 MG TABLET, -20 MG TABLET, -40 MG TABLET CRESTOR 5 MG TABLET rosuvastatin calcium 2 rosuvastatin calcium 2 LESCOL 20 MG CAPSULE fluvastatin 3 LESCOL 40 MG CAPSULE fluvastatin 3 LESCOL XL fluvastatin 3 LIPITOR atorvastatin calcium 2 LIVALO pitavastatin calcium 3 lovastatin 10 mg tablet 1 lovastatin 20 mg tablet, -40 mg tablet 1 MEVACOR [G] lovastatin 3 PRAVACHOL [G] pravastatin 3 pravastatin sodium SIMCOR 1,000-20 MG TABLET, 750-20 MG TABLET SIMCOR 500-20 MG TABLET simvastatin tablet S7950_2011_DOC7aPC 1 niacin/simvastatin 2 niacin/simvastatin 2 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug VYTORIN 10-10 MG TABLET Generic ezetimibe/simvastatin VYTORIN 10-20 MG TABLET, -10-40 MG TABLET, -10-80 MG TABLET ZOCOR [G] ezetimibe/simvastatin simvastatin Tier Restrictions 2 [QLL, 34/34][ST] 2 [QLL, 34/34] 3 [QLL, 34/34][ST] HYPOLIPOPROTEINEMICS ANTARA fenofibrate cholestyramine/sucrose cholestyramine/aspartame fenofibrate fenofibrate fenofibric acid colesevelam ezetimibe 3 1 1 3 1 1 3 3 3 1 3 3 3 2 3 2 1 3 3 2 3 2 2 2 torsemide ethacrynic acid 1 1 3 3 cholestyramine cholestyramine light COLESTID [G] colestipol colestipol hcl fenofibrate FENOFIBRIC ACID FENOGLIDE FIBRICOR fenofibric acid fenofibrate fenofibric acid gemfibrozil LIPOFEN LOFIBRA [G] LOPID [G] LOVAZA NIACOR NIASPAN fenofibrate fenofibrate gemfibrozil omega-3 acid ethyl esters niacin niacin prevalite QUESTRAN [G] QUESTRAN LIGHT [G] TRICOR TRIGLIDE TRILIPIX WELCHOL ZETIA [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] LOOP DIURETICS bumetanide injection [INJ] bumetanide tablet DEMADEX [G] EDECRIN S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug furosemide injection [INJ] furosemide solution, -tablet LASIX [G] SODIUM EDECRIN [INJ] torsemide injection [INJ] torsemide tablet Generic furosemide ethacrynate sodium Tier 1 1 3 3 1 1 Restrictions NITRATES DILATRATE-SR IMDUR [G] ISMO [G] ISOCHRON [G] ISORDIL ISORDIL TITRADOSE [G] isosorbide dinitrate isosorbide mononitrate isosorbide mononitrate isosorbide dinitrate isosorbide dinitrate isosorbide dinitrate isosorbide dinitrate isosorbide mononitrate MINITRAN [G] MONOKET [G] nitroglycerin isosorbide mononitrate nitro-bid NITRO-DUR [G] nitroglycerin nitroglycerin in d5w [INJ] nitroglycerin injection [INJ] nitroglycerin patch nitroglycerin tablet sublingual NITROLINGUAL NITROMIST nitroglycerin nitroglycerin nitroquick NITROSTAT nitroglycerin 2 3 3 3 3 3 1 1 3 3 1 3 1 1 1 1 2 3 1 2 OTHER ANTIARRHYTHMICS BETAPACE [G] BETAPACE AF [G] CORVERT [INJ] sotalol sotalol ibutilide fumarate ibutilide fumarate [INJ] lidocaine hcl 10% vial [INJ] MULTAQ sorine S7950_2011_DOC7aPC dronedarone 3 3 2 1 1 3 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary sotalol sotalol af Drug SOTALOL HCL [INJ] TIKOSYN Generic sotalol dofetilide Tier 1 1 3 2 Restrictions 3 1 3 1 3 2 1 1 2 1 1 1 2 3 3 2 1 2 2 1 1 3 1 1 3 1 3 3 1 1 3 1 [ST] OTHER ANTIHYPERTENSIVES ACCURETIC [G] quinapril/hctz amlodipine besylate-benazepril ATACAND HCT candesartan cilexetil/hctz atenolol-chlorthalidone AVALIDE AZOR irbesartan/hctz amlodipine bes/olmesartan med benazepril hcl-hctz benazepril-hydrochlorothiazide BENICAR HCT olmesartan medoxomil/hctz bisoprolol fumarate-hctz bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide CLORPRES CORLOPAM [INJ] CORZIDE [G] DIOVAN HCT clonidine hcl/chlorthalidone fenoldopam mesylate bendroflumethiazide/nadolol hctz/valsartan enalapril-hydrochlorothiazide EXFORGE EXFORGE HCT amlodipine/valsartan amlodipine/valsartan/hctz fosinopril-hydrochlorothiazide hydra-zide HYZAAR [G] losartan /hctz lisinopril-hctz lisinopril-hydrochlorothiazide LOPRESSOR HCT [G] hctz/metoprolol losartan-hydrochlorothiazide LOTENSIN HCT [G] LOTREL [G] benazepril/hctz benazepril/amlodipine besylate methyldopa-hydrochlorothiazide metoprolol-hydrochlorothiazide MICARDIS HCT moexipril-hydrochlorothiazide S7950_2011_DOC7aPC telmisartan/hctz [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug nadolol-bendroflumethiazide PRINZIDE [G] propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide quinaretic reserpine TARKA [G] TEKTURNA TEKTURNA HCT TENORETIC 100 [G] TENORETIC 50 [G] TEVETEN HCT trandolapril-verapamil TRIBENZOR TWYNSTA UNIRETIC [G] VALTURNA VASERETIC [G] ZESTORETIC [G] ZIAC [G] Generic lisinopril/hctz trandolapril/verapamil aliskiren hemifumarate aliskiren/hydrochlorothiazid chlorthalidone/atenolol chlorthalidone/atenolol eprosartan mesylate/hctz olmesartan med/amlodipine/hct telmisartan/amlodipine moexipril/hctz aliskiren/valsartan enalapril maleate/hctz lisinopril/hctz hctz/bisoprolol fumarate Tier 1 3 1 1 1 1 3 2 2 3 3 3 1 3 3 3 3 3 3 3 Restrictions [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] OTHER CARDIOVASCULAR DRUGS alprostadil injection [INJ] dobutamine hcl [INJ] dobutamine hcl in dextrose [INJ] dopamine hcl [INJ] dopamine hcl in 5% dextrose [INJ] isoproterenol hcl [INJ] ISUPREL [INJ] isoproterenol hcl midodrine hcl norepinephrine bitartrate [INJ] pentopak pentoxifylline tablet sustained action pentoxil PROAMATINE [G] PROSTIN VR PEDIATRIC [INJ] RANEXA TRENTAL [G] S7950_2011_DOC7aPC midodrine alprostadil ranolazine pentoxifylline 1 1 1 1 1 1 3 1 1 1 1 1 3 3 2 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions [PAR][QLL, 68/34] OTHER VASODILATING DRUGS ADCIRCA adcirca (tadalafil) 4 BIDIL isosorb dinit/hydralazine hcl 3 1 3 3 4 4 4 epoprostenol sodium [INJ] FLOLAN [INJ] NATRECOR [INJ] REMODULIN [INJ][LA] REVATIO INJECTION [INJ] REVATIO TABLET epoprostenol na nesiritide treprostinil sodium revatio (sildenafil citrate) revatio (sildenafil citrate) [PAR][QLL, 102/34] POTASSIUM SPARING DIURETICS ALDACTAZIDE [G] ALDACTONE [G] spironolactone/hctz spironolactone amiloride hcl tablet amiloride-hydrochlorothiazide DYAZIDE [G] DYRENIUM hctz/triamterene triamterene eplerenone INSPRA [G] MAXZIDE [G] MAXZIDE-25 MG [G] MIDAMOR eplerenone hctz/triamterene hctz/triamterene amiloride hydrochloride spironolactone tablet spironolactone-hctz triamterene-hctz 3 3 1 1 3 3 1 3 3 3 3 1 1 1 THIAZIDE AND RELATED DRUGS chlorothiazide chlorothiazide sodium [INJ] chlorthalidone DIURIL DIURIL SODIUM [INJ][G] hydrochlorothiazide capsule, -tablet indapamide S7950_2011_DOC7aPC chlorothiazide chlorothiazide sodium 1 4 1 3 3 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug methyclothiazide tablet metolazone MICROZIDE [G] NATURETIN-5 THALITONE ZAROXOLYN [G] Generic hydrochlorothiazide bendroflumethiazide chlorthalidone metolazone Tier 1 1 3 3 3 3 Restrictions [QLL, 34/34] [QLL, 68/34] [QLL, 34/34] [QLL, 34/34] [QLL, 68/34] VASODILATOR ANTIHYPERTENSIVES CARDURA 1 MG TABLET, -2 MG TABLET, -4 MG TABLET [G] CARDURA 8 MG TABLET [G] doxazosin 3 doxazosin 3 CARDURA XL doxazosin 3 doxazosin mesylate 1 mg tab, -2 mg tab, -4 mg tab doxazosin mesylate 8 mg tab 1 hydralazine hcl injection [INJ] hydralazine hcl tablet 1 1 3 1 1 1 MINIPRESS [G] 1 prazosin minoxidil tablet prazosin hcl terazosin 1 mg capsule, -2 mg capsule, -5 mg capsule terazosin 10 mg capsule 1 [QLL, 34/34] [QLL, 68/34] DERMATOLOGICAL MEDICATIONS ANTIACNE DRUGS ACANYA ACZONE clindamycin phos/benz per dapsone adapalene AKNE-MYCIN ATRALIN AVAR AVAR LS AVAR-E S7950_2011_DOC7aPC erythromycin base tretinoin sulfacetamide/sulfur sulfacetamide/sulfur sulfacetamide/sulfur 3 3 1 3 3 3 3 3 [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug AVAR-E GREEN AVAR-E LS CREAM AVITA [G] AZELEX BENZACLIN BENZAMYCIN BENZAMYCINPAK Generic sulfacetamide/sulfur sulfacetamide/sulfur tretinoin azelaic acid clindamycin/benz per/hyalur na erythromycin base/benz per erythromycin base/benz per bp 10-1 CLARIFOAM EF sulfacetamide/sulfur clenia cleanser CLENIA CREAM CLEOCIN T [G] sulfacetamide/sulfur clindamycin phosphate clinda-derm CLINDAGEL CLINDAMAX GEL, -LOTION [INJ] clindamycin phosphate clindamycin phosphate clindamycin phosphate foam, -gel, lotion, -solution non-oral, -swab medicated clindamycin-benzoyl peroxide CLINDAREACH CLINDETS [INJ] DIFFERIN [G] DUAC CS EMGEL [INJ] EPIDUO clindamycin phosphate clindamycin phosphate adapalene clindamycin/benzoyl prx/skn #5 erythromycin base adapalene/benzoyl peroxide ery erythromycin gel, -solution non-oral erythromycin-benzoyl peroxide EVOCLIN [G] FINACEA METROCREAM [G] METROGEL METROLOTION [G] clindamycin phosphate azelaic acid metronidazole metronidazole metronidazole metronidazole cream, -gel, -lotion NORITATE PLEXION metronidazole sulfacetamide/sulfur prascion prascion fc prascion ts RETIN-A [G] S7950_2011_DOC7aPC tretinoin Tier Restrictions 3 3 3 [PAR] 3 3 3 3 1 3 1 3 3 1 3 3 1 1 3 3 3 3 3 3 1 1 1 3 2 3 2 3 1 3 3 1 1 1 3 [PAR] [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug RETIN-A MICRO RETIN-A MICRO PUMP rosaderm cleanser sodium sulfacetamide-sulfur cleanser, -foam, -pads medicated, sulfacetamide-sulfur lotn, -sulf-sulfur wash, -suspensions, (not oral) sulfatol c sulzee SUMAXIN topisulf tretinoin 0.025% cream, -0.05% cream, -0.1% cream, -gel TRETIN-X vitazol ZIANA tretinoin tretinoin Generic sulfacetamide/sulfur tretinoin/emol cmb9/skin cln1 Tier Restrictions 3 [PAR] 3 [PAR] 1 1 1 1 3 1 1 clindamycin/tretinoin 3 1 3 hydroxyzine pamoate 1 1 1 3 [PAR] [PAR] [PAR] ANTIPRURITIC DRUGS hydroxyzine hcl injection [INJ] hydroxyzine hcl syrup, -tablet hydroxyzine pamoate capsule VISTARIL [G] [PAR] [PAR] [PAR] ANTIPSORIASIS AND ANTIECZEMA DRUGS calcipotriene DOVONEX CREAM DOVONEX SOLUTION DRITHOCREME HP DRITHO-SCALP KLARON [G] calcipotriene calcipotriene anthralin anthralin sulfacetamide sodium seb-prev 10% cream, -10% gel selenium sulfide 2.25% shampoo, 2.5% lotion, -sulf 2.5% shampoo selenos SELSEB SORIATANE SORIATANE CK 10 MG KIT SORIATANE CK 25 MG KIT S7950_2011_DOC7aPC selenium sulfide acitretin acitretin/emollient comb acitretin/emollient comb 1 2 3 2 3 3 1 1 1 3 4 2 4 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug sulfacetamide sodium lotion, suspension topical TACLONEX TACLONEX SCALP TAZORAC TERSI FOAM VECTICAL ZITHRANOL-RR Generic Tier 1 betamet diprop/calcipotriene betamet diprop/calcipotriene tazarotene selenium sulfide calcitriol anthralin 3 3 2 3 3 3 podofilox podofilox 2 3 Restrictions [PAR] KERATOLYTIC DRUGS CONDYLOX GEL CONDYLOX SOLUTION NON-ORAL [G] podofilox 1 ORAL DERMATOLOGICAL DRUGS 8-MOP ACCUTANE methoxsalen isotretinoin amnesteem claravis OXSORALEN-ULTRA methoxsalen sotret 4 3 1 1 4 1 SCABICIDES acticin ELIMITE EURAX LINDANE permethrin crotamiton benzene hexachloride gamma malathion OVIDE [G] malathion permethrin cream ULESFIA benzyl alcohol 1 3 2 2 1 3 1 3 TOPICAL ANTI-INFLAMMATORY DRUGS FLECTOR S7950_2011_DOC7aPC diclofenac epolamine 2 [QLL, 60/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug PENNSAID VOLTAREN GEL Generic diclofenac sodium diclofenac sodium Tier Restrictions 3 [ST] 2 [ST] TOPICAL CORTICOSTEROID DRUGS ACLOVATE [G] ALA-CORT [G] ALA-SCALP HP alclometasone hydrocortisone hydrocortisone alclometasone dipropionate amcinonide ANAMANTLE HC CREAM WITH APPLICATOR, -KIT ANAMANTLE HC FORTE APEXICON [INJ] APEXICON E hc acetate/lidocaine hcl hc acetate/lidocaine hcl diflorasone diflorasone betamethasone dipropionate cream, -gel, -lotion, -ointment betamethasone valerate cream, lotion, -ointment betanate beta-val CAPEX SHAMPOO CARMOL HC clobetasol emollient clobetasol propionate cream, -foam, -gel, -ointment, -solution non-oral CLOBEX CLODERM CORDRAN LOTION, -OINTMENT CORDRAN SP CORDRAN TAPE MEDICATED fluocinolone acetonide hydrocortisone acetate/urea 1 1 3 3 1 1 clobetasol propionate clocortolone pivalate flurandrenolide flurandrenolide flurandrenolide 3 3 3 3 3 fluticasone propionate del-beta DERMA-SMOOTHE-FS DERMATOP [G] DESONATE desonide cream, -lotion, -ointment S7950_2011_DOC7aPC 3 3 3 1 [ST] [ST] [ST] [ST] 1 cormax CUTIVATE [G] 3 3 3 1 1 3 fluocinolone acetonide prednicarbate desonide 1 3 1 3 3 3 1 [ST] [ST] [ST] [ST] [ST] [QLL, 900 square cm/34][ST] [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug DESOWEN Generic desonide/emollient combo #30 desoximetasone cream, -gel, ointment diflorasone diacetate DIPROLENE [G] DIPROLENE AF [G] DIPROSONE ELOCON [G] FIRST-HYDROCORTISONE betameth/propylene glycol betameth/propylene glycol betamethasone dipropionate mometasone hydrocortisone fluocinolone acetonide cream, ointment, -solution non-oral fluocinonide cream, -gel, -ointment, -solution non-oral fluocinonide emollient fluocinonide-e fluticasone propionate cream, ointment halobetasol propionate HALOG HALONATE lidazone hc lidocaine-hc lidocaine-hydrocortisone cream, cream with applicator, -kit, -lotion LOCOID [G] LOCOID LIPOCREAM LOKARA [G] LUXIQ S7950_2011_DOC7aPC [ST] [ST] [ST] [ST] 1 1 1 halcinonide halobetasol prop/amonium lac triamcinolone acetonide hc acetate/lidocaine hcl hydrocortisone butyrate hydrocortisone butyrate desonide betamethasone valerate mometasone furoate MOMEXIN 1 3 3 3 3 3 1 1 halonate pac hydrocortisone 1% absorbase, -1% cream, -1% lotion, -1% oin, -1% oint, -1% ointment, -2.5% cream, 2.5% lotion, -2.5% ointment, -aloe 1% cream, -plus 1% cream hydrocortisone butyrate hydrocortisone valerate KENALOG LIDAMANTLE HC Tier Restrictions 3 [ST] 1 mometasone furoat/ammonium l 1 3 3 1 1 1 1 3 3 1 1 1 3 3 3 3 1 3 [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug OLUX OLUX-E OLUX-OLUX-E PANDEL PEDIADERM HC PERANEX HC PADS MEDICATED Generic clobetasol propionate clobetasol propionate clobetasol propionate hydrocortisone buteprate hydrocortisone/emol no.45 hc acetate/lidocaine hcl prednicarbate SCALACORT TEMOVATE [G] TEMOVATE EMOLLIENT TEXACORT TOPICORT [G] TOPICORT LP [G] hydrocortisone clobetasol propionate clobetasol propionate hydrocortisone desoximetasone desoximetasone triamcinolone acetonide cream, lotion, -ointment triderm TRIDESILON U-CORT ULTRAVATE [G] ULTRAVATE PAC VANOS VERDESO WESTCORT [G] desonide hydrocortisone acetate/urea halobetasol propionate halobetasol prop/amonium lac fluocinonide desonide hydrocortisone valerate Tier 3 3 3 3 3 3 1 3 3 3 3 3 3 1 1 3 3 3 3 3 3 3 Restrictions [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] TOPICAL DERMATOLOGICAL DRUGS ALDARA [G] ammonium lactate 12% cream, 12% lotion CARAC imiquimod 3 1 fluorouracil 3 1 3 3 2 2 1 cerovel DRYSOL EFUDEX [G] ELIDEL FLUOROPLEX fluorouracil cream, -solution nonoral GORDO-UREA HYDRO 35 HYDRO 40 S7950_2011_DOC7aPC aluminum chloride hexahydrate fluorouracil pimecrolimus fluorouracil urea urea urea [ST] 3 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary hypercare imiquimod Drug KERAFOAM Generic urea keratol 40 keratol plus LAC-HYDRIN [G] LACLOTION [G] LEVULAN METVIXIA OXSORALEN PANRETIN PROTOPIC PRUDOXIN REGRANEX lactate, ammonium lactate, ammonium aminolevulinic acid hcl methyl aminolevulinate hcl methoxsalen alitretinoin tacrolimus doxepin becaplermin remeven re-u40 SANTYL SOLARAZE collagenase diclofenac sodium u-kera e urea emollient UMECTA UMECTA PD URAMAXIN urea 40 urea 40% cream, -40% nail film susp, -45% cream, -50% cream, 50% nail stick, -50% nailstik, -foam, -gel, -kit, -lotion, -ointment, towelette urealac cream, -gel, -lotion, -soln, top VEREGEN XERAC AC urea urea urea 1 sinecatechins aluminum chloride hexahydrate x-viate ZONALON ZYCLARA S7950_2011_DOC7aPC Tier Restrictions 1 1 3 1 1 3 3 3 3 2 4 2 [ST] 2 2 [PAR][QLL, 30 gm/34] 1 1 2 2 [PAR] 1 3 3 3 1 1 doxepin imiquimod 3 3 1 2 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS DIAGNOSTIC PRODUCTS CHEMET EXJADE [LA] succimer deferasirox 2 4 pegademase bovine aminocaproic acid aminocaproic acid 4 3 3 1 1 3 4 3 4 4 MISCELLANEOUS DRUGS ADAGEN [INJ][LA] AMICAR SYRUP [INJ] AMICAR TABLET aminocaproic acid injection [INJ] aminocaproic acid syrup, -tablet AMMONUL [INJ] AMPYRA [LA] ANTIZOL [INJ][G] BUPHENYL COPAXONE [INJ] sodium benzoate/na ph-acetate dalfampridine fomepizole sodium phenylbutyrate glatiramer acetate CYKLOKAPRON [INJ] ENDRATE [INJ] tranexamic acid endrate disodium hetastarch/e-lytes,lactate 2 3 1 1 3 1 3 tranexamic acid nitisinone hemin pralidoxime chloride sodium tetradecyl sulfate thalidomide hetastarch/na chlor 0.9% collagenase clostridium hist. 3 4 3 2 3 4 3 4 ergoloid mesylates tablet fomepizole [INJ] HESPAN [INJ] hetastarch/na chlor 0.9% hetastarch in ns [INJ] HEXTEND LACTATED ELECTROLYTE [INJ] LYSTEDA ORFADIN [LA] PANHEMATIN [INJ] PROTOPAM CHLORIDE [INJ] SOTRADECOL [INJ] THALOMID VOLUVEN [INJ] XIAFLEX [INJ][LA] S7950_2011_DOC7aPC [PAR] [PAR][QLL, 30 ml/30] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions EAR-NOSE-THROAT MEDICATIONS DRUGS AFFECTING THE EAR aabp a-b otic acetasol hc acetic acid solution non-oral acetic acid-aluminum acetic acid-hydrocortisone antipyrine-benzocaine aurodex aurodex ear drops auroguard BENZOTIC antipyrine/benzocaine borofair chloroxylenol-pramoxine hcl CIPRO HC ciprofloxacin/hc CIPRODEX ciprofloxacin/dexameth COLY-MYCIN S neomycin sulfate/colist sul/hc CORTISPORIN SUSPENSION DROPS, neomycin sulfate/polymyxin/hc -SOLUTION NON-ORAL [G] CORTISPORIN-TC neomycin/colist sul/hc/thonz cortomycin solution non-oral, suspension drops DERMOTIC DOMEBORO DROPS [INJ] FLOXIN fluocinolone acetonide acetic acid/aluminum acetate ofloxacin neomycin-polymyxin-hc solution, solution non-oral, -suspension drops ofloxacin drops otic edge oticin hc ear solution, -suspension drops otocidin otomycet-hc PEDIOTIC neomycin suf/polymy/buffers/hc pramoxine hcl/chloroxylenol treagan otic VOSOL [G] S7950_2011_DOC7aPC 3 1 2 3 3 1 1 1 1 pr otic solution PRAMOTIC 1 1 1 1 1 1 1 1 1 1 3 1 1 3 2 3 3 acetic acid 1 1 3 1 3 1 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug VOSOL HC [INJ] Generic acetic acid/hydrocortisone Tier 3 Restrictions ASTELIN [G] azelastine hcl 3 ASTEPRO 0.15% NASAL SPRAY azelastine hcl 2 ASTEPRO 137 MCG NASAL SPRAY azelastine hcl 2 ATROVENT 0.03% SPRAY [G] ipratropium 3 ATROVENT 0.06% SPRAY [G] ipratropium 3 [QLL, 60 ml/34] [QLL, 60 ml/34] [QLL, 60/34] [QLL, 60 ml/34] [QLL, 30 ml/34] [QLL, 60 ml/34] [QLL, 50 gm/34] [QLL, 32 gm/34] [QLL, 75 ml/34] [QLL, 75/34] [QLL, 32 gm/34] [QLL, 60 ml/34] [QLL, 30 ml/34] [QLL, 33 gm/34] [QLL, 75/34] [QLL, 51 gm/34] [QLL, 25 gm/34] [QLL, 61 gm/34] DRUGS AFFECTING THE NOSE azelastine hcl aerosol spray w/pump 1 BECONASE AQ beclomethasone 3 FLONASE [G] fluticasone propionate 3 flunisolide 0.025% spray 1 flunisolide 29 mcg-0.025% spr 1 fluticasone propionate nasal inhaled steroids ipratropium 0.03% spray 1 ipratropium 0.06% spray 1 1 NASACORT AQ triamcinolone acetonide 2 NASAREL flunisolide 3 NASONEX mometasone 3 OMNARIS ciclesonide 3 PATANASE olopatadine hcl 3 S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug RHINOCORT AQUA Generic budesonide TYZINE VERAMYST tetrahydrozoline fluticasone furoate Tier Restrictions 3 [QLL, 26 gm/34] 2 2 [QLL, 20 gm/34] DRUGS AFFECTING THE THROAT AND MOUTH APHTHASOL ARESTIN amlexanox minocycline lidocaine 3 3 1 3 1 3 2 3 3 1 1 3 1 1 3 1 3 methimazole 1 1 1 3 chlorhexidine gluconate mouthwash DEBACTEROL sulfuric acid/sulf phenol doxycycline hyclate 20 mg tab EVOXAC FIRST-MOUTHWASH BLM ORALONE ORASEP cevimeline mag hydrox/alh/smc/dpha/lido triamcinolone acetonide b-caine/tan ac/menth/cpyrd oraxyl periogard PERIOSTAT [G] doxycycline hyclate perisol pilocarpine hcl tablet SALAGEN [G] pilocarpine hcl triamcinolone acetonide paste XYLOCAINE 2% VIAL [INJ] ENDOCRINE MEDICATIONS ANTITHYROID DRUGS methimazole tablet northyx propylthiouracil TAPAZOLE [G] GLUCOCORTICOID DRUGS A-HYDROCORT [INJ] a-methapred [INJ] ARISTOSPAN [INJ] S7950_2011_DOC7aPC hydrocortisone sod succinate triamcinolone hexacetonide 3 1 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug baycadron betamethasone acetate-sod phos [INJ] CELESTONE INJECTION [INJ] CELESTONE SOLUTION ORAL CORTEF [G] Generic betamethasone/betamethasone betamethasone hydrocortisone cortisone tablet DEPO-MEDROL [INJ][G] dexamethasone elixir, -solution oral, -tablet dexamethasone intensol dexamethasone sodium phosphate injection [INJ] DEXPAK [G] methylprednisolone acetate dexamethasone triamcinolone acetonide triamcinolone acetonide methylprednisolone meprolone unipak methylprednisolone acetate injection [INJ] methylprednisolone sod succ [INJ] methylprednisolone tablet, -tablet dose pack MILLIPRED MILLIPRED DP ORAPRED [G] ORAPRED ODT PEDIAPRED [G] prednisolone sodium phosphate solution prednisolone solution oral prednisone intensol prednisone solution, -tablet, -tablet dose pack PRELONE [G] SOLU-CORTEF [INJ] SOLU-CORTEF (PF) [INJ] SOLU-MEDROL [INJ][G] SOLU-MEDROL (PF) [INJ] S7950_2011_DOC7aPC Restrictions 2 2 3 1 3 1 1 1 hydrocortisone tablet KENALOG-10 [INJ] KENALOG-40 [INJ] MEDROL [G] Tier 1 1 3 1 3 3 3 1 1 1 1 prednisolone prednisolone prednisolone sod phosphate prednisolone sod phosphate prednisolone sod phosphate 3 3 3 3 3 1 1 1 1 prednisolone hydrocortisone sod succinate hydrocortisone sod succinate methylprednisolone sod succ methylprednisolone sod succ 3 3 3 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug triamcinolone acetonide injection Tier 3 3 1 veripred 20 zema-pak 1 1 STERAPRED STERAPRED DS prednisone prednisone Generic Restrictions [INJ] GLUCOSE ELEVATING DRUGS glucagon, human recombinant glucagon, human recombinant diazoxide 2 2 2 BYETTA 10 MCG DOSE PEN INJ [INJ] BYETTA 5 MCG DOSE PEN INJ [INJ] exenatide 2 exenatide 2 SYMLIN [INJ] pramlintide acetate 2 SYMLINPEN 120 [INJ] pramlintide acetate 2 SYMLINPEN 60 [INJ] pramlintide acetate 2 VICTOZA 2-PAK [INJ] liraglutide 3 VICTOZA 3-PAK [INJ] liraglutide 3 GLUCAGEN [INJ] GLUCAGON EMERGENCY KIT [INJ] PROGLYCEM HYPOGLYCEMIC DRUGS [PAR][QLL, 5 ml/34] [PAR][QLL, 2 ml/34] [PAR][QLL, 35 ml/34] [PAR][QLL, 22 ml/34] [PAR][QLL, 12 pens/34] [PAR][QLL, 3/30] [PAR][QLL, 3 pens/30] INSULIN APIDRA [INJ] APIDRA SOLOSTAR [INJ] HUMALOG [INJ] HUMALOG MIX 50-50 [INJ] HUMALOG MIX 75-25 [INJ] HUMULIN 50-50 [INJ] HUMULIN 70-30 [INJ] HUMULIN N [INJ] S7950_2011_DOC7aPC 3 3 2 2 2 2 2 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug HUMULIN R [INJ] LANTUS [INJ] LANTUS SOLOSTAR [INJ] LEVEMIR [INJ] NOVOLIN 70-30 100 UNIT/ML VIAL, -U100 CARTRIDGE [INJ] NOVOLIN 70-30 INNOLET [INJ] NOVOLIN N 100 UNIT/ML INNOLET, -100 UNITS/ML CARTRDG, -100 UNITS/ML VIAL [INJ] NOVOLIN R 100 UNIT/ML CARTRIDG, -100 UNIT/ML INNOLET, -100 UNITS/ML VIAL [INJ] NOVOLOG [INJ] NOVOLOG MIX 70-30 [INJ] RELION NOVOLIN 70-30 VIAL, RELION VIAL [INJ] RELION NOVOLIN N 100 UNITS/ML, -RELION 100 UNITS/ML [INJ] RELION NOVOLIN R 100 UNITS/ML [INJ] Generic Tier 2 2 2 2 2 Restrictions 2 2 2 2 2 3 3 3 MINERALOCORTICOID DRUGS fludrocortisone acetate tablet 1 ORAL HYPOGLYCEMICS AND COMBOS acarbose ACTOPLUS MET pioglitazone hcl/metformin hc 1 2 ACTOPLUS MET XR 15-1,000 MG TB pioglitazone hcl/metformin hc 2 ACTOPLUS MET XR 30-1,000 MG TB pioglitazone hcl/metformin hc 2 ACTOS pioglitazone hcl 2 AMARYL [G] AVANDAMET glimepiride rosiglitazone/metformin hcl 3 2 S7950_2011_DOC7aPC [QLL, 102/34][ST] [QLL, 68/34][ST] [QLL, 34/34][ST] [QLL, 34/34][ST] [QLL, 68/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug AVANDARYL Generic rosiglitazone maleate/glimepir AVANDIA 2 MG TABLET, -4 MG TABLET AVANDIA 8 MG TABLET rosiglitazone maleate DIABETA DUETACT glyburide pioglitazone/glimepiride FORTAMET metformin rosiglitazone maleate glimepiride glipizide er glipizide tablet glipizide xl glipizide-metformin GLUCOPHAGE [G] GLUCOPHAGE XR [G] GLUCOTROL [G] GLUCOTROL XL [G] GLUCOVANCE [G] GLUMETZA metformin metformin glipizide glipizide glyburide/metformin hcl metformin glyburide glyburide micronized glyburide-metformin hcl glycron GLYNASE [G] GLYSET JANUMET glyburide miglitol sitagliptin phos/metformin hcl JANUVIA sitagliptin phosphate METAGLIP [G] glipizide/metformin hcl metformin hcl metformin hcl er nateglinide ONGLYZA saxagliptin hydrochloride PRANDIMET repaglinide/metformin hcl PRANDIN repaglinide S7950_2011_DOC7aPC Tier Restrictions 2 [QLL, 34/34][ST] 2 [QLL, 68/34][ST] 2 [QLL, 34/34][ST] 3 2 [QLL, 34/34][ST] 3 [ST] 1 1 1 1 1 3 [ST] 3 [ST] 3 3 3 3 [ST] 1 1 1 1 3 3 2 [QLL, 68/34] 2 [QLL, 34/34] 3 1 1 1 2 [QLL, 34/34] 3 [QLL, 170/34] 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug PRECOSE [G] RIOMET STARLIX [G] acarbose metformin nateglinide Generic tolazamide tolbutamide Tier Restrictions 3 2 [ST] 3 1 1 OTHER ENDOCRINE DRUGS ACTHAR H.P. [INJ] ACTHREL [INJ] ACTONEL 150 MG TABLET corticotropin corticorelin ovine triflutate risedronate 4 3 2 ACTONEL 30 MG TABLET, -5 MG TABLET ACTONEL 35 MG TABLET risedronate 2 risedronate 2 ACTONEL 75 MG TABLET risedronate 2 ACTONEL WITH CALCIUM risedron sod/calcium carbona 2 ALDURAZYME [INJ][LA] laronidase 4 1 alendronate sodium 10 mg tab, -40 mg tab, -5 mg tablet alendronate sodium 35 mg tab, -70 mg tab 1 AREDIA 30 MG VIAL [INJ][G] AREDIA 90 MG VIAL [INJ][G] BONIVA 150 MG TABLET pamidronate disodium pamidronate disodium ibandronate 3 4 2 BONIVA 2.5 MG TABLET ibandronate 2 BONIVA INJECTION [INJ] ibandronate 3 1 cabergoline calcitonin-salmon CEREDASE [INJ][LA] CEREZYME [INJ][LA] DDAVP 4 MCG/ML AMPUL [INJ][G] DDAVP 4 MCG/ML VIAL [INJ][G] DDAVP SOLUTION, -AEROSOL SPRAY W/PUMP, -TABLET [G] S7950_2011_DOC7aPC alglucerase imiglucerase desmopressin acetate desmopressin acetate desmopressin acetate 1 4 4 4 3 3 [QLL, 1/34][ST] [QLL, 34/34][ST] [QLL, 5/35][ST] [QLL, 2/34][ST] [QLL, 35/35][ST] [QLL, 34/34] [QLL, 5/35] [QLL, 1/34][ST] [QLL, 34/34][ST] [PAR] [QLL, 20/34] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug desmopressin acetate aerosol spray w/pump, -solution, -tablet desmopressin acetate injection [INJ] DIDRONEL [G] ELAPRASE [INJ][LA] etidronate disodium EVISTA FABRAZYME [INJ][LA] FORTEO [INJ] Generic Tier 1 raloxifene agalsidase teriparatide 1 3 4 1 2 4 2 FOSAMAX 10 MG TABLET, -40 MG TABLET, -5 MG TABLET [G] FOSAMAX 35 MG TABLET, -70 MG TABLET [G] FOSAMAX PLUS D alendronate 1 3 alendronate 3 alendronate/vitamin d3 3 FOSAMAX SOLUTION alendronate 3 KUVAN [LA] LUMIZYME [INJ][LA] MIACALCIN AEROSOL SPRAY W/PUMP [G] MIACALCIN INJECTION [INJ] MYOZYME [INJ][LA] NAGLAZYME [INJ][LA] pamidronate disodium [INJ] PROLIA [INJ] RECLAST [INJ] SAMSCA sapropterin dihydrochloride alglucosidase alfa calcitonin 4 4 3 calcitonin alglucosidase alfa galsulfase denosumab zoledronic acid tolvaptan 2 4 4 1 3 4 4 SENSIPAR SKELID SOMAVERT [INJ][LA] STIMATE VPRIV [INJ] ZAVESCA [LA] ZOMETA [INJ] cinacalcet hcl tiludronate pegvisomant desmopressin acetate velaglucerase alfa miglustat zoledronic acid 2 3 4 3 4 4 4 etidronate idursulfase fortical S7950_2011_DOC7aPC Restrictions [PAR] [PAR][QLL, 1/28] [QLL, 34/34][ST] [QLL, 5/35][ST] [QLL, 5/35][ST] [QLL, 375 ml/35][ST] [PAR] [PAR][QLL, 68/34] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic THYROID SUPPLEMENTS ARMOUR THYROID CYTOMEL [G] thyroid liothyronine levothroid levothyroxine sodium injection [INJ] levothyroxine sodium tablet levoxyl liothyronine sodium injection [INJ] liothyronine sodium tablet nature-throid SYNTHROID [G] levothyroxine thyroid tablet THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 TIROSINT TRIOSTAT [INJ] liotrix liotrix liotrix liotrix liotrix levothyroxine liothyronine unithroid westhroid Tier Restrictions 2 3 1 1 1 1 1 1 1 3 1 2 2 2 2 2 3 3 1 1 GASTROINTESTINAL MEDICATIONS ANTIDIARRHEAL DRUGS diphenoxylate-atropine LOMOTIL [G] diphenoxylate/atropine sulfate lonox loperamide capsule MOTOFEN difenoxin/atropine sulfate paregoric 1 3 1 1 3 1 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY BENTYL CAPSULE, -SYRUP, -TABLET [G] BENTYL INJECTION [INJ] CANTIL S7950_2011_DOC7aPC dicyclomine 3 dicyclomine mepenzolate 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug dicyclomine hcl capsule, -syrup, tablet dicyclomine hcl injection [INJ] glycopyrrolate injection [INJ] glycopyrrolate tablet methscopolamine bromide metoclopramide hcl injection [INJ] metoclopramide hcl solution oral, tablet METOZOLV ODT PAMINE [G] PAMINE FORTE [G] propantheline bromide REGLAN INJECTION [INJ][G] REGLAN TABLET [G] ROBINUL FORTE [G] ROBINUL INJECTION [INJ][G] ROBINUL TABLET [G] SCOPOLAMINE HYDROBROMIDE INJECTION [INJ] Generic Tier 1 Restrictions 1 1 1 1 1 1 metoclopramide methscopolamine methscopolamine metoclopramide metoclopramide glycopyrrolate glycopyrrolate glycopyrrolate scopolamine 3 3 3 1 3 3 3 3 3 3 ANTIULCER DRUGS AXID [G] nizatidine 3 1 cimetidine 200 mg tablet, -300 mg tablet, -400 mg tablet, -800 mg tablet, -solution cimetidine injection [INJ] famotidine 20 mg tablet, -40 mg tablet, -suspension oral famotidine injection [INJ] nizatidine PEPCID INJECTION [INJ] PEPCID SUSPENSION ORAL, TABLET [G] 1 1 famotidine famotidine ranitidine 150 mg tablet, -300 mg tablet, -capsule, -syrup ranitidine hcl injection [INJ] ZANTAC 25 ZANTAC INJECTION [INJ][G] S7950_2011_DOC7aPC 1 1 3 3 1 ranitidine ranitidine 1 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ZANTAC SYRUP, -TABLET [G] Generic ranitidine Tier 3 Restrictions IRRITABLE BOWEL DRUGS AMITIZA LOTRONEX lubiprostone alosetron 2 4 sodium phosphate/na biphos 1 2 1 sodium phosphate/na biphos 2 sucralfate sucralfate misoprostol 2 3 3 1 1 ursodiol hydrocortisone mesalamine mesalamine mesalamine sulfasalazine 3 3 2 2 2 3 1 2 4 3 3 3 3 LAXATIVES AND CATHARTICS glycerin liquid OSMOPREP polyethylene glycol 3350, -pkt, powd VISICOL OTHER ANTIULCER DRUGS CARAFATE SUSPENSION ORAL CARAFATE TABLET [G] CYTOTEC [G] misoprostol sucralfate suspension oral, -tablet OTHER GI DRUGS ACTIGALL [G] ANUSOL-HC [G] APRISO ASACOL ASACOL HD AZULFIDINE [G] balsalazide disodium CANASA CHENODAL [LA] COLAZAL [G] COLOCORT [G] COLYTE COLYTE WITH FLAVOR PACKETS [INJ] S7950_2011_DOC7aPC mesalamine chenodiol balsalazide disodium hydrocortisone electrolyte solution/peg's electrolyte solution/peg's © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic CORTENEMA [G] hydrocortisone CORTIFOAM hydrocortisone acetate CREON amylase/lipase/protease DIPENTUM olsalazine ENTOCORT EC budesonide ENZYMAX 500 MG TABLET enzymes, digestive gavilyte-c gavilyte-g gavilyte-n GOLYTELY [G] electrolyte solution/peg's HALFLYTELY-BISACODYL electrolyte solution/peg's HELIDAC tetracyc hcl/bis ss/metronid hydrocortisone enema LIALDA mesalamine mesalamine MOVIPREP electrolyte solution/peg's NULYTELY WITH FLAVOR PACKS [G] electrolyte solution/peg's OCL electrolyte solution/peg's PANCREAZE amylase/lipase/protease PANCRELIPASE 5,000 amylase/lipase/protease peg 3350-electrolyte peg-3350 and electrolytes peg-3350 with flavor packs PENTASA mesalamine PREVPAC lansoprazole/amox tr/clarith PROCTOCORT [G] PROCTOCREAM-HC [G] hydrocortisone hydrocortisone procto-pak proctosol-hc proctozone-hc PYLERA RELISTOR [INJ] ROWASA [G] SFROWASA [INJ] sulfasalazine dr sulfasalazine tablet sulfazine sulfazine ec trilyte with flavor packets S7950_2011_DOC7aPC bismuth/metronid/tetracyclin methylnaltrexone bromide mesalamine mesalamine Tier Restrictions 3 2 2 3 2 2 1 1 1 3 3 3 1 3 1 2 3 2 3 3 1 1 1 2 3 [QLL, 14/14] 3 3 1 1 1 2 2 3 3 1 1 1 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Restrictions amylase/lipase/protease Tier 3 3 1 3 ACIPHEX DEXILANT DR 30 MG CAPSULE rabeprazole sodium dexlansoprazole 3 3 DEXILANT DR 60 MG CAPSULE KAPIDEX DR 30 MG CAPSULE dexlansoprazole dexlansoprazole 3 3 KAPIDEX DR 60 MG CAPSULE dexlansoprazole 3 1 [ST] [QLL, 34/34][ST] [ST] [QLL, 34/34][ST] [ST] [QLL, 34/34] URSO [G] URSO FORTE [G] Generic ursodiol ursodiol ursodiol capsule, -tablet ZENPEP PROTON PUMP INHIBITORS lansoprazole dr 15 mg capsule lansoprazole dr 30 mg capsule NEXIUM 10 MG PACKET, -20 MG CAPSULE, -20 MG PACKET NEXIUM 40 MG CAPSULE, -40 MG PACKET NEXIUM I.V. [INJ] esomeprazole mag trihyd 1 2 esomeprazole mag trihyd 2 esomeprazole mag trihyd 2 1 omeprazole dr 10 mg capsule omeprazole dr 20 mg capsule, -dr 40 mg capsule omeprazole-bicarb 20-1,100 cap 1 omeprazole-bicarb 40-1,100 cap pantoprazole sod dr 20 mg tab 1 1 pantoprazole sod dr 40 mg tab lansoprazole 1 3 lansoprazole 3 omeprazole 3 omeprazole magnesium-legend 3 PREVACID 30 MG CAPSULE DR, -30 MG SOLUTAB, -DR 30 MG CAPSULE PREVACID DR 15 MG CAPSULE, -15 MG SOLUTAB [G] PRILOSEC DR 10 MG CAPSULE, -DR 20 MG CAPSULE [G] PRILOSEC DR 40 MG CAPSULE, -PKT [G] S7950_2011_DOC7aPC 1 [QLL, 34/34][ST] [ST] [QLL, 34/34] [QLL, 34/34] [QLL, 34/34][ST] [ST] [ST] [QLL, 34/34][ST] [QLL, 34/34][ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug PROTONIX DR 20 MG TABLET [G] PROTONIX DR 40 MG TABLET, -PKT [G] PROTONIX IV [INJ] ZEGERID 20 MG CAPSULE [G] pantoprazole Tier Restrictions 3 [QLL, 34/34][ST] 3 [ST] pantoprazole omeprazole/sodium bicarbonat 3 3 ZEGERID 20 MG PACKET omeprazole/sodium bicarbonat 3 ZEGERID 40 MG CAPSULE [G] ZEGERID 40 MG PACKET omeprazole/sodium bicarbonat omeprazole/sodium bicarbonat 3 3 [QLL, 34/34][ST] [QLL, 34/34][ST] [ST] [ST] somatropin 4 [PAR] somatropin 3 [PAR] somatropin somatropin somatropin somatropin somatropin somatropin somatropin somatropin somatropin somatropin somatropin somatropin 4 4 4 4 4 4 4 4 4 4 4 4 [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] haemophilus b-tet toxoid 2 pantoprazole Generic IMMUNOLOGICALS AND VACCINES GROWTH HORMONES AND RELATED DRUGS GENOTROPIN 12 MG CARTRIDGE, 5 MG CARTRIDGE [INJ] GENOTROPIN MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, -MINIQUICK 0.8 MG, MINIQUICK 1 MG, -MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, -MINIQUICK 2 MG [INJ] HUMATROPE [INJ] NORDITROPIN [INJ] NORDITROPIN FLEXPRO [INJ] NORDITROPIN NORDIFLEX [INJ] NUTROPIN [INJ] NUTROPIN AQ [INJ] NUTROPIN AQ NUSPIN [INJ] OMNITROPE [INJ] SAIZEN [INJ] SEROSTIM [INJ][LA] TEV-TROPIN [INJ] ZORBTIVE [INJ][LA] IMMUNOLOGICALS AND VACCINES ACTHIB [INJ] S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ADACEL [INJ] ARANESP 100 MCG/0.5 ML AUTOINJ, -100 MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL, -150 MCG/0.3 ML AUTOINJ, -150 MCG/0.3 ML SYRINGE, -150 MCG/0.75 ML VIAL, -200 MCG/0.4 ML AUTOINJ, -200 MCG/0.4 ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6 ML AUTOINJ, -300 MCG/0.6 M [INJ] ARANESP 25 MCG/0.42 ML AUTOINJ, -25 MCG/0.42 ML SYRING, -25 MCG/ML VIAL, -40 MCG/0.4 ML AUTOINJ, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML VIAL [INJ] ATGAM [INJ] ATTENUVAX VACCINE WITH DILUENT [INJ] BOOSTRIX [INJ] CARIMUNE NF NANOFILTERED [INJ] CERVARIX [INJ] COMVAX [INJ] DAPTACEL [INJ] DIPHTHERIA-TETANUS TOXOID [INJ] ENGERIX-B [INJ] EPOGEN 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL [INJ] EPOGEN 2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL [INJ] GAMASTAN S-D [INJ] GAMMAGARD LIQUID [INJ] GAMMAGARD S-D [INJ] GAMUNEX [INJ] GARDASIL [INJ] HAVRIX [INJ] S7950_2011_DOC7aPC Generic diphther,pertuss,tetanus vac darbepoetin alfa Tier Restrictions 2 4 [PAR] darbepoetin alfa 2 [PAR] lymphocyte immune globulin measles vaccine,atten 4 2 [PAR] diphther,pertuss,tetanus vac immune globulin - iv human papillomav vacc bival/pf hepatitis b/haemophilus b vacc diphther,pertuss,tetanus vac tetanus,diphtheria toxoid 2 4 2 2 2 2 hepatitis b virus vaccine epoetin alfa 2 4 [PAR] epoetin alfa 3 [PAR] immune globulin - im immune globulin - iv immune globulin - iv immune globulin - iv human papillomavirus vacc hepatatis a virus vaccine 2 4 4 4 2 2 [PAR] [PAR] [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug HEPAGAM B [INJ] HIBERIX [INJ] HIBTITER [INJ] HIZENTRA 1 GRAM/5 ML VIAL [INJ] HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20 ML VIAL [INJ] HYPERHEP B S-D [INJ] HYPERRAB S-D [INJ] HYPERRHO S-D [INJ] HYPERTET S-D [INJ] IMOGAM RABIES-HT [INJ] IMOVAX RABIES VACCINE [INJ] INFANRIX [INJ] IPOL [INJ] IXIARO [INJ] JE-VAX [INJ] KEPIVANCE [INJ][LA] MENACTRA [INJ] MENOMUNE-A-C-Y-W-135 [INJ] MENVEO A-C-Y-W-135-DIP MERUVAX II VACCINE W-DILUENT [INJ] MICRHOGAM [INJ] MICRHOGAM PLUS [INJ] M-M-R II VACCINE [INJ] MOZOBIL [INJ] MUMPSVAX VACCINE W-DILUENT [INJ] OCTAGAM [INJ] PEDIARIX [INJ] PEDVAXHIB [INJ] PENTACEL [INJ] PRIVIGEN [INJ] PROCRIT 10,000 UNITS/ML VIAL, 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL [INJ] PROCRIT 20,000 UNITS/ML VIAL, 40,000 UNITS/ML VIAL [INJ] PROQUAD [INJ] S7950_2011_DOC7aPC Generic hep.b immune glob/maltose haemophilus b-tet toxoid haemophilus b vaccine immune globulin- sq immune globulin- sq Tier Restrictions 3 3 2 2 [PAR] 4 [PAR] hepatitis b immune globulin rabies immune globulin rho(d) immune globulin tetanus immune globulin rabies immune globulin rabies vaccine,human diploid diphther,pertuss,tetanus vac poliomyelitis vac,killed japanese encephalitis vaccine japanese encephalitis vaccine palifermin meningococcal vac a,c,y,w-135 meningococcal vac a,c,y,w-135 mening vac a,c,y,w-135 dip rubella vaccine 2 3 2 3 2 2 2 2 2 2 4 2 2 3 2 rho(d) immune globulin rho(d) immune globulin measles,mumps&rubella vaccine plerixafor mumps vaccine,live 3 3 2 4 2 immune globulin - iv hep b vaccine/dp (a) t-polio haemophilus b vaccine dp (a) t-polio/hib conj-tet/pf immune globulin - iv epoetin alfa 4 2 2 3 4 2 [PAR] epoetin alfa 4 [PAR] measles,mumps,rub,varicella 2 [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug RABAVERT [INJ] RECOMBIVAX HB [INJ] RHOGAM RHOGAM PLUS [INJ] RHOPHYLAC [INJ] ROTARIX ROTATEQ SYNAGIS [INJ][LA] TETANUS DIPHTHERIA TOXOIDS [INJ] tetanus toxoid adsorbed [INJ] TETANUS-DIPHTERIA-DECAVAC [INJ] THYMOGLOBULIN [INJ] TICE BCG [INJ] TRIHIBIT [INJ] TRIPEDIA [INJ] TWINRIX [INJ] TYPHIM VI [INJ] VAQTA [INJ] VARIVAX VACCINE [INJ] VIVAGLOBIN [INJ] WINRHO SDF [INJ] YF-VAX [INJ] ZOSTAVAX [INJ] Generic rabies vac,pf chick-emb cell hepatitis b virus vaccine rho(d) immune globulin rho(d) immune globulin rho(d) immune globulin rotavirus vac, live att, 89-12 rotavirus vac, live pentav palivizumab tetanus,diphtheria toxoid Tier 2 2 3 3 3 3 2 4 2 Restrictions tetanus,diphtheria toxoid 1 2 lymphocyte immune globulin bcg vaccine dp (a) ped/hib conj-tet diphther,pertuss,tetanus vac hep b vir recomb/hep a vir typhoid vaccine hepatatis a virus vaccine varicella virus vaccine live immune globulin- sq rho(d) immune globulin yellow fever vaccine varicella vacc/pf 4 2 2 2 2 2 2 2 4 3 2 2 [PAR] mecasermin 4 [PAR] ACTIMMUNE [INJ][LA] AVONEX [INJ] interferon gamma-1b,recomb. interferon beta-1a 4 4 AVONEX ADMINISTRATION PACK [INJ] BETASERON [INJ] interferon beta-1a 4 interferon beta-1b 4 [PAR] INSULIN LIKE GROWTH FACTORS-1 INCRELEX [INJ][LA] INTERFERONS S7950_2011_DOC7aPC [PAR][QLL, 4 kits/28] [PAR][QLL, 4 kits/28] [PAR][QLL, 15/30] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug INFERGEN [INJ] INTRON A 10 MILLION UNIT PEN, 10 MILLION UNIT/ML, -18 MILLION UNITS VIAL, -5 MILLION UNIT/ML PEN, -50 MILLION UNITS VIAL, -6 MILLION UNIT/ML VL [INJ] INTRON A 10 MILLION UNITS VIAL, -3 MILLION UNIT/ML PEN [INJ] PEGASYS 180 MCG/0.5 ML CONV.PK [INJ] interferon alfacon-1 interferon alfa-2b , recomb. Tier Restrictions 4 [PAR][QLL, 15 trays/30] 4 4 interferon alfa-2b , recomb. 2 peginterferon alfa-2a 4 PEGASYS 180 MCG/ML VIAL [INJ] peginterferon alfa-2a 4 PEGINTRON 120 MCG KIT, -150 MCG KIT, -80 MCG KIT [INJ] PEGINTRON 50 MCG KIT [INJ] peginterferon alfa-2b 4 peginterferon alfa-2b 4 PEGINTRON REDIPEN [INJ] peginterferon alfa-2b 4 REBIF 22 MCG/0.5 ML SYRINGE, -44 MCG/0.5 ML SYRINGE [INJ] interferon beta-1a/albumin 4 REBIF TITRATION PACK [INJ] interferon beta-1a/albumin 4 EXTAVIA [INJ] Generic interferon beta-1b [PAR][QLL, 4 syringes/28] [PAR][QLL, 4/28] [PAR][QLL, 5/34] [PAR][QLL, 5 kits/34] [PAR][QLL, 5 pens/34] [PAR][QLL, 8 syringes/35] [PAR][QLL, 12 syringes/28] INTERLEUKIN RECPTR ANTAGONIST ACTEMRA 200 MG/10 ML VIAL, -400 MG/20 ML VIAL [INJ] ACTEMRA 80 MG/4 ML VIAL [INJ] ARCALYST [INJ][LA] ILARIS [INJ] KINERET [INJ] tocilizumab 4 [PAR] tocilizumab rilonacept canakinumab anakinra 2 4 2 4 [PAR] [PAR] oprelvekin 4 [QLL, 21 vials/21] [PAR] INTERLEUKINS NEUMEGA [INJ] S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug PROLEUKIN [INJ] ZENAPAX [INJ] aldesleukin daclizumab Generic Tier Restrictions 4 4 [PAR] MYELOID STIMULANTS LEUKINE [INJ] NEULASTA [INJ] sargramostim pegfilgrastim 4 4 NEUPOGEN [INJ] filgrastim 4 eltrombopag olamine 4 [PAR][QLL, 2/30] [PAR] THROMBOPOIETIC AGENTS PROMACTA [LA] MEDICAL (MISCELLANEOUS) SUPPLIES DIABETIC SUPPLIES 1ST TIER UNIFINE PENTIPS ACCUSURE AIMSCO ULTRA THIN II ALCOHOL PREP PADS ALCOHOL PREP SWABS ALCOHOL SWABS ALCOHOL WIPES ANTI-STICK INSULIN AUTO INJECTOR AUTOJECT 2 AUTOPEN CURAD GAUZE PADS CURITY ALCOHOL PREPS CURITY GAUZE SPONGES EASY COMFORT INSULIN SYRINGE EASY TOUCH NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE EXEL INSULIN SYRINGE GLUCOPRO SYRINGE EMPTY DISPOSABLE HUMAPEN LUXURA HD HUMAPEN MEMOIR IN CONTROL PEN NEEDLE S7950_2011_DOC7aPC misc supp (dress,tape,gauze) misc supp (dress,tape,gauze) 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic INJECT-EASE INSULIN PEN NEEDLE INSULIN SYRINGE INSUMED INSUPEN INTEGRA SYRINGE SYRINGE EMPTY DISPOSABLE LISCO SPONGES misc supp (dress,tape,gauze) LITE TOUCH INSULIN PEN NEEDLES LITE TOUCH SYRINGE EMPTY DISPOSABLE LUER-LOK SYRINGE SYRINGE EMPTY DISPOSABLE MEDI-JECTOR NEEDLE-FREE SYR A MEDI-JECTOR NEEDLE-FREE SYR B MEDI-JECTOR NEEDLE-FREE SYR C MEDI-JECTOR VISION MONOJECT 0.5 ML SYRN 28GX1/2 MONOJECT INSULIN SAFETY SYRNG MONOJECT INSULIN SYRINGE NANO PEN NEEDLE NORDIPEN 15 NORDIPEN 5 NOVOFINE 32 NOVOFINE AUTOCOVER NOVOPEN 3 NOVOPEN JR ORSINI INSULIN SYRINGE PEN 12MM 29G NEEDLES, 31GX3/16, -31GX5/16, -6MM 31G, 8MM 31G NEEDLES, -AURORA 6MM 31G, -AURORA S 12MM 29G, AURORA S 8MM 31G, -BD 29GX1/2, -BD 29GX3/16, -BD 29GX5/16, -BD MINI 31GX3/16, -BD ORIG 29GX1/2, -BD SHORT 31GX5/16, -LIVE BETTER 6MM 31G, -LIVE B PEN NEEDLES PRECISION SYRINGE EMPTY DISPOSABLE S7950_2011_DOC7aPC Tier 2 2 2 2 2 2 Restrictions 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic PRODIGY INSULIN SYRINGE PRODIGY PEN NEEDLE SAFESNAP INSULIN SYRINGE SAFETYGLIDE INSULIN SYRINGE SAFETYGLIDE SYRINGE SYRINGE EMPTY DISPOSABLE SINGLE USE SWAB SURE COMFORT SURE COMFORT ALCOHOL SURE-FINE PEN NEEDLES SURE-JECT INSULIN SYRINGE SURE-PREP ALCOHOL PREP PADS TERUMO INSULIN SYRINGE TERUMO SURGUARD THINPRO INSULIN SYRINGE TOPCARE CLICKFINE TOPCARE ULTRA COMFORT ULTICARE NEEDLE DISPOSABLE, SYRINGE EMPTY DISPOSABLE ULTIGUARD 30GX0.5 ML SYRINGE, 30GX1 ML SYRINGE, -SYRINGE EMPTY DISPOSABLE ULTILET ALCOHOL SWAB ULTILET INSULIN SYRINGE ULTILET PEN NEEDLE ULTRA COMFORT ULTRACOMFORT DISPOSABLE SYRINGE, -NEEDLE DISPOSABLE, SYRINGE EMPTY DISPOSABLE UNIFINE PENTIPS VANISHPOINT SYRINGE EMPTY DISPOSABLE VERSALON ALL PURPOSE SPONGE misc supp (dress,tape,gauze) WEBCOL Tier 2 2 2 2 2 Restrictions 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 MUSCULOSKELETAL MEDICATIONS CNS MUSCLE RELAXANTS AMRIX carisoprodol compound S7950_2011_DOC7aPC cyclobenzaprine 3 1 [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug carisoprodol compound-codeine carisoprodol tablet chlorzoxazone cyclobenzaprine hcl tablet FEXMID FLEXERIL [G] metaxalone methocarbamol tablet NORFLEX [INJ][G] orphenadrine citrate injection [INJ] orphenadrine citrate tablet sustained action orphenadrine compound orphenadrine compound forte PARAFON FORTE DSC [G] RILUTEK ROBAXIN INJECTION [INJ] ROBAXIN TABLET [G] ROBAXIN-750 [G] SKELAXIN [G] SOMA [G] Generic cyclobenzaprine cyclobenzaprine orphenadrine chlorzoxazone riluzole methocarbamol methocarbamol methocarbamol metaxalone carisoprodol Tier 1 1 1 1 3 3 1 1 3 1 1 Restrictions [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] 1 1 3 4 3 3 3 3 3 [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] DIRECT MUSCLE RELAXANTS ANECTINE [INJ] succinylcholine baclofen tablet DANTRIUM CAPSULE [G] DANTRIUM INJECTION [INJ] dantrolene dantrolene dantrolene sodium DYSPORT [INJ] revonto [INJ] abobotulinumtoxina tizanidine hcl ZANAFLEX [G] tizanidine 3 1 3 3 1 3 1 1 3 DRUGS TO PREVENT AND TREAT GOUT allopurinol sodium [INJ] allopurinol tablet ALOPRIM [INJ][G] S7950_2011_DOC7aPC allopurinol 1 1 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug COLCRYS Generic colchicine probenecid probenecid-colchicine ULORIC ZYLOPRIM [G] febuxostat allopurinol Tier Restrictions 2 1 1 2 [ST] 3 NON-STEROIDAL ANTIINFLAMMATORY AGENTS ANAPROX [G] ANAPROX DS [G] ANSAID ARTHROTEC 50 ARTHROTEC 75 CATAFLAM [G] CELEBREX CLINORIL [G] DAYPRO [G] diclofenac potassium diclofenac sodium tablet enteric coated, -tablet sustained release 24hr EC-NAPROSYN [G] naproxen sodium naproxen sodium flurbiprofen diclofenac sodium/misoprostol diclofenac sodium/misoprostol diclofenac potassium celecoxib sulindac oxaprozin 3 3 3 3 3 3 2 3 3 1 1 [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] [ST] naproxen 3 1 3 1 1 1 [ST] etodolac FELDENE [G] fenoprofen calcium flurbiprofen tablet ibuprofen 100 mg/5 ml, -100 mg/5 ml sus, -100 mg/5 ml susp, -400 mg tablet, -600 mg tablet, -800 mg tablet INDOCIN INDOCIN INDOCIN INDOCIN I.V. [INJ] SR SUPPOSITORY RECTAL SUSPENSION ORAL indomethacin capsule, -capsule sustained action indomethacin injection [INJ] ketoprofen capsule, -capsule 24hr sustained release pellets S7950_2011_DOC7aPC piroxicam indomethacin sodium trihydrate indomethacin indomethacin indomethacin 3 3 3 3 1 [ST] [ST] [ST] 4 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ketorolac tromethamine injection [INJ] ketorolac tromethamine tablet meclofenamate sodium capsule meloxicam 15 mg tablet, suspension oral meloxicam 7.5 mg tablet MOBIC 15 MG TABLET, SUSPENSION ORAL [G] MOBIC 7.5 MG TABLET [G] Generic naproxen 250 mg tablet, -375 mg tablet, -suspension oral, -tablet enteric coated naproxen 500 mg tablet naproxen sodium 275 mg tab, -550 mg tab NEOPROFEN [INJ] [QLL, 20/5] 1 [QLL, 34/34] [ST] meloxicam 3 fenoprofen naproxen sodium naproxen naproxen 1 3 3 3 3 1 [QLL, 34/34][ST] [ST] [ST] [ST] [ST] 1 1 ibuprofen lysine ketorolac naproxen/esomeprazole mag diclofenac sodium 3 1 1 3 1 1 3 3 3 diclofenac sodium diclofenac potassium 3 3 penicillamine penicillamine 2 3 mefenamic acid sulindac tablet tolmetin sodium TORADOL [INJ] VIMOVO VOLTAREN TABLET ENTERIC COATED VOLTAREN-XR [G] ZIPSOR 1 1 1 3 oxaprozin piroxicam capsule PONSTEL Restrictions meloxicam nabumetone NALFON NAPRELAN NAPRELAN CR DOSE CARD NAPROSYN [G] Tier 1 [ST] [ST] [ST] [ST] [ST] OTHER DRUGS FOR ARTHRITIS CUPRIMINE DEPEN S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug gold sodium thiomalate [INJ] myochrysine [INJ] RIDAURA SYPRINE Generic auranofin trientine Tier 1 1 2 2 Restrictions SALICYLATES AND RELATED DRUGS aspirin ec 975 mg tablet choline mag trisalicylate diflunisal EASPRIN 1 1 1 3 1 3 aspirin salsalate ZORPRIN aspirin NUTRITION,BLOOD MODIFIERS,ELECTROLYTES ANTIPLATELET DRUGS AGGRASTAT [INJ] AGGRENOX tirofib hc m-hyd/na chlor aspirin/dipyridamole cilostazol dipyridamole tablet EFFIENT INTEGRILIN [INJ] PERSANTINE [G] PLAVIX PLETAL [G] REOPRO [INJ] prasugrel eptifibatide dipyridamole clopidogrel cilostazol abciximab ticlopidine hcl 3 2 1 1 2 3 3 2 3 3 1 BLOOD DETOXICANTS constulose enulose FOSRENOL lanthanum carbonate generlac KRISTALOSE lactulose lactulose RENAGEL RENVELA S7950_2011_DOC7aPC sevelamer sevelamer carbonate 1 1 3 1 3 1 3 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions ELECTROLYTES, IRRIGATING SOLUTIONS, ETC. ALBUMINAR-25 [INJ] alburx [INJ] albutein [INJ] alcohol in dextrose [INJ] AMINOSYN [INJ] AMINOSYN II [INJ] AMINOSYN II 3.5% M-DEXTROSE 5% [INJ] AMINOSYN II 3.5%-DEXTROSE 25% [INJ] AMINOSYN II 3.5%-DEXTROSE 5% [INJ] AMINOSYN II 4.25% M-DEXT 10% [INJ] AMINOSYN II 4.25%-DEXTROSE 25% [INJ] AMINOSYN II 5% IN 25% DEXTROSE [INJ] AMINOSYN II IN DEXTROSE [INJ] AMINOSYN II WITH LYTES-CA-DW [INJ] AMINOSYN M [INJ] AMINOSYN WITH ELECTROLYTES [INJ] AMINOSYN-HBC [INJ] AMINOSYN-HF [INJ] AMINOSYN-PF [INJ] AMINOSYN-RF [INJ] AMMONIUM CHLORIDE INJECTION [INJ] BRANCHAMIN [INJ] BUMINATE [INJ] calcium chloride injection [INJ] CLINIMIX [INJ] CLINIMIX E [INJ] CLINISOL [INJ] CYSTAGON [LA] S7950_2011_DOC7aPC albumin human amino acids amino acids amino acids 3 1 1 1 2 2 2 amino acids 2 amino acids 2 amino acids 2 amino acids 2 amino acids 2 amino acids amino acids 2 2 amino acids amino acids 2 2 amino acids amino acids amino acids amino acids ammonium chloride 2 2 2 2 2 amino acids albumin human 2 3 1 2 2 2 2 amino acids amino acids amino acids cysteamine © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug d5w/kcl 10 meq/l iv solution, -30 meq/l iv solution [INJ] dextrose 10%-1/4ns [INJ] dextrose 10%-1/4ns-kcl [INJ] dextrose 2.5%-lr 1/2 str sol [INJ] dextrose 5%-1/2ns-kcl [INJ] dextrose 5%-1/3ns-kcl [INJ] dextrose 5%-1/4ns-kcl [INJ] dextrose 5%-electrolyte #48 [INJ] dextrose 5%-electrolyte #75 [INJ] dextrose 5%-ns-kcl [INJ] dextrose in ringers injection [INJ] dextrose in water [INJ] dextrose with sodium chloride [INJ] FLEXBUMIN [INJ] FREAMINE HBC [INJ] FREAMINE III [INJ] FREAMINE III WITH ELECTROLYTES [INJ] HEPATAMINE [INJ] HEPATASOL [INJ] HUMAN ALBUMIN 25% IV SOLUTION [INJ] HYPERLYTE CR [INJ] IONOSOL B WITH DEXTROSE 5% [INJ] IONOSOL MB-DEXTROSE 5% [INJ] IONOSOL T-DEXTROSE 5% [INJ] ISOLYTE H WITH DEXTROSE [INJ] ISOLYTE M WITH DEXTROSE [INJ] ISOLYTE P WITH DEXTROSE [INJ] ISOLYTE S [INJ] ISOLYTE S WITH DEXTROSE [INJ] kcl 40 meq in d5w-lact ringer [INJ] lactated ringers injection [INJ] magnesium sulfate injection [INJ] MAGNESIUM SULFATE-D5W [INJ] mannitol injection [INJ] NEPHRAMINE [INJ] NEUT [INJ] S7950_2011_DOC7aPC Generic Tier 1 albumin human amino acids amino acids aa 3%/electrolyte-tpn/glycerin 1 1 1 1 1 1 1 1 1 1 1 1 3 3 2 3 amino acids amino acids albumin human 2 2 3 electrolyte solutions electrolyte solutions 3 2 electrolyte solutions electrolyte solutions dextrose/electrolytes dextrose/electrolytes dextrose/electrolytes electrolyte solutions dextrose/electrolytes 2 2 2 2 2 2 2 1 1 1 2 1 2 2 magnesium sulfate/d5w amino acids sodium bicarbonate Restrictions © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug NORMOSOL-M AND DEXTROSE [INJ] NORMOSOL-R [INJ] NORMOSOL-R AND DEXTROSE [INJ] NORMOSOL-R PH 7.4 [INJ] NOVAMINE [INJ] nutrilyte [INJ] nutrilyte ii [INJ] OSMITROL [INJ] PLASBUMIN-25 [INJ] PLASMA-LYTE 148 [INJ] PLASMA-LYTE 148 IN DEXTROSE [INJ] PLASMA-LYTE 56 [INJ] PLASMA-LYTE 56 IN DEXTROSE [INJ] PLASMA-LYTE A PH 7.4 [INJ] PLASMA-LYTE R [INJ] potassium chl-normal saline [INJ] potassium chloride-nacl [INJ] PREMASOL [INJ] PROCALAMINE [INJ] PROSOL [INJ] RENAMIN [INJ] RESECTISOL R-GENE 10 [INJ] ringers injection [INJ] sodium acetate [INJ] sodium bicarbonate injection [INJ] sodium chloride 0.45% irrig, -0.9% irrig., -sterile saline 0.9% irr sodium chloride 0.45% soln, -0.45% soln-excel con, -0.9% soln, -0.9% soln., -0.9% soln-excel cont, -0.9% solution, -3% iv soln, -4 meq/ml vl, -5% iv soln, -cl 2.5 meq/ml vial [INJ] sodium lactate [INJ] sodium phosphate injection [INJ] TPN ELECTROLYTES [INJ][G] S7950_2011_DOC7aPC Generic dextrose/electrolytes Tier 2 electrolyte solutions electrolyte solutions electrolyte solutions amino acids mannitol albumin human electrolyte solutions electrolyte solutions 2 2 2 2 1 1 3 3 2 2 electrolyte solutions d5w/electrolyte-56 solution 2 2 electrolyte solutions electrolyte solutions 2 2 1 1 2 2 3 2 3 2 1 1 1 1 amino acids aa 3%/electrolyte-tpn/glycerin amino acids amino acids mannitol arginine Restrictions 1 electrolyte solutions 1 1 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug TPN ELECTROLYTES II [INJ] TRAVASOL [INJ] TRAVASOL WITH DEXTROSE [INJ] TRAVASOL WITH ELECTROLYTES [INJ] TROPHAMINE [INJ] Generic electrolyte solutions amino acids amino acids amino acids Tier 2 2 2 2 amino acids 2 sodium fluoride sodium fluoride 3 3 1 1 1 1 1 3 3 1 1 3 1 1 3 3 1 1 3 1 1 3 3 3 3 3 1 1 1 1 Restrictions FLUORIDE PRODUCTS CAVIRINSE CONTROL RX denta 5000 plus dentagel easygel epiflur ethedent FLUORABON FLUOR-A-DAY DROPS sodium fluoride sodium fluoride fluor-a-day tablet chewable fluoridex daily defense FLUORIDEX SENSITIVITY RELIEF sodium fluoride/pot nitrate fluoritab tablet chewable flura FLURA-DROPS GEL-KAM sodium fluoride stannous fluoride lozi-flur ludent fluoride LURIDE sodium fluoride neutragard advanced perio med PHOS-FLUR PREVIDENT PREVIDENT 5000 PREVIDENT 5000 PLUS PREVIDENT 5000 SENSITIVE renaf sf sf 5000 plus sodium fluoride drops, -solution non-oral, -tablet, -tablet chewable S7950_2011_DOC7aPC sodium fluoride sodium fluoride sodium fluoride sodium fluoride sodium fluoride/pot nitrate © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic stanimax stannous fluoride solution Tier 1 1 Restrictions HEPARIN ANTAGONISTS PROTAMINE SULFATE [INJ] protamine 3 fondaparinux sodium 4 fondaparinux sodium 2 1 INJECTABLE ANTICOAGULANTS ARIXTRA 10 MG SYRINGE, -5 MG SYRINGE, -7.5 MG SYRINGE [INJ] ARIXTRA 2.5 MG SYRINGE [INJ] enoxaparin 100 mg/ml syr, -30 mg/0.3 ml syr, -40 mg/0.4 ml syr, 60 mg/0.6 ml syr, -80 mg/0.8 ml syr [INJ] enoxaparin 120 mg/0.8 ml syr, -150 mg/ml syr [INJ] FRAGMIN 10,000 UNITS SYRINGE, 10,000 UNITS/ML VIAL, -12,500 UNITS SYRINGE, -15,000 UNITS SYRINGE, -18,000 UNITS SYRINGE, -25,000 UNITS/ML VIAL, -7,500 UNITS SYRINGE [INJ] FRAGMIN 2,500 UNITS SYRINGE, 5,000 UNITS SYRINGE [INJ] heparin sodium in 0.45% nacl [INJ] heparin sodium in 0.9% nacl [INJ] 4 dalteparin (porcine) 4 dalteparin (porcine) 3 1 1 1 heparin sodium in 5% dextrose [INJ] heparin sodium injection [INJ] INNOHEP [INJ] tinzaparin sodium, porcine LOVENOX 100 MG PREFILLED SYR, - enoxaparin 120 MG PREFILLED SYR, -150 MG PREFILLED SYR, -300 MG VIAL, -60 MG PREFILLED SYRN, -80 MG PREFILLED SYRN [INJ] LOVENOX 30 MG PREFILLED SYRN, enoxaparin -40 MG PREFILLED SYRN [INJ] S7950_2011_DOC7aPC 1 3 4 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ORAL ANTICOAGULANTS, VITAMIN K ARGATROBAN [INJ] COUMADIN INJECTION [INJ] COUMADIN TABLET [G] Generic argatroban warfarin sodium warfarin sodium jantoven warfarin sodium Tier Restrictions 3 3 3 1 1 OTHER DRUGS AFFECTING COAGULATION ATRYN [INJ] REFLUDAN [INJ] THROMBATE III [INJ] antithrombin iii, human recomb lepirudin,recombinant antithrombin iii,human 3 2 3 POTASSIUM REMOVING RESINS kalexate KAYEXALATE [G] KIONEX POWDER [G] sodium polystyrene sulfonate sodium polystyrene sulfonate kionex suspension oral marlexate sodium polystyrene sulfonate sps 1 3 3 1 1 1 1 POTASSIUM SUPPLEMENTS cytra-2 dextrose 5%-lr iv solution [INJ] EFFER-K 10 MEQ TABLET EFF, -20 MEQ TABLET EFF potassium bicarb/ca effer-k 25 meq tablet eff epiklor k effervescent KAOCHLOR potassium chloride kaon-cl 10 KAY CIEL kcl 20 meq in d5w solution, -20 meq/l iv solution, -40 meq in d5w solution, -40 meq/l iv solution [INJ] S7950_2011_DOC7aPC potassium chloride 1 1 3 1 1 1 3 1 3 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug kcl 20 meq in d5w-lact ringer, -40 meq in d5w-lact ringer [INJ] klor-con 10 klor-con 20 meq packet KLOR-CON 25 MEQ PACKET klor-con 8 klor-con m10 klor-con m15 klor-con m20 klor-con-ef K-PHOS NEUTRAL K-TAB liqui-dualcitra MICRO-K [INJ] ORACIT phospha 250 neutral potassium acetate injection [INJ] potassium bicarbonate tablet effervescent potassium chloride capsule sustained action, -cl 20 meq tab er, -cl er 10 meq tablet, -cl er 20 meq tablet, -cl er 8 meq tablet, -solution potassium chloride injection [INJ] potassium cl 10 meq tab sa, -tablet effervescent sodium citrate & citric acid vis-phos n Generic potassium chloride phosphorus potassium chloride potassium chloride sodium citrate/citric acid Tier 1 Restrictions 1 1 3 1 1 1 1 1 3 3 1 3 3 1 1 1 1 1 1 1 1 THERAPEUTIC VITAMINS AND MINERALS CALCIJEX [INJ][G] calcitriol calcitriol capsule, -solution calcitriol injection [INJ] calcium acetate CARNITOR INJECTION [INJ][G] CARNITOR SF CARNITOR SOLUTION, -TABLET [G] levocarnitine levocarnitine levocarnitine eliphos HECTOROL CAPSULE S7950_2011_DOC7aPC doxercalciferol 3 1 1 1 3 3 3 1 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug HECTOROL INJECTION [INJ] levocarnitine injection [INJ] levocarnitine solution, -tablet PHOSLO [G] ROCALTROL [G] ZEMPLAR CAPSULE ZEMPLAR INJECTION [INJ] Generic doxercalciferol calcium acetate calcitriol paricalcitol paricalcitol Tier 3 1 1 3 3 2 2 Restrictions VITAMINS AND MINERALS AND RELATED PRODUCTS INTRALIPID 30% IV FAT EMUL [INJ][G] INTRALIPID 10% IV FAT EMUL, 20% IV FAT EMUL [INJ][G] LIPOSYN II [INJ] liposyn iii [INJ] fat emulsions 2 fat emulsions 3 fat emulsions 2 1 OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS ABORTIFACIENTS CERVIDIL HEMABATE [INJ] PROSTIN E2 VAGINAL SUPPOSITORY dinoprostone carboprost tromethamine dinoprostone 3 2 2 oxymetholone testosterone testosterone methyltestosterone fluoxymesterone 4 3 2 3 2 1 3 3 3 3 2 4 3 ANDROGEN DRUGS ANADROL-50 ANDRODERM ANDROGEL ANDROID ANDROXY danazol capsule DELATESTRYL [INJ][G] DEPO-TESTOSTERONE [INJ][G] FIRST-TESTOSTERONE FIRST-TESTOSTERONE MC METHITEST OXANDRIN 10 MG TABLET [G] OXANDRIN 2.5 MG TABLET [G] S7950_2011_DOC7aPC testosterone enanthate testosterone cypionate testosterone propionate testosterone propionate methyltestosterone oxandrolone oxandrolone [PAR] [PAR] [PAR] [PAR] [PAR] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary oxandrolone Drug STRIANT TESTIM TESTOPEL [INJ] Generic testosterone testosterone testosterone testosterone cypionate injection Tier Restrictions 1 [PAR] 3 [PAR] 2 [PAR] 2 1 [INJ] testosterone enanthate [INJ] TESTRED methyltestosterone 1 3 CONTRACEPTIVES apri aranelle aviane azurette balziva BREVICON [G] norethindrone-ethin estradiol caziant cesia cryselle CYCLESSA [G] DEMULEN 1-50-21 DESOGEN [G] desogestrel-ethinyl estradiol ethynodiol diace-eth estradiol desogestrel-ethinyl estradiol enpresse ESTROSTEP FE [G] FEMCON FE noreth a-et estra/fe fumarate noreth-ethinyl estradiol/iron gianvi gildess fe jolessa junel junel fe kariva kelnor 1-35 leena lessina LEVLEN 28 levonorgestrel-ethin estradiol levora-28 LOESTRIN [G] LOESTRIN 24 FE LOESTRIN FE [G] S7950_2011_DOC7aPC norethindrone a-e estradiol noreth a-et estra/fe fumarate noreth a-et estra/fe fumarate 1 1 1 1 1 3 1 1 1 3 3 3 1 3 3 1 1 1 1 1 1 1 1 1 3 1 3 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug LO-OVRAL-28 [G] LOSEASONIQUE low-ogestrel lutera LYBREL microgestin microgestin fe MIRCETTE MODICON [G] mononessa NATAZIA necon next choice NORDETTE-28 [G] norgestrel-ethiny estra NORINYL 1+35 [G] NORINYL 1+50 nortrel NUVARING ocella ogestrel ORTHO EVRA ORTHO TRI-CYCLEN ORTHO TRI-CYCLEN LO ORTHO-CEPT [G] ORTHO-CYCLEN [G] ORTHO-NOVUM [G] OVCON-35 [G] OVCON-50 PLAN B [G] PLAN B ONE-STEP portia previfem quasense reclipsen SEASONALE [G] SEASONIQUE solia sprintec S7950_2011_DOC7aPC Generic norgestrel-ethinyl estradiol l-norgest-eth estr/ethin estr levonorgestrel-ethin estradiol desog-et estra/ethin estra norethindrone-ethin estradiol estradiol valerate/dienogest levonorgestrel-ethin estradiol norethindrone-ethin estradiol norethindrone-mestranol etonogestrel/ethin estradiol ethinyl estradiol/norelgest norgestimate-ethinyl estradiol norgestimate-ethinyl estradiol desogestrel-ethinyl estradiol norgestimate-ethinyl estradiol norethindrone-ethin estradiol norethindrone-ethin estradiol norethindrone-ethin estradiol levonorgestrel levonorgestrel levonorgestrel-ethin estradiol l-norgest-eth estr/ethin estr Tier 3 3 1 1 3 1 1 3 3 1 3 1 1 3 1 3 3 1 3 1 1 3 3 3 3 3 3 3 3 3 3 1 1 1 1 3 3 1 1 Restrictions © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary sronyx tilia fe tri-legest fe tri-lo-sprintec trinessa Drug TRI-NORINYL [G] Generic norethindrone-ethin estradiol tri-previfem tri-sprintec trivora-28 velivet YASMIN 28 [G] YAZ [G] eth estradiol/drospirenone eth estradiol/drospirenone zenchent zovia 1-35e zovia 1-50e Tier 1 1 1 1 1 3 1 1 1 1 3 3 1 1 1 Restrictions [QLL, 10/35] ESTROGEN DRUGS ALORA estradiol 3 CENESTIN CLIMARA [G] DELESTROGEN [INJ][G] DEPO-ESTRADIOL [INJ] DIVIGEL estrogen,conjug,synthetic a estradiol estradiol valerate estradiol cypionate estradiol 3 3 3 3 3 ELESTRIN estradiol 3 ENJUVIA ESTRACE CREAM WITH APPLICATOR ESTRACE TABLET [G] ESTRADERM estrogen,conjug,synthetic b estradiol 2 2 estradiol estradiol 3 2 ESTRASORB estradiol 1 1 1 3 ESTRING estradiol 2 estradiol patch transdermal weekly estradiol tablet estradiol valerate injection [INJ] S7950_2011_DOC7aPC [QLL, 5/35] [QLL, 34/34] [QLL, 144 gm/34] [QLL, 10/35] [QLL, 5/35] [QLL, 118/34] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary EVAMIST estradiol FEMRING FEMTRACE GYNODIOL MENEST MENOSTAR OGEN [G] ORTHO-EST PREMARIN CREAM WITH APPLICATOR, -TABLET PREMARIN INJECTION [INJ] VAGIFEM VIVELLE estradiol estradiol estradiol estrogens,esterified estradiol estropipate estropipate estrogens,conjugated Tier Restrictions 1 3 [QLL, 16 ml/34] 3 3 3 3 3 [QLL, 5/35] 3 3 2 estrogens,conjugated estradiol estradiol 2 2 2 VIVELLE-DOT estradiol 2 estropipate Drug Generic [QLL, 10/35] [QLL, 10/35] ESTROGEN/PROGESTIN COMBINATIONS ACTIVELLA [G] ANGELIQ CLIMARA PRO COMBIPATCH estradiol/noreth ac estradiol/drospirenone estradiol/levonorgestrel estradiol/noreth ac estradiol/norgestimate estrogen/medroxyprogesterone estrogen/medroxyprogesterone 3 3 2 2 1 3 1 3 2 2 acetic ac/ricinoleic/oxyquinol sulfanilamide clindamycin phosphate clindamycin phosphate 3 3 3 3 estradiol-norethindrone acetat FEMHRT norethindrone a-e estradiol mimvey PREFEST PREMPHASE PREMPRO [QLL, 5/35] OB/GYN TOPICAL ANTIINFECTIVES ACID JELLY AVC CLEOCIN [G] CLINDAMAX CREAM WITH APPLICATOR S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug clindamycin phosphate cream with applicator CLINDESSE fem ph METROGEL-VAGINAL [G] metronidazole gel with applicator RELAGARD vandazole Generic clindamycin phosphate metronidazole acetic acid/oxyquin so4 Tier 1 Restrictions 3 1 3 1 3 1 OXYTOCICS METHERGINE INJECTION [INJ] METHERGINE TABLET oxytocin injection [INJ] PITOCIN [INJ] methylergonovine methylergonovine oxytocin 2 2 1 3 PRENATAL VITAMINS advanced care plus advanced natalcare cal-nate carenatal dha cavan one omega cavan-alpha kit cavan-ec sod dha CITRANATAL 90 DHA CITRANATAL DHA CITRANATAL RX prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) combi rx complete natal dha completenate co-natal fa CONCEPT DHA CONCEPT OB docosavit dualvit ob edge ob elite ob dha elite-ob S7950_2011_DOC7aPC prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) 1 1 1 1 1 1 1 3 3 3 1 1 1 1 3 3 1 1 1 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug fe c plus tablet folbecal folcal dha folcaps omega-3 folinatal plus b folivane-ec calcium dha nf folivane-ob folivane-prx dha nf foltabs foltabs 90 plus dha gentex ade GESTICARE GESTICARE DHA Generic prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) hip prenatal ICAR-C PLUS iron,carbonyl/vit c/vit b12/fa inatal advance inatal gt inatal ultra kolnatal dha LACTOCAL-F prenatal vit( = or > 1mg fa) maternity multinatal plus multi-nate 30 multi-nate 30 dha multi-nate dha extra mynatal mynatal advance mynatal plus mynatal-z mynate 90 plus natacaps NATACHEW NATAFORT prenatal vitamins (< 1mg fa) prenatal vitamins (< 1mg fa) natalcare pic forte natalcare plus natatab NATELLE NATELLE C NATELLE ONE S7950_2011_DOC7aPC prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) Tier 1 1 1 1 1 1 1 1 1 1 1 3 3 1 3 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 3 3 1 1 1 3 3 3 Restrictions © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug NATELLE PLUS NATELLE PREFER NATELLE-EZ NEEVO NOVANATAL NOVASTART prenatal prenatal prenatal prenatal prenatal prenatal Generic vit( = or > 1mg fa) vit( = or > 1mg fa) vit( = or > 1mg fa) vit( = or > 1mg fa) vit( = or > 1mg fa) vit( = or > 1mg fa) nutrinate nutrispire ob + dha ob 90 + dha ob-natal one OBTREX O-CAL FA O-CAL PRENATAL OPTINATE prenatal vit( = or prenatal vit( = or prenatal vit( = or prenatal vit( = or > 1mg fa) > 1mg fa) > 1mg fa) > 1mg fa) pnv-dha pnv-iron pnv-omega pnv-select poly iron pn POLY IRON PN FORTE prenatal vitamins (< 1mg fa) pr natal 430 pr natal 430 ec pr natal 440 ec PREFERA-OB PREFERA-OB ONE PREFERA-OB PLUS DHA prenacare prenafirst prenaplus prenatabs fa prenatabs obn prenatabs rx prenatal 19 prenatal ad prenatal formula tablet prenatal low iron prenatal mr 90 fe prenatal multivitamin w-iron S7950_2011_DOC7aPC prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) Tier 3 3 3 3 3 3 1 1 1 1 1 3 3 3 3 1 1 1 1 1 3 1 1 1 3 3 3 1 1 1 1 1 1 1 1 1 1 1 1 Restrictions © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary prenatal plus prenatal rx 1 prenatal z prenatal-u Drug PRENATE DHA PRENATE ELITE PRENATE ESSENTIAL Generic prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenate plus PRENEXA PREQUE 10 prenatal vitamins (< 1mg fa) prenatal vitamins (< 1mg fa) previt+dha previte rx pruet dha pruet dha ec re-nata 29 re-nata 29 ob renate renate dha renate dha extra rovin-nv rovin-nv dha se-care se-care conceive se-care gesture SELECT-OB SELECT-OB + DHA prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) se-natal 19 se-natal 90 se-natal one se-plete dha se-tan dha setonet setonet-ec TANDEM DHA TANDEM OB taron a prenatal taron ec calcium taron-c dha taron-ec cal S7950_2011_DOC7aPC prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) Tier 1 1 1 1 3 3 3 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3 1 1 1 1 1 1 1 3 3 1 1 1 1 Restrictions © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug taron-prex prenatal tri rx triadvance TRICARE TRICARE PRENATAL DHA ONE trifera ob trimesis rx trinatal rx 1 trinate triveen-one triveen-prx rnf triveen-u ultimatecare advantage ultimatecare one ultimatecare one nf vinacal vinate az vinate az extra vinate c vinate calcium vinate care vinate gt vinate ic vinate ii vinate iii vinate one vinate pn care vinate ultra vinate-m vitafol-ob VITAFOL-OB+DHA vitafol-pn vitanatal ob + dha vitaphil vitaphil + dha vitaphil + dha 90 vitaphil aide vitaspire VOL-TAB RX S7950_2011_DOC7aPC Generic prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) prenatal vit( = or > 1mg fa) Tier 1 1 1 3 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 1 1 1 1 3 Restrictions © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary vynatal-fa zatean-pn zatean-pn dha zatean-pn plus Drug Generic Tier 1 1 1 1 Restrictions PROGESTIN DRUGS norethindrone acetate AYGESTIN [G] progesterone medroxyprogesterone 3 1 3 3 medroxyprogesterone 3 camila CRINONE DEPO-PROVERA 150 MG/ML VIAL [INJ][G] DEPO-SUBQ PROVERA 104 [INJ] errin FIRST-PROGESTERONE FIRST-PROGESTERONE FIRST-PROGESTERONE FIRST-PROGESTERONE FIRST-PROGESTERONE VGS VGS VGS VGS VGS 100 200 25 400 50 progesterone progesterone progesterone progesterone progesterone jolivette medroxyprogesterone acetate injection [INJ] medroxyprogesterone acetate tablet MICRONOR [G] progesterone medroxyprogesterone 1 3 1 1 3 3 1 1 2 3 leuprolide 1 4 norethindrone nora-be norethindrone acetate tablet NOR-Q-D [G] PROCHIEVE norethindrone progesterone progesterone in oil [INJ] progesterone injection [INJ] PROMETRIUM PROVERA [G] 1 2 2 2 2 2 1 1 [QLL, 1 ml/90] [QLL, 1 syringe/90] [QLL, 1 ml/90] SPECIALIZED OB/GYN DRUGS leuprolide acetate [INJ] LUPRON [INJ] S7950_2011_DOC7aPC © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug LUPRON DEPOT 11.25 MG 3MO KIT, -22.5 MG 3MO KIT, -3.75 MG KIT, 4 MONTH KIT [INJ] LUPRON DEPOT 7.5 MG KIT [INJ] LUPRON DEPOT-PED [INJ] PREPIDIL SUPPRELIN LA [INJ] SYNAREL Generic leuprolide leuprolide leuprolide dinoprostone histrelin ac nafarelin Tier Restrictions 2 [PAR] 4 4 3 4 4 [PAR] [PAR] OPHTHALMIC MEDICATIONS ANTIGLAUCOMA DRUGS acetazolamide capsule sustained action, -tablet acetazolamide sodium [INJ] ALPHAGAN P 0.1% DROPS ALPHAGAN P 0.15% EYE DROPS [G] 1 brimonidine tartrate brimonidine tartrate apraclonidine hcl AZOPT BETAGAN [G] brinzolamide levobunolol betaxolol hcl drops BETIMOL BETOPTIC S timolol betaxolol brimonidine 0.2% eye drop brimonidine tartrate 0.15% drp carteolol hcl COMBIGAN COSOPT [G] DIAMOX SEQUELS [G] brimonidine tartrate/timolol dorzolamide/timolol acetazolamide dorzolamide hcl dorzolamide-timolol IOPIDINE [G] ISOPTO CARBACHOL ISOPTO CARPINE ISTALOL apraclonidine carbachol pilocarpine hcl timolol levobunolol hcl LUMIGAN bimatoprost methazolamide metipranolol MIOSTAT [INJ] S7950_2011_DOC7aPC carbachol 1 2 3 1 3 3 1 3 3 1 1 1 2 3 3 1 1 3 3 3 3 1 3 1 1 3 [ST] [ST] [ST] [ST] [ST] [ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug OPTIPRANOLOL [G] PHOSPHOLINE IODIDE pilocarpine hcl drops PILOPINE HS PROPINE timolol maleate drops, -gel-forming solution TIMOPTIC TIMOPTIC OCUDOSE TIMOPTIC-XE [G] TRAVATAN TRAVATAN Z TRUSOPT [G] XALATAN Generic metipranolol echothiophate iodide pilocarpine hcl dipivefrin timolol timolol timolol travoprost travoprost dorzolamide latanoprost Tier Restrictions 3 [ST] 2 1 2 3 1 3 3 3 2 2 3 2 [ST] [ST] [ST] OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS BLEPHAMIDE BLEPHAMIDE S.O.P. CORTISPORIN SUSPENSION DROPS sulfacetamide/prednisolone ac sulfacetamide/prednisolone ac neomycin sulfate/polymyxin/hc cortomycin ointment dexasporin MAXITROL [G] neomycin/polymyxin/dexameth methadex neomycin-bacitracin-poly-hc neomycin-polymyxin-dexameth neomycin-polymyxin-hc suspension drops poly-dex POLY-PRED PRED-G neomycin/polymyxin/prednisol gentamicin/prednisolone sulfacetamide-prednisolone TOBRADEX [G] tobramycin sulfate/dexameth tobramycin-dexamethasone ZYLET tobramycin/lotepred etab 3 3 3 1 1 3 1 1 1 1 1 2 2 1 3 1 2 OPHTHALMIC CORTICOSTEROID DRUGS ALREX S7950_2011_DOC7aPC loteprednol etabonate 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug dexamethasone sodium phosphate drops dexasol DUREZOL FLAREX fluorometholone FML [G] FML FORTE FML S.O.P. LOTEMAX MAXIDEX OMNIPRED [G] PRED FORTE [G] PRED MILD prednisol prednisolone acetate suspension drops prednisolone sodium phosphate drops RETISERT TRIESENCE [INJ] VEXOL Generic difluprednate fluorometholone fluorometholone fluorometholone fluorometholone loteprednol etabonate dexamethasone prednisolone acetate prednisolone acetate prednisolone acetate Tier 1 Restrictions 1 3 3 1 3 3 2 2 3 3 3 2 1 1 1 fluocinolone acetonide triamcinolone acetonide rimexolone 3 3 3 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS ak-poly-bac aktob AZASITE azithromycin bacitracin 500 unit/gm ointmnt bacitracin-polymyxin eye oint BESIVANCE BLEPH-10 [G] CILOXAN [G] besifloxacin sulfacetamide sodium ciprofloxacin ciprofloxacin hcl drops erythromycin ointment gentak gentamicin 3 mg/gm eye oint gentamicin sulfate drops gentasol IQUIX S7950_2011_DOC7aPC levofloxacin 1 1 2 1 1 3 3 3 1 1 1 1 1 1 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic neocidin neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin NEOSPORIN DROPS [G] OCUFLOX [G] neomycin/gramicidin/polymyxin ofloxacin ofloxacin drops polycin-b polymyxin b sul-trimethoprim POLYTRIM [G] QUIXIN polymyxin b sulfate/tmp levofloxacin romycin sulfac sulfacetamide sodium drops sulfamide TERRAMYCIN WITH POLYMYXIN oxytetracycline hcl/polymyxin tobramycin sulfate drops tobrasol TOBREX [G] VIGAMOX ZYMAR ZYMAXID tobramycin moxifloxacin gatifloxacin gatifloxacin Tier 1 1 1 3 3 1 1 1 3 3 1 1 1 1 3 1 1 3 2 2 2 Restrictions OPHTHALMIC TOPICAL ANTIVIRAL DRUGS trifluridine VIROPTIC [G] trifluridine 1 3 OTHER OPHTHALMIC DRUGS ACULAR [G] ACULAR LS [G] ACULAR PF ACUVAIL ketorolac ketorolac ketorolac ketorolac ak-con ak-dilate akorn balanced salt ak-pentolate AKTEN ALAMAST S7950_2011_DOC7aPC lidocaine pemirolast potassium 3 3 3 3 1 1 1 1 3 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ALBALON ALCAINE [G] naphazoline proparacaine Generic allersol ALOCRIL ALOMIDE nedocromil lodoxamide altafrin atropine care atropine sulfate drops, -ointment azelastine hcl drops BEPREVE BETADINE SOLUTION BOTOX [INJ] BSS [INJ] BSS PLUS CROLOM bepotastine besilate povidone-iodine botulinum toxin a sodium/calcium/mag/potassium sodium/calcium/mag/potassium cromolyn cromolyn sodium drops CYCLOGYL 0.5% EYE DROPS, -2% EYE DROPS CYCLOGYL 1% EYE DROPS [INJ] cyclopentolate cyclopentolate cyclopentolate hcl cylate diclofenac sodium drops ELESTAT EMADINE epinastine hcl emedastine difumarate flurbiprofen sodium homatropaire homatropine ISOPTO ATROPINE ISOPTO HOMATROPINE ISOPTO HYOSCINE atropine sulfate homatropine hbr scopolamine ketorolac tromethamine drops LACRISERT LUCENTIS [INJ] MYDFRIN hydroxypropylmethylcellulose ranibizumab phenylephrine hcl mydral MYDRIACYL [G] tropicamide naphazoline hcl drops NATACYN natamycin neofrin NEVANAC S7950_2011_DOC7aPC nepafenac Tier Restrictions 3 3 1 3 3 1 1 1 1 3 3 2 [PAR] 3 3 3 1 3 3 1 1 1 3 3 1 1 1 3 3 3 1 3 3 3 1 3 1 2 1 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug OCUFEN [G] OPHTHETIC OPTIVAR [G] Generic flurbiprofen proparacaine azelastine hcl parcaine PATADAY PATANOL olopatadine hcl olopatadine hcl phenylephrine hcl drops proparacaine hcl RESTASIS cyclosporine tropicacyl tropicamide VISUDYNE [INJ] VITRASERT VOLTAREN DROPS [G] XIBROM ZIRGAN verteporfin ganciclovir diclofenac sodium bromfenac ganciclovir Tier Restrictions 3 3 3 1 2 2 1 1 2 [QLL, 60 vials/30] 1 1 2 3 3 3 3 RESPIRATORY MEDICATIONS ANTIHISTAMINE/DECONGESTANT COMBINATIONS ALLEGRA-D 12 HOUR [G] pse/fexofenadine 3 ALLEGRA-D 24 HOUR pse/fexofenadine 3 CLARINEX-D 12 HOUR pse/desloratadine 3 CLARINEX-D 24 HOUR pse/desloratadine 3 fexofenadine-pse er 1 promethazine vc pse/acrivas 1 3 ALLEGRA 180 MG TABLET [G] fexofenadine 3 ALLEGRA 60 MG TABLET [G] fexofenadine 3 SEMPREX-D [QLL, 68/34][ST] [QLL, 34/34][ST] [QLL, 68/34][ST] [QLL, 34/34][ST] [QLL, 68/34] [PAR] ANTIHISTAMINES S7950_2011_DOC7aPC [QLL, 34/34][ST] [QLL, 68/34][ST] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug ALLEGRA ODT fexofenadine ALLEGRA SUSPENSION ORAL fexofenadine Tier Restrictions 3 [QLL, 68/34][ST] 3 [ST] 1 [PAR] 1 1 desloratadine desloratadine 3 3 ben-tann carbinoxamine maleate cetirizine 1 mg/1 ml soln, -1 mg/ml soln, -1 mg/ml syrup, -5 mg/5 ml syrup CLARINEX SYRUP CLARINEX TABLET, -TABLET DISPERSIBLE LINGUAL Generic clemastine fum 2.68 mg tab, -syrup complete allergy medicine cyproheptadine hcl syrup, -tablet dexchlorpheniramine maleate diphenhydramine 12.5 mg/5 ml, -25 mg cap, -50 mg cap, -50 mg capsule diphenhydramine hcl injection [INJ] diphenmax DYTAN 1 1 1 1 1 diphenhydramine tannate fexofenadine hcl 180 mg tablet fexofenadine hcl 30 mg tablet, -60 mg tablet palgic PHENERGAN [INJ][G] 1 promethazine promethazine hcl injection [INJ] promethazine hcl syrup, -tablet tripohist triprolidine hcl syrup XYZAL SOLUTION XYZAL TABLET 1 1 3 1 levocetirizine dihydrochlor levocetirizine dihydrochlor 1 3 1 1 1 1 2 2 [ST] [QLL, 34/34][ST] [PAR] [PAR] [PAR] [PAR] [PAR] [PAR] [QLL, 34/34] [QLL, 68/34] [PAR] [ST] [QLL, 34/34][ST] BETA-2 ADRENERGIC DRUGS albuterol sulfate nebs, -solution nonoral, -syrup, -tablet, -tablet sustained release 12hr, -vial nebulizer S7950_2011_DOC7aPC 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug FORADIL Generic formoterol fumarate MAXAIR AUTOHALER pirbuterol metaproterenol sulfate syrup, -tablet PROAIR HFA albuterol PROVENTIL HFA albuterol SEREVENT DISKUS salmeterol terbutaline sulfate injection [INJ] terbutaline sulfate tablet VENTOLIN HFA albuterol VOSPIRE ER [G] XOPENEX HFA albuterol levalbuterol Tier Restrictions 2 [QLL, 120/34] 3 [QLL, 28/34] 1 2 [QLL, 26 gm/34] 3 [QLL, 20 gm/34] 2 [QLL, 120 doses/34] 1 1 2 [QLL, 54 gm/34] 3 3 [QLL, 45 gm/34] LEUKOTRIENE MODIFIERS ACCOLATE SINGULAIR ZYFLO ZYFLO CR zafirlukast montelukast sodium zileuton zileuton 3 2 3 2 METHYL XANTHINE DRUGS aminophylline injection [INJ] aminophylline tablet CAFCIT SOLUTION [INJ] caffeine citrated caffeine citrate solution dylix ELIXOPHYLLIN LUFYLLIN THEO-24 theochron theophylline theophylline anhydrous tablet sustained release 12hr S7950_2011_DOC7aPC theophylline dyphylline theophylline 1 1 3 1 1 3 3 3 1 1 1 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug UNIPHYL theophylline Generic Tier 3 Restrictions [QLL, 4/2] OTHER DRUGS FOR ASTHMA ADRENACLICK [INJ] ADRENALIN CHLORIDE INJECTION [INJ] ADRENALIN CHLORIDE SOLUTION NON-ORAL ADVAIR DISKUS epinephrine hcl epinephrine hcl 3 3 epinephrine hcl 3 salmeterol/fluticasone 2 ADVAIR HFA salmeterol/fluticasone 2 AEROBID flunisolide 3 AEROBID-M flunisolide 3 ALVESCO 160 MCG INHALER ciclesonide 3 ALVESCO 80 MCG INHALER ciclesonide 3 ASMANEX TWISTHALER 110 MCG #30 ASMANEX TWISTHALER 220 MCG #14 ASMANEX TWISTHALER 220 MCG #30 ASMANEX TWISTHALER 220 MCG #60 ASMANEX TWISTHALR 220 MCG #120 ATROVENT HFA mometasone 2 mometasone 2 mometasone 2 mometasone 2 mometasone 2 ipratropium 2 AZMACORT triamcinolone acetonide 3 COMBIVENT albuterol sulfate/ipratropium 2 cromolyn sodium ampul for nebulization DULERA S7950_2011_DOC7aPC [QLL, 120 doses/34] [QLL, 24 gm/34] [QLL, 21/34] [QLL, 21 gm/34] [QLL, 18 gm/34] [QLL, 12 gm/34] [QLL, 60 doses/30] [QLL, 14 doses/14] [QLL, 60 doses/34] [QLL, 120 doses/34] [QLL, 240 doses/34] [QLL, 26 gm/34] [QLL, 60/34] [QLL, 44 gm/34] 1 mometasone/formoterol 3 [PAR][QLL, 120/30] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul, -1 mg/ml vial [INJ] EPINEPHRINE 0.15 MG AUTOINJCT, -0.3 MG AUTO-INJECT [INJ] EPINEPHRINE 0.3 MG/0.3 ML SYR [INJ] EPIPEN [INJ] Tier 1 Restrictions epinephrine hcl 3 [QLL, 4/2] epinephrine hcl 3 epinephrine hcl 2 EPIPEN JR [INJ] epinephrine hcl 2 FLOVENT 100 MCG DISKUS, -50 MCG DISKUS FLOVENT 250 MCG DISKUS fluticasone propionate 2 fluticasone propionate 2 FLOVENT HFA 110 MCG INHALER fluticasone propionate 2 FLOVENT HFA 220 MCG INHALER fluticasone propionate 2 FLOVENT HFA 44 MCG INHALER fluticasone propionate 2 GASTROCROM INTAL cromolyn cromolyn 2 2 1 PULMICORT 180 MCG FLEXHALER budesonide 3 PULMICORT 90 MCG FLEXHALER budesonide 3 QVAR beclomethasone 2 SPIRIVA tiotropium bromide 2 SYMBICORT budesonide/formoterol fum 2 TWINJECT [INJ] epinephrine hcl 3 XOLAIR [INJ][LA] omalizumab 4 ipratropium bromide solution nonoral S7950_2011_DOC7aPC Generic [QLL, 4 pens/2] [QLL, 4 pens/2] [QLL, 120 doses/34] [QLL, 300 doses/34] [QLL, 12 gm/34] [QLL, 36 gm/34] [QLL, 21 gm/34] [QLL, 3 inhalers/34] [QLL, 2 inhalers/34] [QLL, 22 gm/34] [QLL, 60 capsules/34] [QLL, 20 gm/34] [QLL, 4 pens/2] [PAR][QLL, 6/28] © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug Generic Tier Restrictions 4 4 4 [PAR] [PAR] [PAR] tolterodine tartrate tolterodine tartrate oxybutynin 3 3 3 [ST] [ST] [ST] oxybutynin 3 darifenacin hydrobromide 2 1 3 [QLL, 34/34][ST] [ST] OTHER RESPIRATORY DRUGS ARALAST [INJ][LA] PROLASTIN [INJ][LA] ZEMAIRA [INJ][LA] alpha-1-proteinase inhibitor alpha-1-proteinase inhibitor alpha-1-proteinase inhibitor UROLOGICAL MEDICATIONS ANTICHOLINERGIC ANTISPASMODICS DETROL DETROL LA DITROPAN XL 10 MG TABLET, -15 MG TABLET [G] DITROPAN XL 5 MG TABLET, -5 MG TABLET SA [G] ENABLEX flavoxate hcl GELNIQUE oxybutynin oxybutynin chloride syrup, -tablet oxybutynin cl er 10 mg tablet, -cl er 15 mg tablet oxybutynin cl er 5 mg tablet [QLL, 34/34][ST] 1 1 1 OXYTROL oxybutynin 3 SANCTURA SANCTURA XR TOVIAZ VESICARE trospium chloride trospium chloride fesoterodine fumarate solifenacin succinate 2 2 3 3 bethanechol 1 3 [QLL, 34/34] [QLL, 10/35][ST] [ST] [ST] [ST] [ST] CHOLINERGIC STIMULANTS bethanechol chloride tablet URECHOLINE [G] OTHER GENITOURINARY PRODUCTS acetic acid 0.25% irrig soln AVODART S7950_2011_DOC7aPC dutasteride 1 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Drug CYSTADANE betaine hcl Generic cytra-3 cytra-k ELMIRON pentosan polysulfate sodium finasteride FLOMAX [G] tamsulosin glycine solution JALYN K-PHOS M.F. K-PHOS NO.2 K-PHOS ORIGINAL dutasteride/tamsulosin hcl pot acid phos/sod acid phos pot acid phos/sod acid phos potassium acid phosphate neomycin-polymyxin b [INJ] NEOSPORIN G.U. IRRIGANT [INJ] neomycin sulfate/polymyxin potassium citrate tablet sustained action potassium citrate-citric acid PROSCAR [G] RAPAFLO RENACIDIN RIMSO-50 finasteride silodosin gluconic acid/citric acid dimethyl sulfoxide tamsulosin hcl tricitrates UROXATRAL S7950_2011_DOC7aPC alfuzosin hcl Tier 2 1 1 2 1 3 1 3 2 2 2 1 3 1 Restrictions 1 3 3 2 3 1 1 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary Index: 1ST TIER UNIFINE PENTIPS, 80 8-MOP, 55 aa 3%/electrolyte-tpn/glycerin, 88, 89 aabp, 60 a-b otic, 61 abacavir sulfate, 5 abacavir sulfate/lamivudine, 4 abatacept/maltose, 20 abciximab, 86 ABELCET, 13 ABILIFY DISCMELT, 23 ABILIFY INJECTION, 23 ABILIFY SOLUTION, 23 ABILIFY TABLET, 23 abobotulinumtoxina, 83 ABORTIFACIENTS, 94 acamprosate calcium, 37 ACANYA, 52 acarbose, 66, 67 ACCOLATE, 111 ACCUPRIL, 41 ACCURETIC, 49 ACCUSURE, 80 ACCUTANE, 55 acebutolol, 43 acebutolol hcl capsule, 43 ACEON, 41 acetaminophen-codeine, 29 acetasol hc, 61 acetazolamide, 105 acetazolamide capsule sustained action, tablet, 104 acetazolamide sodium, 104 acetic ac/ricinoleic/oxyquinol, 98 acetic acid, 61 acetic acid 0.25% irrig soln, 115 acetic acid solution non-oral, 61 acetic acid/aluminum acetate, 61 acetic acid/hydrocortisone, 61 acetic acid/oxyquin so4, 98 S7950_2011_DOC7aPC acetic acid-aluminum, 61 acetic acid-hydrocortisone, 61 ACID JELLY, 98 ACIPHEX, 73 acitretin, 55 acitretin/emollient comb, 55 ACLOVATE, 56 ACTEMRA 200 MG/10 ML VIAL, -400 MG/20 ML VIAL, 79 ACTEMRA 80 MG/4 ML VIAL, 79 ACTHAR H.P., 68 ACTHIB, 75 ACTHREL, 68 acticin, 55 ACTIGALL, 72 ACTIMMUNE, 78 ACTIQ, 27 ACTIVELLA, 98 ACTONEL 150 MG TABLET, 68 ACTONEL 30 MG TABLET, -5 MG TABLET, 68 ACTONEL 35 MG TABLET, 68 ACTONEL 75 MG TABLET, 68 ACTONEL WITH CALCIUM, 68 ACTOPLUS MET, 66 ACTOPLUS MET XR 15-1,000 MG TB, 66 ACTOPLUS MET XR 30-1,000 MG TB, 66 ACTOS, 66 ACULAR, 108 ACULAR LS, 108 ACULAR PF, 108 ACUVAIL, 108 acyclovir, 11 acyclovir capsule, -suspension oral, -tablet, 10 acyclovir sodium, 10 ACZONE, 52 ADACEL, 75 ADAGEN, 60 ADALAT CC, 43 adalimumab, 19 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary adapalene, 52, 53 adapalene/benzoyl peroxide, 53 ADCIRCA, 51 adcirca (tadalafil), 51 ADDERALL, 30 ADDERALL XR, 31 adefovir dipivoxil, 10 ADOXA, 16 ADOXA PAK, 16 ADRENACLICK, 112 ADRENALIN CHLORIDE INJECTION, 112 ADRENALIN CHLORIDE SOLUTION NONORAL, 112 ADVAIR DISKUS, 112 ADVAIR HFA, 112 advanced care plus, 99 advanced natalcare, 99 ADVICOR 1,000 MG-20 MG TABLET, -1,000 MG-40 MG TABLET, -750 MG-20 MG TABLET, 46 ADVICOR 500 MG-20 MG TABLET, 46 AEROBID, 112 AEROBID-M, 112 afeditab cr, 43 AFINITOR, 18 agalsidase, 69 AGGRASTAT, 86 AGGRENOX, 86 AGRYLIN, 18 A-HYDROCORT, 63 AIMSCO ULTRA THIN II, 80 ak-con, 108 ak-dilate, 108 AKNE-MYCIN, 52 akorn balanced salt, 108 ak-pentolate, 108 ak-poly-bac, 107 AKTEN, 108 aktob, 107 ALA-CORT, 56 ALAMAST, 108 ALA-SCALP HP, 56 S7950_2011_DOC7aPC ALBALON, 108 albendazole, 3 ALBENZA, 3 albumin human, 86, 87, 88 ALBUMINAR-25, 86 alburx, 86 albutein, 86 albuterol, 111 albuterol sulfate nebs, -solution non-oral, syrup, -tablet, -tablet sustained release 12hr, -vial nebulizer, 111 albuterol sulfate/ipratropium, 113 ALCAINE, 108 alclometasone, 56 alclometasone dipropionate, 56 alcohol in dextrose, 86 ALCOHOL PREP PADS, 80 ALCOHOL PREP SWABS, 80 ALCOHOL SWABS, 80 ALCOHOL WIPES, 80 ALDACTAZIDE, 51 ALDACTONE, 51 ALDARA, 58 aldesleukin, 79 ALDURAZYME, 68 alefacept, 18 alemtuzumab, 18 alendronate, 69 alendronate sodium 10 mg tab, -40 mg tab, 5 mg tablet, 68 alendronate sodium 35 mg tab, -70 mg tab, 68 alendronate/vitamin d3, 69 ALFENTA, 27 alfentanil, 27 alfentanil hydrochloride, 27 alfuzosin hcl, 115 alglucerase, 68 alglucosidase alfa, 69 ALIMTA, 18 ALINIA, 8 aliskiren hemifumarate, 50 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary aliskiren/hydrochlorothiazid, 50 aliskiren/valsartan, 50 alitretinoin, 59 ALLEGRA 180 MG TABLET, 110 ALLEGRA 60 MG TABLET, 110 ALLEGRA ODT, 110 ALLEGRA SUSPENSION ORAL, 110 ALLEGRA-D 12 HOUR, 109 ALLEGRA-D 24 HOUR, 110 allersol, 108 allopurinol, 83 allopurinol sodium, 83 allopurinol tablet, 83 almotriptan, 32 ALOCRIL, 108 ALOMIDE, 108 ALOPRIM, 83 ALORA, 97 alosetron, 71 ALOXI, 25 alpha-1-proteinase inhibitor, 114 ALPHAGAN P 0.1% DROPS, 104 ALPHAGAN P 0.15% EYE DROPS, 104 alprostadil, 51 alprostadil injection, 50 ALREX, 106 ALTABAX, 16 ALTACE, 41 altafrin, 108 ALTOPREV, 46 altretamine, 19 aluminum chloride hexahydrate, 58, 59 ALVESCO 160 MCG INHALER, 112 ALVESCO 80 MCG INHALER, 112 amantadine, 10 AMARYL, 66 ambenonium chloride, 37 AMBIEN, 38 AMBIEN CR, 38 AMBISOME, 13 ambrisentan, 46 amcinonide, 56 S7950_2011_DOC7aPC AMEBICIDES, 3 AMERGE, 31 a-methapred, 63 AMEVIVE, 18 AMICAR SYRUP, 60 AMICAR TABLET, 60 amifostine, 18, 19 amikacin sulfate injection, 3 amiloride hcl tablet, 51 amiloride hydrochloride, 51 amiloride-hydrochlorothiazide, 51 amino acids, 86, 87, 88, 89 aminocaproic acid, 60 aminocaproic acid injection, 60 aminocaproic acid syrup, -tablet, 60 AMINOGLYCOSIDES, 3 aminolevulinic acid hcl, 59 aminophylline injection, 112 aminophylline tablet, 112 aminosalicylic acid, 5 AMINOSYN, 86 AMINOSYN II, 86 AMINOSYN II 3.5% M-DEXTROSE 5%, 86 AMINOSYN II 3.5%-DEXTROSE 25%, 86 AMINOSYN II 3.5%-DEXTROSE 5%, 86 AMINOSYN II 4.25% M-DEXT 10%, 87 AMINOSYN II 4.25%-DEXTROSE 25%, 87 AMINOSYN II 5% IN 25% DEXTROSE, 87 AMINOSYN II IN DEXTROSE, 87 AMINOSYN II WITH LYTES-CA-DW, 87 AMINOSYN M, 87 AMINOSYN WITH ELECTROLYTES, 87 AMINOSYN-HBC, 87 AMINOSYN-HF, 87 AMINOSYN-PF, 87 AMINOSYN-RF, 87 amiodarone, 41 amiodarone hcl injection, 41 amiodarone hcl tablet, 41 AMIODARONES, 41 AMITIZA, 71 amitriptyline hcl tablet, 40 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary amitriptyline/chlordiazepoxide, 35 amitriptyline-chlordiazepoxide, 35 amlexanox, 63 amlodipine, 44 amlodipine bes/olmesartan med, 49 amlodipine besylate, 43 amlodipine besylate-benazepril, 49 amlodipine/atorvast cal, 46 amlodipine/valsartan, 49 amlodipine/valsartan/hctz, 49 ammonium chloride, 87 AMMONIUM CHLORIDE INJECTION, 87 ammonium lactate 12% cream, -12% lotion, 58 AMMONUL, 60 amnesteem, 55 amoclan, 13 amox tr-potassium clavulanate, 13 amoxapine, 37 amoxicillin, 13, 14 amoxicillin clavulanate, 13 amoxicillin-clavulanate er, 13 AMOXIL 125 MG/5 ML SUSPENSION, 13 AMOXIL 400 MG/5 ML SUSPENSION, -50 MG/ML PED DROPS, -CAPSULE, -250 MG/5 ML SUSPENSION, 13 amphetamine salt combo, 31 amphetamine/dextroamphetamine, 30, 31 ampho b c-s, 13 AMPHOTEC 100 MG VIAL, 13 AMPHOTEC 50 MG VIAL, 13 amphotericin b injection, 13 amphotericin b lipid complex, 13 amphotericin b liposome, 13 ampicillin sodium, 13, 14 ampicillin sodium/sulbactam na, 14 ampicillin trihydrate, 13 ampicillin-sulbactam, 13 AMPYRA, 60 AMRIX, 82 amylase/lipase/protease, 72, 73 ANADROL-50, 94 S7950_2011_DOC7aPC ANAFRANIL, 40 anagrelide, 18 anagrelide hcl, 18 anakinra, 79 ANALGESICS, 22 ANAMANTLE HC CREAM WITH APPLICATOR, -KIT, 56 ANAMANTLE HC FORTE, 56 ANAPROX, 83 ANAPROX DS, 83 anastrozole, 18 anastrozole tablet, 18 ANCOBON, 8 ANDRODERM, 94 ANDROGEL, 94 ANDROGEN DRUGS, 94 ANDROID, 94 ANDROXY, 94 ANECTINE, 83 ANESTACON, 2 ANESTHETICS, 1 ANGELIQ, 98 ANGIOTENSIN CONVERTING ENZYME INHIBITORS, 41 ANGIOTENSIN II RECEPTOR ANTAGONISTS, 42 anidulafungin, 13 ANSAID, 83 ANTABUSE, 37 ANTARA, 47 ANTHELMINTICS, 3 anthralin, 54, 55 ANTIACNE DRUGS, 52 ANTICHOLINERGIC ANTISPASMODICS, 114 ANTIDEMENTIA DRUGS, 22 ANTIDIARRHEAL DRUGS, 70 ANTIDYSRHYTHMIC DRUGS, 42 ANTIGLAUCOMA DRUGS, 104 ANTIHISTAMINE/DECONGESTANT COMBINATIONS, 109 ANTIHISTAMINES, 110 ANTIINFECTIVES, 3 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary ANTIINFECTIVES SPECIALIZED INDICATIONS, 3 ANTIMANIA DRUGS, 23 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS, 18 ANTIPARKINSON ANTICHOLINERGIC DRUGS, 23 ANTIPLATELET DRUGS, 86 ANTIPRURITIC DRUGS, 54 ANTIPSORIASIS AND ANTIECZEMA DRUGS, 54 ANTIPSYCHOTIC DRUGS, 23 antipyrine/benzocaine, 61 antipyrine-benzocaine, 61 ANTIRETROVIRALS AND PROTEASE INH, 4 ANTISPASMODICS/DRUGS AFFECT GI MOTILITY, 70 ANTI-STICK INSULIN, 80 antithrombin iii, human recomb, 91 antithrombin iii,human, 91 ANTITHYROID DRUGS, 63 ANTITUBERCULOSIS DRUGS, 5 ANTIULCER DRUGS, 71 ANTIVERT, 25 ANTIVERTIGO AND ANTIEMETIC DRUGS, 25 ANTIZOL, 60 ANUSOL-HC, 72 ANXIOLYTICS, 27 ANZEMET INJECTION, 25 ANZEMET TABLET, 25 apap-caffeine-dihydrocodeine, 29 APEXICON, 56 APEXICON E, 56 APHTHASOL, 63 APIDRA, 65 APIDRA SOLOSTAR, 65 APLENZIN, 35 APOKYN, 36 apomorphine hcl, 36 apraclonidine, 105 apraclonidine hcl, 104 aprepitant, 25, 26 S7950_2011_DOC7aPC apri, 94 APRISO, 72 APTIVUS, 4 ARALAST, 114 ARALEN PHOSPHATE, 14 aranelle, 94 ARANESP 100 MCG/0.5 ML AUTOINJ, -100 MCG/0.5 ML SYRINGE, -100 MCG/ML VIAL, -150 MCG/0.3 ML AUTOINJ, -150 MCG/0.3 ML SYRINGE, -150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML AUTOINJ, -200 MCG/0.4 ML SYRINGE, -200 MCG/ML VIAL, -300 MCG/0.6 ML AUTOINJ, -300 MCG/0.6 M, 75 ARANESP 25 MCG/0.42 ML AUTOINJ, -25 MCG/0.42 ML SYRING, -25 MCG/ML VIAL, 40 MCG/0.4 ML AUTOINJ, -40 MCG/0.4 ML SYRINGE, -40 MCG/ML VIAL, 76 ARAVA, 18 ARCALYST, 79 AREDIA 30 MG VIAL, 68 AREDIA 90 MG VIAL, 68 ARESTIN, 63 argatroban, 91 ARGATROBAN, 91 arginine, 89 ARICEPT 10 MG TABLET, -5 MG TABLET, 22 ARICEPT 23 MG TABLET, 22 ARICEPT ODT, 22 ARIMIDEX, 18 aripiprazole, 23 ARISTOSPAN, 63 ARIXTRA 10 MG SYRINGE, -5 MG SYRINGE, 7.5 MG SYRINGE, 90 ARIXTRA 2.5 MG SYRINGE, 90 armodafinil, 31 ARMOUR THYROID, 69 AROMASIN, 18 artemether/lumefantrine, 14 ARTHROTEC 50, 83 ARTHROTEC 75, 83 ASACOL, 72 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary ASACOL HD, 72 ascomp with codeine, 32 asenapine, 25 ASMANEX TWISTHALER 110 MCG #30, 112 ASMANEX TWISTHALER 220 MCG #14, 112 ASMANEX TWISTHALER 220 MCG #30, 113 ASMANEX TWISTHALER 220 MCG #60, 113 ASMANEX TWISTHALR 220 MCG #120, 113 aspirin, 85 aspirin ec 975 mg tablet, 85 aspirin/dipyridamole, 86 ASTELIN, 62 ASTEPRO 0.15% NASAL SPRAY, 62 ASTEPRO 137 MCG NASAL SPRAY, 62 ASTRAMORPH-PF, 27 ATACAND, 42 ATACAND HCT, 49 atazanavir sulfate, 4 atenolol, 43 atenolol tablet, 43 atenolol-chlorthalidone, 49 ATGAM, 76 atomoxetine, 37 atorvastatin calcium, 46 atovaquone, 9 atovaquone/proguanil hcl, 15 ATRALIN, 52 ATRIPLA, 4 atropine care, 108 atropine sulfate, 109 atropine sulfate drops, -ointment, 108 atropine sulfate injection, 37 ATROVENT 0.03% SPRAY, 62 ATROVENT 0.06% SPRAY, 62 ATROVENT HFA, 113 ATRYN, 91 ATTENUVAX VACCINE WITH DILUENT, 76 AUGMENTIN 125-31.25 SUSPEN, -TABLET CHEWABLE, 13 AUGMENTIN 400-57 MG/5 ML, -250-62.5 MG/5 ML, -TABLET, 13 AUGMENTIN ES-600, 13 S7950_2011_DOC7aPC AUGMENTIN XR, 13 auranofin, 85 aurodex, 61 aurodex ear drops, 61 auroguard, 61 AUTO INJECTOR, 80 AUTOJECT 2, 80 AUTONOMIC AND CNS MEDICATIONS, 22 AUTOPEN, 80 AVALIDE, 49 AVANDAMET, 66 AVANDARYL, 66 AVANDIA 2 MG TABLET, -4 MG TABLET, 66 AVANDIA 8 MG TABLET, 66 AVAPRO, 42 AVAR, 53 AVAR LS, 53 AVAR-E, 53 AVAR-E GREEN, 53 AVAR-E LS CREAM, 53 AVASTIN, 18 AVC, 98 AVELOX, 15 AVELOX ABC PACK, 15 AVELOX IV, 15 aviane, 94 AVIDOXY, 16 AVINZA, 27 AVITA, 53 AVODART, 115 AVONEX, 78 AVONEX ADMINISTRATION PACK, 78 AXERT 12.5 MG TABLET, 32 AXERT 6.25 MG TABLET, 32 AXID, 71 AYGESTIN, 103 azacitidine, 21 AZACTAM 1 GM VIAL, 8 AZACTAM 2 GM VIAL, 9 AZACTAM-ISO-OSMOT 1 GM/50 ML, 9 AZACTAM-ISO-OSMOT 2 GM/50 ML, 9 AZASAN, 18 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary AZASITE, 107 azathioprine, 18, 19 azathioprine sodium, 18 azathioprine tablet, 18 azelaic acid, 53 azelastine hcl, 62, 109 azelastine hcl aerosol spray w/pump, 62 azelastine hcl drops, 108 AZELEX, 53 AZILECT, 36 azithromycin, 11, 12, 107 azithromycin 100 mg/5 ml susp, 11 azithromycin 200 mg/5 ml susp, 11 azithromycin 250 mg tablet, 11 azithromycin 500 mg tablet, 11 azithromycin 600 mg tablet, -packet, 11 azithromycin injection, 11 AZMACORT, 113 AZOPT, 104 AZOR, 49 aztreonam, 8, 9 aztreonam 1 gm vial, 9 aztreonam 2 gm vial, 9 aztreonam/dextrose water, 9 AZULFIDINE, 72 azurette, 94 baciim, 9 bacitracin 500 unit/gm ointmnt, 107 bacitracin injection, 9 bacitracin-polymyxin eye oint, 107 baclofen tablet, 83 BACTOCILL, 13 BACTRIM, 15 BACTRIM DS, 15 BACTROBAN, 16 BACTROBAN NASAL, 16 balsalazide disodium, 72 balziva, 94 BANZEL 200 MG TABLET, 34 BANZEL 400 MG TABLET, 34 BARACLUDE SOLUTION, 10 BARACLUDE TABLET, 10 S7950_2011_DOC7aPC basiliximab, 21 baycadron, 63 b-caine/tan ac/menth/cpyrd, 63 bcg vaccine, 21, 78 becaplermin, 59 beclomethasone, 62, 114 BECONASE AQ, 62 benazepril, 41 benazepril hcl, 41 benazepril hcl-hctz, 49 benazepril/amlodipine besylate, 50 benazepril/hctz, 49 benazepril-hydrochlorothiazide, 49 bendroflumethiazide, 52 bendroflumethiazide/nadolol, 49 BENICAR, 42 BENICAR HCT, 49 ben-tann, 110 BENTYL CAPSULE, -SYRUP, -TABLET, 70 BENTYL INJECTION, 70 BENZACLIN, 53 BENZAMYCIN, 53 BENZAMYCINPAK, 53 benzene hexachloride gamma, 55 BENZOTIC, 61 benztropine, 23 benztropine mesylate injection, 23 benztropine mesylate tablet, 23 benzyl alcohol, 55 bepotastine besilate, 108 BEPREVE, 108 besifloxacin, 107 BESIVANCE, 107 BETA-2 ADRENERGIC DRUGS, 111 BETA-ADRENERGIC ANTAGONIST DRUGS, 43 BETADINE SOLUTION, 108 BETAGAN, 104 betaine hcl, 115 betamet diprop/calcipotriene, 55 betameth/propylene glycol, 57 betamethasone, 64 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary betamethasone acetate-sod phos, 63 betamethasone dipropionate, 57 betamethasone dipropionate cream, -gel, lotion, -ointment, 56 betamethasone valerate, 57 betamethasone valerate cream, -lotion, ointment, 56 betamethasone/betamethasone, 63 betanate, 56 BETAPACE, 48 BETAPACE AF, 49 BETASERON, 78 beta-val, 56 betaxolol, 43, 104 betaxolol hcl drops, 104 betaxolol hcl tablet, 43 bethanechol, 115 bethanechol chloride tablet, 115 BETIMOL, 104 BETOPTIC S, 104 bevacizumab, 18 bexarotene, 21 BIAXIN, 11 BIAXIN XL, 11 bicalutamide, 18 BICILLIN C-R, 13 BICILLIN L-A, 13 BIDIL, 51 BILTRICIDE, 3 bimatoprost, 105 bismuth/metronid/tetracyclin, 73 bisoprolol, 43 bisoprolol fumarate, 43 bisoprolol fumarate-hctz, 49 bisoprolol-hydrochlorothiazide, 49 BLEPH-10, 107 BLEPHAMIDE, 105 BLEPHAMIDE S.O.P., 105 BLOOD DETOXICANTS, 86 BONIVA 150 MG TABLET, 68 BONIVA 2.5 MG TABLET, 68 BONIVA INJECTION, 68 S7950_2011_DOC7aPC BOOSTRIX, 76 borofair, 61 bortezomib, 21 bosentan, 46 BOTOX, 108 botulinum toxin a, 108 bp 10-1, 53 BRANCHAMIN, 87 BREVICON, 94 brimonidine 0.2% eye drop, 105 brimonidine tartrate, 104 brimonidine tartrate 0.15% drp, 105 brimonidine tartrate/timolol, 105 brinzolamide, 104 bromfenac, 109 bromocriptine mesylate, 36 bromocriptine mesylate capsule, -tablet, 36 BSS, 108 BSS PLUS, 108 budeprion sr, 35 budeprion xl, 35 budesonide, 62, 72, 113, 114 budesonide/formoterol fum, 114 bumetanide injection, 48 bumetanide tablet, 48 BUMINATE, 87 BUPHENYL, 60 bupivacaine, 1, 2 bupivacaine hcl injection, 1 bupivacaine hcl/dextrose-h2o, 1, 2 bupivacaine hcl-epinephrine, 1 bupivacaine hydrochloride/epi, 1, 2 bupivacaine-dextrose, 1 BUPRENEX, 22 buprenorphine, 22, 30 buprenorphine hcl tablet sublingual, 29 buprenorphine injection, 22 buprenorphine/naloxone, 30 buproban, 40 bupropion, 36, 40 bupropion hbr, 35 bupropion hcl, 35 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary bupropion hcl sr 100 mg tab, -100 mg tablet, -200 mg tab, 35 bupropion sr 150 mg tablet, 35 bupropion xl, 35 BUSPAR, 27 buspirone, 27 buspirone hcl tablet, 27 butalbital compound-codeine, 32 butalbital-caff-apap-codeine, 32 butenafine, 12 butoconazole, 17 butorphanol tartrate aerosol spray, 32 butorphanol tartrate injection, 22 BYETTA 10 MCG DOSE PEN INJ, 65 BYETTA 5 MCG DOSE PEN INJ, 65 BYSTOLIC, 43 cabergoline, 68 CADUET, 46 CAFCIT INJECTION, 31 CAFCIT SOLUTION, 112 CAFERGOT, 32 caffeine citrate injection, 31 caffeine citrate solution, 112 caffeine citrated, 31, 112 CALAN, 43 CALAN SR, 44 CALCIJEX, 93 calcipotriene, 54 calcitonin, 69 calcitonin-salmon, 68 calcitriol, 55, 93 calcitriol capsule, -solution, 93 calcitriol injection, 93 calcium acetate, 93 CALCIUM ANTAGONISTS, 43 calcium chloride injection, 87 cal-nate, 99 camila, 103 CAMPATH, 18 CAMPRAL, 37 canakinumab, 79 CANASA, 72 S7950_2011_DOC7aPC CANCIDAS, 13 candesartan cilexetil, 42 candesartan cilexetil/hctz, 49 CANTIL, 70 CAPASTAT SULFATE, 5 CAPEX SHAMPOO, 56 CAPITAL W-CODEINE, 30 CAPOTEN, 41 capreomycin, 5 captopril, 41 captopril tablet, 41 captopril-hydrochlorothiazide, 49 CARAC, 58 CARAFATE SUSPENSION ORAL, 72 CARAFATE TABLET, 72 carbachol, 105 carbamazepine, 27 carbamazepine suspension oral, -tablet, tablet chewable, 27 carbamazepine xr, 27 CARBAMAZEPINES, 27 CARBATROL, 27 carbidopa, 36 carbidopa/levodopa, 36 carbidopa/levodopa/entacap, 36, 37 carbidopa-levodopa, 36 carbinoxamine maleate, 110 CARBOCAINE, 1 carboprost tromethamine, 94 CARDIAC GLYCOSIDES, 45 CARDIOVASCULAR MEDICATIONS, 41 CARDIZEM, 44 CARDIZEM CD, 44 CARDIZEM LA, 44 CARDURA 1 MG TABLET, -2 MG TABLET, -4 MG TABLET, 52 CARDURA 8 MG TABLET, 52 CARDURA XL, 52 carenatal dha, 99 CARIMUNE NF NANOFILTERED, 76 carisoprodol, 83 carisoprodol compound, 82 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary carisoprodol compound-codeine, 82 carisoprodol tablet, 82 CARMOL HC, 56 CARNITOR INJECTION, 93 CARNITOR SF, 93 CARNITOR SOLUTION, -TABLET, 93 carteolol hcl, 105 cartia xt, 44 carvedilol, 43 CASODEX, 18 caspofungin acetate, 13 CATAFLAM, 83 CATAPRES, 45 CATAPRES-TTS 1, 45 CATAPRES-TTS 2, 45 CATAPRES-TTS 3, 45 cavan one omega, 99 cavan-alpha kit, 99 cavan-ec sod dha, 99 CAVIRINSE, 89 caziant, 95 CEDAX, 5 CEENU, 18 cefaclor, 5, 6 cefaclor er, 5 cefadroxil, 6 cefazolin 1 gm add-van vial, -1 gm vial, -1 gm-d5w bag, -10 gm vial, -20 gm bulk vial, -500 mg vial, 6 cefdinir, 6 cefditoren pivoxil, 6 cefepime, 6 cefepime hcl, 6 cefixime, 7 cefotaxime, 6 cefotaxime sodium, 6 cefotetan, 6 cefoxitin, 6 cefoxitin sodium, 6 cefpodoxime, 7 cefpodoxime proxetil, 6 cefprozil, 6 S7950_2011_DOC7aPC ceftazidime, 6, 7 ceftibuten, 5 CEFTIN, 6 ceftriaxone, 6 cefuroxime, 7 cefuroxime axetil, 6 cefuroxime injection, 6 cefuroxime sod 1.5 gm vial, -sod 7.5 gm vial, -sod 750 mg vial, 6 cefuroxime tablet, 6 CELEBREX, 83 celecoxib, 83 CELESTONE INJECTION, 63 CELESTONE SOLUTION ORAL, 64 CELEXA SOLUTION, 38 CELEXA TABLET, 38 CELLCEPT CAPSULE, 18 CELLCEPT INJECTION, 18 CELLCEPT TABLET, -SUSPENSION RECONSTITUTED ORAL, 18 CELONTIN, 40 CENESTIN, 97 CENTANY, 16 CENTRALLY ACTING ANTIHYPERTENSIVES, 45 cephalexin, 6 CEPHALOSPORINS, 5 CEREBYX, 33 CEREDASE, 68 CEREZYME, 68 cerovel, 58 certolizumab pegol, 19 CERVARIX, 76 CERVIDIL, 94 CESAMET, 25 cesia, 95 cetirizine 1 mg/1 ml soln, -1 mg/ml soln, -1 mg/ml syrup, -5 mg/5 ml syrup, 110 cevimeline, 63 CHANTIX, 40 CHEMET, 60 CHENODAL, 72 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary chenodiol, 72 chlorambucil, 19 chloramphenicol sod succinate, 7 CHLORAMPHENICOLS, 7 chlorhexidine gluconate mouthwash, 63 chloroprocaine, 2 chloroprocaine hcl, 1 chloroquine phosphate, 14 chloroquine phosphate tablet, 14 chlorothiazide, 51, 52 chlorothiazide sodium, 51, 52 chloroxylenol-pramoxine hcl, 61 chlorpromazine hcl injection, 23 chlorpromazine hcl tablet, 23 chlorthalidone, 51, 52 chlorthalidone/atenolol, 50 chlorzoxazone, 82 cholestyramine, 47 cholestyramine light, 47 cholestyramine/aspartame, 47 cholestyramine/sucrose, 47 choline mag trisalicylate, 85 CHOLINERGIC STIMULANTS, 115 ciclesonide, 62, 112 ciclopirox, 12 ciclopirox cream, -gel, -kit, -shampoo, suspension topical, 12 ciclopirox solution non-oral, 12 ciclopirox/nail lacquer remov, 12 cidofovir, 11 cilostazol, 86 CILOXAN, 107 cimetidine 200 mg tablet, -300 mg tablet, 400 mg tablet, -800 mg tablet, -solution, 71 cimetidine injection, 71 CIMZIA, 19 cinacalcet hcl, 69 CIPRO, 15 CIPRO HC, 61 CIPRO I.V., 15 CIPRO XR, 15 S7950_2011_DOC7aPC CIPRODEX, 61 ciprofloxacin, 15, 107 ciprofloxacin er, 15 ciprofloxacin hcl drops, 107 ciprofloxacin hcl tablet, 15 ciprofloxacin/dexameth, 61 ciprofloxacin/hc, 61 ciprofloxacin-d5w, 15 citalopram, 38 citalopram hbr, 38 CITRANATAL 90 DHA, 99 CITRANATAL DHA, 99 CITRANATAL RX, 99 CLAFORAN, 6 claravis, 55 CLARIFOAM EF, 53 CLARINEX SYRUP, 110 CLARINEX TABLET, -TABLET DISPERSIBLE LINGUAL, 110 CLARINEX-D 12 HOUR, 110 CLARINEX-D 24 HOUR, 110 clarithromycin, 11 clarithromycin er, 11 CLASS II NARCOTICS, 27 CLASS III NARCOTICS, 29 clemastine fum 2.68 mg tab, -syrup, 110 clenia cleanser, 53 CLENIA CREAM, 53 CLEOCIN, 98 CLEOCIN HCL, 7 CLEOCIN PALMITATE, 7 CLEOCIN PHOSPHATE, 7 CLEOCIN PHOSPHATE IN D5W, 7 CLEOCIN T, 53 CLIMARA, 97 CLIMARA PRO, 98 clinda-derm, 53 CLINDAGEL, 53 CLINDAMAX CREAM WITH APPLICATOR, 98 CLINDAMAX GEL, -LOTION, 53 clindamycin hcl, 7 clindamycin hcl capsule, 7 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary clindamycin palmitate, 7 clindamycin palmitate hcl, 7 clindamycin phos/benz per, 52 clindamycin phosphate, 7, 53, 98 clindamycin phosphate cream with applicator, 98 clindamycin phosphate foam, -gel, -lotion, solution non-oral, -swab medicated, 53 clindamycin phosphate injection, 7 clindamycin/benz per/hyalur na, 53 clindamycin/benzoyl prx/skn #5, 53 clindamycin/tretinoin, 54 clindamycin-benzoyl peroxide, 53 CLINDAMYCINS, 7 CLINDAREACH, 53 CLINDESSE, 98 CLINDETS, 53 CLINIMIX, 87 CLINIMIX E, 87 CLINISOL, 87 CLINORIL, 83 clobetasol emollient, 56 clobetasol propionate, 56, 58 clobetasol propionate cream, -foam, -gel, ointment, -solution non-oral, 56 CLOBEX, 56 clocortolone pivalate, 56 CLODERM, 56 clomipramine, 40 clomipramine hcl capsule, 40 clonidine, 45 clonidine hcl injection, 45 clonidine hcl tablet, 45 clonidine hcl/chlorthalidone, 49 clopidogrel, 86 CLORPRES, 49 clotrimazole 1% cream, -1% solution, -af 1% cream, 12 clotrimazole troche, 8 clotrimazole/betamethasone, 17 clotrimazole-betamethasone, 17 clozapine, 23 S7950_2011_DOC7aPC CLOZARIL, 23 CNL 8, 12 CNS MUSCLE RELAXANTS, 82 CNS STIMULANT DRUGS, 30 COARTEM, 14 codeine phosphate injection, 27 codeine phosphate/apap, 30 codeine sulfate, 28 codeine/apap/caffeine/butalb, 32 codeine/asa/caffeine/butalb, 32 COGENTIN, 23 co-gesic, 30 COGNEX, 22 COLAZAL, 72 colchicine, 83 COLCRYS, 83 colesevelam, 47 COLESTID, 47 colestipol, 47 colestipol hcl, 47 colistimethate 150 mg vial, 9 colistimethate, sodium, 9 collagenase, 59 collagenase clostridium hist., 60 COLOCORT, 72 COLY-MYCIN M PARENTERAL, 9 COLY-MYCIN S, 61 COLYTE, 72 COLYTE WITH FLAVOR PACKETS, 72 combi rx, 99 COMBIGAN, 105 COMBIPATCH, 98 COMBIVENT, 113 COMBIVIR, 4 COMBUNOX, 28 COMPAZINE INJECTION, 25 COMPAZINE SYRUP, 25 complete allergy medicine, 110 complete natal dha, 99 completenate, 99 compro, 25 COMTAN, 36 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary COMVAX, 76 co-natal fa, 99 CONCEPT DHA, 99 CONCEPT OB, 99 CONCERTA, 31 CONDYLOX GEL, 55 CONDYLOX SOLUTION NON-ORAL, 55 constulose, 86 CONTRACEPTIVES, 94 CONTROL RX, 89 COPAXONE, 60 COPEGUS, 10 CORDARONE, 41 CORDRAN LOTION, -OINTMENT, 56 CORDRAN SP, 56 CORDRAN TAPE MEDICATED, 56 COREG, 43 COREG CR, 43 CORGARD, 43 CORLOPAM, 49 cormax, 56 CORTEF, 64 CORTENEMA, 72 corticorelin ovine triflutate, 68 corticotropin, 68 CORTIFOAM, 72 cortisone tablet, 64 CORTISPORIN CREAM, -OINTMENT, 16 CORTISPORIN SUSPENSION DROPS, 105 CORTISPORIN SUSPENSION DROPS, SOLUTION NON-ORAL, 61 CORTISPORIN-TC, 61 cortomycin ointment, 105 cortomycin solution non-oral, -suspension drops, 61 CORVERT, 49 CORZIDE, 49 COSOPT, 105 COUMADIN INJECTION, 91 COUMADIN TABLET, 91 COVERA-HS, 44 COZAAR, 42 S7950_2011_DOC7aPC CREON, 72 CRESTOR 10 MG TABLET, -20 MG TABLET, 40 MG TABLET, 46 CRESTOR 5 MG TABLET, 46 CRINONE, 103 CRIXIVAN, 4 CROLOM, 108 cromolyn, 108, 113 cromolyn sodium ampul for nebulization, 113 cromolyn sodium drops, 108 crotamiton, 55 cryselle, 95 CUBICIN, 9 CUPRIMINE, 85 CURAD GAUZE PADS, 80 CURITY ALCOHOL PREPS, 80 CURITY GAUZE SPONGES, 80 CUTIVATE, 56 CYCLESSA, 95 cyclobenzaprine, 82 cyclobenzaprine hcl tablet, 82 CYCLOGYL 0.5% EYE DROPS, -2% EYE DROPS, 108 CYCLOGYL 1% EYE DROPS, 108 cyclopentolate, 108 cyclopentolate hcl, 108 cyclophosphamide tablet, 19 cycloserine, 5 CYCLOSERINE, 5 cyclosporine, 20, 109 cyclosporine capsule, -solution, 19 cyclosporine injection, 19 cyclosporine modified, 19 CYKLOKAPRON, 60 cylate, 108 CYMBALTA 20 MG CAPSULE, -60 MG CAPSULE, 35 CYMBALTA 30 MG CAPSULE, 35 cyproheptadine hcl syrup, -tablet, 110 CYSTADANE, 115 CYSTAGON, 87 cysteamine, 87 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary CYTOMEL, 69 CYTOTEC, 72 CYTOVENE, 10 cytra-2, 92 cytra-3, 115 cytra-k, 115 D.H.E.45, 32 d5w/electrolyte-56 solution, 88 d5w/kcl 10 meq/l iv solution, -30 meq/l iv solution, 87 daclizumab, 79 dalfampridine, 60 dalteparin (porcine), 91 d-amphetamine, 31 danazol capsule, 94 DANTRIUM CAPSULE, 83 DANTRIUM INJECTION, 83 dantrolene, 83 dantrolene sodium, 83 dapsone, 3, 52 DAPSONE, 3 DAPTACEL, 76 daptomycin, 9 DARAPRIM, 14 darbepoetin alfa, 75, 76 darifenacin hydrobromide, 114 darunavir ethanolate, 4 dasatinib, 21 DAYPRO, 84 DAYTRANA, 31 DAZIDOX, 28 DDAVP 4 MCG/ML AMPUL, 68 DDAVP 4 MCG/ML VIAL, 68 DDAVP SOLUTION, -AEROSOL SPRAY W/PUMP, -TABLET, 68 DEBACTEROL, 63 deferasirox, 60 DELATESTRYL, 94 delavirdine mesylate, 4 del-beta, 56 DELESTROGEN, 97 DEMADEX, 48 S7950_2011_DOC7aPC demeclocycline hcl, 16 DEMEROL, 28 DEMSER, 45 DEMULEN 1-50-21, 95 DENAVIR, 10 denosumab, 69 denta 5000 plus, 89 dentagel, 89 DEPACON, 41 depade, 37 DEPAKENE, 41 DEPAKOTE, 41 DEPAKOTE ER, 41 DEPAKOTE SPRINKLE, 41 DEPEN, 85 DEPO-ESTRADIOL, 97 DEPO-MEDROL, 64 DEPO-PROVERA 150 MG/ML VIAL, 103 DEPO-PROVERA 400 MG/ML VIAL, 19 DEPO-SUBQ PROVERA 104, 103 DEPO-TESTOSTERONE, 94 DERMA-SMOOTHE-FS, 56 DERMATOLOGICAL MEDICATIONS, 52 DERMATOP, 57 DERMOTIC, 61 desipramine, 38 desipramine hcl, 37 desloratadine, 110 desmopressin acetate, 68, 69 desmopressin acetate aerosol spray w/pump, -solution, -tablet, 68 desmopressin acetate injection, 68 DESOGEN, 95 desogestrel-ethinyl estradiol, 95, 96 desog-et estra/ethin estra, 95 DESONATE, 57 desonide, 57, 58 desonide cream, -lotion, -ointment, 57 desonide/emollient combo #30, 57 DESOWEN, 57 desoximetasone, 58 desoximetasone cream, -gel, -ointment, 57 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary DESOXYN, 31 desvenlafaxine succinate, 35 DETROL, 114 DETROL LA, 114 dexamethasone, 64, 106 dexamethasone elixir, -solution oral, -tablet, 64 dexamethasone intensol, 64 dexamethasone sodium phosphate drops, 106 dexamethasone sodium phosphate injection, 64 dexasol, 106 dexasporin, 105 dexchlorpheniramine maleate, 110 DEXEDRINE, 31 DEXILANT DR 30 MG CAPSULE, 73 DEXILANT DR 60 MG CAPSULE, 73 dexlansoprazole, 73, 74 dexmethylphenidate, 31 dexmethylphenidate hcl, 31 DEXPAK, 64 dextroamphetamine sulfate, 31 dextroamphetamine-amphetamine, 31 dextrose 10%-1/4ns, 87 dextrose 10%-1/4ns-kcl, 87 dextrose 2.5%-lr 1/2 str sol, 87 dextrose 5%-1/2ns-kcl, 87 dextrose 5%-1/3ns-kcl, 87 dextrose 5%-1/4ns-kcl, 87 dextrose 5%-electrolyte #48, 87 dextrose 5%-electrolyte #75, 87 dextrose 5%-lr iv solution, 92 dextrose 5%-ns-kcl, 87 dextrose in ringers injection, 87 dextrose in water, 87 dextrose with sodium chloride, 87 dextrose/electrolytes, 88 DIABETA, 66 DIABETIC SUPPLIES, 80 DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS, 60 S7950_2011_DOC7aPC DIAGNOSTIC PRODUCTS, 60 DIAMOX SEQUELS, 105 diazoxide, 65 DIBENZYLINE, 45 diclofenac epolamine, 56 diclofenac potassium, 83, 84, 85 diclofenac sodium, 56, 59, 85, 109 diclofenac sodium drops, 108 diclofenac sodium tablet enteric coated, tablet sustained release 24hr, 84 diclofenac sodium/misoprostol, 83 dicloxacillin sodium, 14 dicyclomine, 70 dicyclomine hcl capsule, -syrup, -tablet, 70 dicyclomine hcl injection, 70 didanosine, 4, 5 DIDRONEL, 68 difenoxin/atropine sulfate, 70 DIFFERIN, 53 diflorasone, 56 diflorasone diacetate, 57 DIFLUCAN 100 MG TABLET, -200 MG TABLET, -50 MG TABLET, 8 DIFLUCAN 150 MG TABLET, 8 DIFLUCAN IN DEXTROSE, 13 DIFLUCAN IN SALINE, 13 DIFLUCAN SUSPENSION, 8 diflunisal, 85 difluprednate, 106 digoxin, 45 digoxin injection, 45 digoxin solution, -tablet, 45 dihydrocodeine/apap/caffeine, 30 dihydrocodeine/asa/caffeine, 30 dihydroergotamine, 32 dihydroergotamine mesylate injection, 32 DILACOR XR, 44 DILANTIN 100 MG CAPSULE, 33 DILANTIN 30 MG CAPSULE, -30 MG KAPSEAL, -TABLET CHEWABLE, 33 DILANTIN-125, 33 DILATRATE-SR, 48 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary DILAUDID INJECTION, 28 DILAUDID TABLET, 28 DILAUDID-5, 28 DILAUDID-HP, 28 dilt-cd, 44 diltia xt, 44 diltiazem, 44 diltiazem 24hr er, 44 diltiazem er, 44 diltiazem hcl injection, 44 diltiazem hcl tablet, 44 dilt-xr, 44 diltzac er, 44 dimenhydrinate injection, 25 dimethyl sulfoxide, 115 dinoprostone, 94, 104 DIOVAN, 42 DIOVAN HCT, 49 DIPENTUM, 72 diphenhydramine 12.5 mg/5 ml, -25 mg cap, -50 mg cap, -50 mg capsule, 110 diphenhydramine hcl injection, 110 diphenhydramine tannate, 110 diphenmax, 110 diphenoxylate/atropine sulfate, 70 diphenoxylate-atropine, 70 diphther,pertuss,tetanus vac, 75, 76, 77, 78 DIPHTHERIA-TETANUS TOXOID, 76 dipivefrin, 105 DIPROLENE, 57 DIPROLENE AF, 57 DIPROSONE, 57 dipyridamole, 86 dipyridamole tablet, 86 DIRECT MUSCLE RELAXANTS, 83 diskets, 28 disulfiram, 37 DITROPAN XL 10 MG TABLET, -15 MG TABLET, 114 DITROPAN XL 5 MG TABLET, -5 MG TABLET SA, 114 DIURIL, 52 S7950_2011_DOC7aPC DIURIL SODIUM, 52 divalproex, 41 divalproex sodium, 41 divalproex sodium er, 41 DIVIGEL, 97 dobutamine hcl, 50 dobutamine hcl in dextrose, 50 docosavit, 99 dofetilide, 49 dolasetron mesylate, 25 DOLOPHINE HCL, 28 DOLOREX FORTE, 30 DOMEBORO DROPS, 61 donepezil, 22 dopamine hcl, 50 dopamine hcl in 5% dextrose, 50 DORIBAX, 9 doripenem, 9 DORYX, 16 dorzolamide, 105 dorzolamide hcl, 105 dorzolamide/timolol, 105 dorzolamide-timolol, 105 DOVONEX CREAM, 54 DOVONEX SOLUTION, 54 doxazosin, 52 doxazosin mesylate 1 mg tab, -2 mg tab, -4 mg tab, 52 doxazosin mesylate 8 mg tab, 52 doxepin, 59 doxepin hcl capsule, -solution, 40 doxercalciferol, 93 doxycycline, 16 doxycycline hyclate, 16, 63 doxycycline hyclate 100 mg tab, -capsule, capsule enteric coated, 16 doxycycline hyclate 20 mg tab, 63 doxycycline hyclate injection, 16 doxycycline monohydrate, 16 doxy-lemmon, 16 dp (a) ped/hib conj-tet, 78 dp (a) t-polio/hib conj-tet/pf, 77 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary DRITHOCREME HP, 54 DRITHO-SCALP, 54 dronabinol, 26 dronabinol 10 mg capsule, -5 mg capsule, 25 dronabinol 2.5 mg capsule, 25 dronedarone, 49 droperidol, 1 droperidol injection, 1 DROXIA, 19 DRUGS AFFECTING THE EAR, 60 DRUGS AFFECTING THE NOSE, 62 DRUGS AFFECTING THE THROAT AND MOUTH, 63 DRUGS FOR PHEOCHROMOCYTOMA, 45 DRUGS TO PREVENT AND TREAT GOUT, 83 DRUGS TO PREVENT AND TREAT HEADACHES, 31 DRYSOL, 58 DUAC CS, 53 dualvit ob, 99 DUETACT, 67 DULERA, 113 duloxetine, 35 DURACLON, 45 DURAGESIC, 28 DURAMORPH, 28 DUREZOL, 106 dutasteride, 115 dutasteride/tamsulosin hcl, 115 DYAZIDE, 51 dylix, 112 DYNACIN, 16 DYNACIRC CR, 44 dyphylline, 112 DYRENIUM, 51 DYSPORT, 83 DYTAN, 110 E.E.S. 200, 7 E.E.S. 400, 7 EAR-NOSE-THROAT MEDICATIONS, 60 EASPRIN, 85 EASY COMFORT INSULIN SYRINGE, 80 S7950_2011_DOC7aPC EASY TOUCH NEEDLE DISPOSABLE, SYRINGE EMPTY DISPOSABLE, 80 easygel, 89 echothiophate iodide, 105 EC-NAPROSYN, 84 econazole nitrate cream, 12 EDECRIN, 48 edge ob, 99 EDLUAR, 38 edrophonium, 37 edrophonium/atropine sulfate, 37 efalizumab, 20 efavirenz, 4 EFFER-K 10 MEQ TABLET EFF, -20 MEQ TABLET EFF, 92 effer-k 25 meq tablet eff, 92 EFFEXOR, 35 EFFEXOR XR 150 MG CAPSULE, -37.5 MG CAPSULE, 35 EFFEXOR XR 75 MG CAPSULE, 35 EFFIENT, 86 EFUDEX, 58 ELAPRASE, 68 ELDEPRYL, 36 electrolyte solution/peg's, 72, 73 electrolyte solutions, 88, 89 ELECTROLYTES, IRRIGATING SOLUTIONS, ETC., 86 ELESTAT, 108 ELESTRIN, 97 eletriptan, 33 ELIDEL, 58 ELIGARD, 19 ELIMITE, 55 eliphos, 93 elite ob dha, 99 ELITEK, 19 elite-ob, 99 ELIXOPHYLLIN, 112 ELMIRON, 115 ELOCON, 57 eltrombopag olamine, 79 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary EMADINE, 109 EMBEDA, 28 EMCYT, 19 emedastine difumarate, 109 EMEND 125 MG CAPSULE, -40 MG CAPSULE, 25 EMEND 80 MG CAPSULE, 26 EMEND INJECTION, 26 EMEND TRIFOLD PACK, 26 EMGEL, 53 EMLA, 2 EMSAM, 33 emtricitabine, 4 emtricitabine/tenofovir, 5 emtricitabine/tenofovir/efavir, 4 EMTRIVA, 4 ENABLEX, 114 enalapril, 42 enalapril maleate tablet, 41 enalapril maleate/hctz, 50 enalaprilat, 41 enalapril-hydrochlorothiazide, 49 ENBREL, 19 endocet, 28 ENDOCRINE MEDICATIONS, 63 endodan, 28 ENDOTHELIN RECPTR ANTAGONIST, 46 ENDRATE, 60 endrate disodium, 60 enfuvirtide, 4 ENGERIX-B, 76 ENJUVIA, 97 ENLON, 37 ENLON-PLUS, 37 enoxaparin, 91 enoxaparin 100 mg/ml syr, -30 mg/0.3 ml syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr, -80 mg/0.8 ml syr, 90 enoxaparin 120 mg/0.8 ml syr, -150 mg/ml syr, 90 enpresse, 95 entacapone, 36 S7950_2011_DOC7aPC entecavir, 10 ENTOCORT EC, 72 enulose, 86 ENZYMAX 500 MG TABLET, 72 enzymes, digestive, 72 EPIDUO, 53 epiflur, 89 epiklor, 92 epinastine hcl, 108 epinephrine 0.1 mg/ml syringe, -1 mg/ml ampul, -1 mg/ml vial, 113 EPINEPHRINE 0.15 MG AUTO-INJCT, -0.3 MG AUTO-INJECT, 113 EPINEPHRINE 0.3 MG/0.3 ML SYR, 113 epinephrine hcl, 112, 113, 114 EPIPEN, 113 EPIPEN JR, 113 epitol, 27 EPIVIR, 4 EPIVIR HBV, 10 eplerenone, 51 epoetin alfa, 76, 77 EPOGEN 10,000 UNITS/ML VIAL, -20,000 UNITS/2 ML VIAL, -20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL, 76 EPOGEN 2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -4,000 UNITS/ML VIAL, 76 epoprostenol na, 51 epoprostenol sodium, 51 eprosartan mesylate, 42 eprosartan mesylate/hctz, 50 eptifibatide, 86 EPZICOM, 4 EQUETRO, 27 ERAXIS (ALCOHOL DILUENT), 13 ERAXIS (WATER DILUENT), 13 ergoloid mesylates tablet, 60 ERGOMAR, 32 ergotamine, 32 ergotamine tartrate/caffeine, 32 ergotamine-caffeine, 32 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary erlotinib hcl, 21 errin, 103 ERTACZO, 12 ertapenem sodium, 9 ery, 53 ERYPED 200, 7 ERYPED 400, 7 ERY-TAB, 7 ERYTHROCIN LACTOBIONATE, 7 erythrocin stearate, 7 erythromycin base, 7, 52, 53 erythromycin base/benz per, 53 erythromycin capsule enteric coated, -tablet, 7 erythromycin ethylsuccinate, 7 erythromycin ethylsuccinate tablet, 7 erythromycin gel, -solution non-oral, 53 erythromycin lactobionate, 7 erythromycin ointment, 107 erythromycin-benzoyl peroxide, 53 ERYTHROMYCINS, 7 erythromycin-sulfisoxazole, 15 escitalopram oxalate, 39 ESKALITH, 23 esomeprazole mag trihyd, 74 ESTRACE CREAM WITH APPLICATOR, 97 ESTRACE TABLET, 97 ESTRADERM, 97 estradiol, 97, 98 estradiol cypionate, 97 estradiol patch transdermal weekly, 97 estradiol tablet, 97 estradiol valerate, 97 estradiol valerate injection, 97 estradiol valerate/dienogest, 95 estradiol/drospirenone, 98 estradiol/levonorgestrel, 98 estradiol/noreth ac, 98 estradiol/norgestimate, 98 estradiol-norethindrone acetat, 98 estramustine phosphate sodium, 19 ESTRASORB, 97 S7950_2011_DOC7aPC ESTRING, 97 ESTROGEN DRUGS, 97 estrogen,conjug,synthetic a, 97 estrogen,conjug,synthetic b, 97 estrogen/medroxyprogesterone, 98 ESTROGEN/PROGESTIN COMBINATIONS, 98 estrogens,conjugated, 97 estrogens,esterified, 97 estropipate, 97 ESTROSTEP FE, 95 eszopiclone, 38 etanercept, 19 eth estradiol/drospirenone, 96 ethacrynate sodium, 48 ethacrynic acid, 48 ethambutol, 5 ethambutol hcl tablet, 5 ethedent, 89 ethinyl estradiol/norelgest, 96 ethionamide, 5 ethosuximide, 40 ethotoin, 33 eth-oxydose, 28 ethynodiol diace-eth estradiol, 95 ETHYOL, 19 etidronate, 68 etidronate disodium, 68 etodolac, 84 etonogestrel/ethin estradiol, 96 etravirine, 4 EURAX, 55 EVAMIST, 97 everolimus, 18, 21 EVISTA, 69 EVOCLIN, 53 EVOXAC, 63 EXALGO, 28 EXEL INSULIN SYRINGE, 80 EXELDERM, 12 EXELON, 22 exemestane, 18 exenatide, 65 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary EXFORGE, 49 EXFORGE HCT, 49 EXJADE, 60 EXTAVIA, 78 EXTINA, 12 ezetimibe, 47 ezetimibe/simvastatin, 47 FABRAZYME, 69 FACTIVE, 15 famciclovir, 10 famciclovir 125 mg tablet, 10 famciclovir 250 mg tablet, 10 famciclovir 500 mg tablet, 10 famotidine, 71 famotidine 20 mg tablet, -40 mg tablet, suspension oral, 71 famotidine injection, 71 FAMVIR 125 MG TABLET, 10 FAMVIR 250 MG TABLET, 10 FAMVIR 500 MG TABLET, 10 FANAPT 1 MG TABLET, -10 MG TABLET, -12 MG TABLET, -2 MG TABLET, -4 MG TABLET, -6 MG TABLET, -8 MG TABLET, 23 FANAPT TITRATION PACK, 23 FANSIDAR, 14 FARESTON, 19 FASLODEX, 19 fat emulsions, 93 FAZACLO, 23 fe c plus tablet, 99 febuxostat, 83 felbamate, 34 FELBATOL, 34 FELDENE, 84 felodipine er, 44 fem ph, 98 FEMARA, 19 FEMCON FE, 95 FEMHRT, 98 FEMRING, 97 FEMTRACE, 97 fenofibrate, 47 S7950_2011_DOC7aPC fenofibric acid, 47 FENOFIBRIC ACID, 47 FENOGLIDE, 47 fenoldopam mesylate, 49 fenoprofen, 84 fenoprofen calcium, 84 fentanyl, 28 fentanyl citrate, 27, 28, 29 fentanyl citrate injection, 28 fentanyl citrate loz, 28 FENTORA, 28 fesoterodine fumarate, 115 FEXMID, 82 fexofenadine, 110 fexofenadine hcl 180 mg tablet, 110 fexofenadine hcl 30 mg tablet, -60 mg tablet, 110 fexofenadine-pse er, 110 FIBRICOR, 47 filgrastim, 79 FINACEA, 53 finasteride, 115 FIORICET WITH CODEINE, 32 FIORINAL WITH CODEINE #3, 32 FIRST-HYDROCORTISONE, 57 FIRST-MOUTHWASH BLM, 63 FIRST-PROGESTERONE VGS 100, 103 FIRST-PROGESTERONE VGS 200, 103 FIRST-PROGESTERONE VGS 25, 103 FIRST-PROGESTERONE VGS 400, 103 FIRST-PROGESTERONE VGS 50, 103 FIRST-TESTOSTERONE, 94 FIRST-TESTOSTERONE MC, 94 FLAGYL, 4 FLAGYL ER, 4 FLAREX, 106 flavoxate hcl, 114 flecainide, 42 flecainide acetate, 42 FLECTOR, 56 FLEXBUMIN, 87 FLEXERIL, 82 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary FLOLAN, 51 FLOMAX, 115 FLONASE, 62 FLOVENT 100 MCG DISKUS, -50 MCG DISKUS, 113 FLOVENT 250 MCG DISKUS, 113 FLOVENT HFA 110 MCG INHALER, 113 FLOVENT HFA 220 MCG INHALER, 113 FLOVENT HFA 44 MCG INHALER, 113 FLOXIN, 61 FLOXIN I.V., 15 floxuridine, 19 fluconazole, 8 fluconazole 100 mg tablet, -200 mg tablet, 50 mg tablet, 8 fluconazole 150 mg tablet, 8 fluconazole in dextrose, 13 fluconazole in saline, 13 fluconazole suspension, 8 fluconazole/dextrose-water, 13 fluconazole/sodium chloride, 13 flucytosine, 8 fludrocortisone acetate tablet, 66 FLUMADINE, 10 flumazenil, 37 flunisolide, 62, 112 flunisolide 0.025% spray, 62 flunisolide 29 mcg-0.025% spr, 62 fluocinolone acetonide, 56, 61, 106 fluocinolone acetonide cream, -ointment, solution non-oral, 57 fluocinonide, 58 fluocinonide cream, -gel, -ointment, -solution non-oral, 57 fluocinonide emollient, 57 fluocinonide-e, 57 FLUORABON, 89 FLUOR-A-DAY DROPS, 89 fluor-a-day tablet chewable, 90 FLUORIDE PRODUCTS, 89 fluoridex daily defense, 90 FLUORIDEX SENSITIVITY RELIEF, 90 S7950_2011_DOC7aPC fluoritab tablet chewable, 90 fluorometholone, 106 FLUOROPLEX, 58 fluorouracil, 58 fluorouracil cream, -solution non-oral, 58 fluoxetine, 39, 40 fluoxetine dr, 38 fluoxetine hcl 10 mg capsule, -10 mg tablet, 38 fluoxetine hcl 20 mg capsule, -20 mg tablet, -solution, 39 fluoxetine hcl 40 mg capsule, 39 fluoxymesterone, 94 fluphenazine decanoate, 23 fluphenazine hcl elixir, -solution, -tablet, 23 fluphenazine hcl injection, 23 flura, 90 FLURA-DROPS, 90 flurandrenolide, 56 flurbiprofen, 83, 109 flurbiprofen sodium, 109 flurbiprofen tablet, 84 flutamide, 19 fluticasone furoate, 63 fluticasone propionate, 56, 62, 113 fluticasone propionate cream, -ointment, 57 fluticasone propionate nasal inhaled steroids, 62 fluvastatin, 46 fluvoxamine, 39 fluvoxamine maleate 100 mg tab, 39 fluvoxamine maleate 25 mg tab, 39 fluvoxamine maleate 50 mg tab, 39 FML, 106 FML FORTE, 106 FML S.O.P., 106 FOCALIN, 31 FOCALIN XR, 31 folbecal, 99 folcal dha, 99 folcaps omega-3, 99 folinatal plus b, 99 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary folivane-ec calcium dha nf, 99 folivane-ob, 99 folivane-prx dha nf, 99 foltabs, 99 foltabs 90 plus dha, 99 fomepizole, 60 fondaparinux sodium, 90 FORADIL, 111 formoterol fumarate, 111 FORTAMET, 67 FORTAZ 1 GM ADD-VANTAGE VIAL, -1 GM VIAL, -2 GM VIAL, -6 GM VIAL, 6 FORTAZ 2 GM ADD-VANTAGE VIAL, 6 FORTAZ 500 MG VIAL, 6 FORTAZ IN ISO-OSMOTIC DEXTROSE, 6 FORTEO, 69 fortical, 69 FOSAMAX 10 MG TABLET, -40 MG TABLET, 5 MG TABLET, 69 FOSAMAX 35 MG TABLET, -70 MG TABLET, 69 FOSAMAX PLUS D, 69 FOSAMAX SOLUTION, 69 fosamprenavir calcium, 4 foscarnet, 10 foscarnet sodium, 10 FOSCAVIR, 10 fosfomycin tromethamine, 17 fosinopril, 42 fosinopril sodium, 41 fosinopril-hydrochlorothiazide, 49 fosphenytoin, 33 fosphenytoin sodium, 33 FOSRENOL, 86 FRAGMIN 10,000 UNITS SYRINGE, -10,000 UNITS/ML VIAL, -12,500 UNITS SYRINGE, -15,000 UNITS SYRINGE, -18,000 UNITS SYRINGE, -25,000 UNITS/ML VIAL, -7,500 UNITS SYRINGE, 91 FRAGMIN 2,500 UNITS SYRINGE, -5,000 UNITS SYRINGE, 91 FREAMINE HBC, 87 S7950_2011_DOC7aPC FREAMINE III, 88 FREAMINE III WITH ELECTROLYTES, 88 FROVA, 32 frovatriptan, 32 fudr, 19 fulvestrant, 19 FURADANTIN, 17 furosemide, 48 furosemide injection, 48 furosemide solution, -tablet, 48 FUZEON, 4 gabapentin, 34 gabapentin capsule, -tablet, 34 GABITRIL, 34 galantamine, 22, 23 galantamine hbr, 22 galantamine hydrobromide, 22 galsulfase, 69 GAMASTAN S-D, 76 GAMMAGARD LIQUID, 76 GAMMAGARD S-D, 76 GAMUNEX, 76 ganciclovir, 10, 109 ganciclovir sodium, 10 GANTRISIN, 15 GARDASIL, 76 GASTROCROM, 113 GASTROINTESTINAL MEDICATIONS, 70 gatifloxacin, 107 gavilyte-c, 72 gavilyte-g, 72 gavilyte-n, 72 gefitinib, 19 GEL-KAM, 90 GELNIQUE, 114 gemfibrozil, 47 gemifloxacin, 15 generlac, 86 gengraf, 19 GENOTROPIN 12 MG CARTRIDGE, -5 MG CARTRIDGE, 75 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary GENOTROPIN MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, MINIQUICK 0.8 MG, -MINIQUICK 1 MG, MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, MINIQUICK 2 MG, 75 gentak, 107 gentamicin 0.1% ointment, -cream, 16 gentamicin 100 mg/ns 100 ml, -60 mg/ns 50 ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50 ml pb, -90 mg/ns 100 ml pb, -gentamicin 100 mg/100 ml, -gentamicin 60 mg/50 ml, -gentamicin 80 mg/50 ml, 3 gentamicin 3 mg/gm eye oint, 107 GENTAMICIN 60 MG/NS 100 ML PB, -80 MG/NS 100 ML PB, -GENTAMICIN 100 MG/50 ML, -GENTAMICIN 60 MG/100 ML, GENTAMICIN 80 MG/100 ML, 3 gentamicin sulfate drops, 107 gentamicin sulfate injection, 3 gentamicin/prednisolone, 106 gentamicin/sodium chloride, 3 gentasol, 107 gentex ade, 99 GEODON CAPSULE, 24 GEODON INJECTION, 24 GESTICARE, 99 GESTICARE DHA, 99 gianvi, 95 gildess fe, 95 glatiramer acetate, 60 GLEEVEC, 19 glimepiride, 66, 67 glipizide, 67 glipizide er, 67 glipizide tablet, 67 glipizide xl, 67 glipizide/metformin hcl, 67 glipizide-metformin, 67 GLUCAGEN, 65 GLUCAGON EMERGENCY KIT, 65 glucagon, human recombinant, 65 S7950_2011_DOC7aPC GLUCOCORTICOID DRUGS, 63 gluconic acid/citric acid, 115 GLUCOPHAGE, 67 GLUCOPHAGE XR, 67 GLUCOPRO SYRINGE EMPTY DISPOSABLE, 80 GLUCOSE ELEVATING DRUGS, 65 GLUCOTROL, 67 GLUCOTROL XL, 67 GLUCOVANCE, 67 GLUMETZA, 67 glyburide, 66, 67 glyburide micronized, 67 glyburide/metformin hcl, 67 glyburide-metformin hcl, 67 glycerin liquid, 71 glycine solution, 115 glycopyrrolate, 71 glycopyrrolate injection, 70 glycopyrrolate tablet, 70 glycron, 67 GLYNASE, 67 GLYSET, 67 gold sodium thiomalate, 85 golimumab, 21 GOLYTELY, 72 GORDO-UREA, 58 goserelin acetate, 21 granisetron, 26 granisetron hcl injection, 26 granisetron hcl tablet, 26 granisol, 26 GRIFULVIN V SUSPENSION ORAL, 8 GRIFULVIN V TABLET, 8 griseofulvin microsize, 8 griseofulvin suspension oral, 8 griseofulvin ultramicrosize, 8 GRIS-PEG, 8 GROWTH HORMONES AND RELATED DRUGS, 75 guanabenz acetate, 45 guanfacine, 37, 45 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary guanfacine hcl, 45 guanidine hcl, 37 GYNAZOLE-1, 17 GYNODIOL, 97 haemophilus b vaccine, 76, 77 haemophilus b-tet toxoid, 75, 76 halcinonide, 57 HALDOL, 24 HALDOL DECANOATE 100, 24 HALDOL DECANOATE 50, 24 HALFAN, 14 HALFLYTELY-BISACODYL, 72 halobetasol prop/amonium lac, 57, 58 halobetasol propionate, 57, 58 halofantrine, 14 HALOG, 57 HALONATE, 57 halonate pac, 57 haloperidol, 24 haloperidol decanoate, 24 haloperidol lactate injection, 24 haloperidol lactate solution, 24 haloperidol tablet, 24 HAVRIX, 76 hc acetate/lidocaine hcl, 56, 57, 58 hctz/bisoprolol fumarate, 50 hctz/metoprolol, 49 hctz/triamterene, 51 hctz/valsartan, 49 HECTOROL CAPSULE, 93 HECTOROL INJECTION, 93 HELIDAC, 73 HEMABATE, 94 hemin, 60 hep b vaccine/dp (a) t-polio, 77 hep b vir recomb/hep a vir, 78 hep.b immune glob/maltose, 76 HEPAGAM B, 76 HEPARIN ANTAGONISTS, 90 heparin sodium in 0.45% nacl, 91 heparin sodium in 0.9% nacl, 91 heparin sodium in 5% dextrose, 91 S7950_2011_DOC7aPC heparin sodium injection, 91 HEPATAMINE, 88 HEPATASOL, 88 hepatatis a virus vaccine, 76, 78 hepatitis b immune globulin, 76 hepatitis b virus vaccine, 76, 77 hepatitis b/haemophilus b vacc, 76 HEPSERA, 10 HESPAN, 60 hetastarch in ns, 60 hetastarch/e-lytes,lactate, 60 hetastarch/na chlor 0.9%, 60 hexachlorophene, 17 HEXALEN, 19 HEXTEND LACTATED ELECTROLYTE, 60 HIBERIX, 76 HIBTITER, 76 hip prenatal, 99 HIPREX, 17 histrelin ac, 21, 104 HIZENTRA 1 GRAM/5 ML VIAL, 76 HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20 ML VIAL, 76 HMG-COA REDUCTASE INHIBITORS, 46 homatropaire, 109 homatropine, 109 homatropine hbr, 109 HUMALOG, 65 HUMALOG MIX 50-50, 65 HUMALOG MIX 75-25, 65 HUMAN ALBUMIN 25% IV SOLUTION, 88 human papillomav vacc bival/pf, 76 human papillomavirus vacc, 76 HUMAPEN LUXURA HD, 80 HUMAPEN MEMOIR, 80 HUMATROPE, 75 HUMIRA 20 MG/0.4 ML SYRINGE, -40 MG/0.8 ML SYRINGE, 19 HUMIRA 40 MG/0.8 ML PEN, -CROHN'S STARTER PACK, -PSORIASIS STARTER PACK, 19 HUMULIN 50-50, 65 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary HUMULIN 70-30, 65 HUMULIN N, 65 HUMULIN R, 65 HYCET, 30 HYDANTOINS, 33 hydralazine hcl injection, 52 hydralazine hcl tablet, 52 hydra-zide, 49 HYDREA, 19 HYDRO 35, 59 HYDRO 40, 59 hydrochlorothiazide, 52 hydrochlorothiazide capsule, -tablet, 52 hydrocodone bitartrate/apap, 30 hydrocodone bitartrate/ibuprof, 30 hydrocodone bit-ibuprofen, 30 hydrocodone-acetaminophen, 30 hydrocortisone, 56, 57, 58, 64, 72, 73 hydrocortisone 1% absorbase, -1% cream, 1% lotion, -1% oin, -1% oint, -1% ointment, -2.5% cream, -2.5% lotion, 2.5% ointment, -aloe 1% cream, -plus 1% cream, 57 hydrocortisone acetate, 72 hydrocortisone acetate/urea, 56, 58 hydrocortisone buteprate, 58 hydrocortisone butyrate, 57 hydrocortisone enema, 73 hydrocortisone sod succinate, 63, 64 hydrocortisone tablet, 64 hydrocortisone valerate, 57, 58 hydrocortisone/emol no.45, 58 hydrogesic, 30 hydromorphone, 28 hydromorphone hcl injection, 28 hydromorphone hcl suppository rectal, tablet, 28 hydroxychloroquine, 15 hydroxychloroquine sulfate tablet, 14 hydroxypropylmethylcellulose, 109 hydroxyurea, 19 hydroxyurea capsule, 19 S7950_2011_DOC7aPC hydroxyzine hcl injection, 54 hydroxyzine hcl syrup, -tablet, 54 hydroxyzine pamoate, 54 hydroxyzine pamoate capsule, 54 hypercare, 59 HYPERHEP B S-D, 76 HYPERLYTE CR, 88 HYPERRAB S-D, 76 HYPERRHO S-D, 76 HYPERTET S-D, 76 HYPOGLYCEMIC DRUGS, 65 HYPOLIPOPROTEINEMICS, 47 HYZAAR, 49 ibandronate, 68 IBUDONE, 30 ibuprofen 100 mg/5 ml, -100 mg/5 ml sus, 100 mg/5 ml susp, -400 mg tablet, -600 mg tablet, -800 mg tablet, 84 ibuprofen lysine, 85 ibutilide fumarate, 49 ICAR-C PLUS, 99 idursulfase, 68 ILARIS, 79 iloperidone, 23 imatinib mesylate, 19 IMDUR, 48 imiglucerase, 68 imipenem/cilastatin sodium, 9 imipramine hcl, 41 imipramine hcl tablet, 40 imipramine pamoate, 40, 41 imiquimod, 58, 59 IMITREX 20 MG NASAL SPRAY, 32 IMITREX 4 MG/0.5 ML SYRNG KIT, -6 MG/0.5 ML SYRNG KIT, 32 IMITREX 5 MG NASAL SPRAY, 32 IMITREX 6 MG/0.5 ML VIAL, -4 MG/0.5 ML KIT REFILL, -6 MG/0.5 ML KIT REFILL, 32 IMITREX TABLET, 32 immune globulin - im, 76 immune globulin - iv, 76, 77 immune globulin- sq, 76, 78 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary IMMUNOLOGICALS AND VACCINES, 75 IMOGAM RABIES-HT, 76 IMOVAX RABIES VACCINE, 77 IMURAN, 19 IN CONTROL PEN NEEDLE, 80 INAPSINE, 1 inatal advance, 99 inatal gt, 99 inatal ultra, 100 INCRELEX, 78 indapamide, 52 INDERAL LA, 43 indinavir, 4 INDOCIN I.V., 84 INDOCIN SR, 84 INDOCIN SUPPOSITORY RECTAL, 84 INDOCIN SUSPENSION ORAL, 84 indomethacin, 84 indomethacin capsule, -capsule sustained action, 84 indomethacin injection, 84 indomethacin sodium trihydrate, 84 INFANRIX, 77 INFERGEN, 78 infliximab, 20 INFUMORPH, 28 INJECTABLE ANTICOAGULANTS, 90 INJECT-EASE, 80 INNOHEP, 91 INNOPRAN XL, 43 INSPRA, 51 INSULIN, 65 INSULIN LIKE GROWTH FACTORS-1, 78 INSULIN PEN NEEDLE, 80 INSULIN SYRINGE, 80 INSUMED, 80 INSUPEN, 80 INTAL, 113 INTEGRA SYRINGE SYRINGE EMPTY DISPOSABLE, 80 INTEGRILIN, 86 INTELENCE, 4 S7950_2011_DOC7aPC interferon alfa-2b , recomb., 78 interferon alfacon-1, 78 interferon beta-1a, 78 interferon beta-1a/albumin, 79 interferon beta-1b, 78 interferon gamma-1b,recomb., 78 INTERFERONS, 78 INTERLEUKIN RECPTR ANTAGONIST, 79 INTERLEUKINS, 79 INTRALIPID 10% IV FAT EMUL, -20% IV FAT EMUL, 93 INTRALIPID 30% IV FAT EMUL, 93 INTRON A 10 MILLION UNIT PEN, -10 MILLION UNIT/ML, -18 MILLION UNITS VIAL, -5 MILLION UNIT/ML PEN, -50 MILLION UNITS VIAL, -6 MILLION UNIT/ML VL, 78 INTRON A 10 MILLION UNITS VIAL, -3 MILLION UNIT/ML PEN, 78 INTUNIV, 37 INVANZ 1 GM ADD-VANTAGE VIAL, 9 INVANZ 1 GM VIAL, 9 INVEGA ER 1.5 MG TABLET, -ER 3 MG TABLET, -ER 9 MG TABLET, 24 INVEGA ER 6 MG TABLET, 24 INVEGA SUSTENNA 117 MG PREF SY, -156 MG PREF SY, -234 MG PREF SY, 24 INVEGA SUSTENNA 39 MG PREF SYR, -78 MG PREF SYR, 24 INVIRASE, 4 IONOSOL B WITH DEXTROSE 5%, 88 IONOSOL MB-DEXTROSE 5%, 88 IONOSOL T-DEXTROSE 5%, 88 IOPIDINE, 105 IPOL, 77 ipratropium, 62, 113 ipratropium 0.03% spray, 62 ipratropium 0.06% spray, 62 ipratropium bromide solution non-oral, 113 IQUIX, 107 irbesartan, 42 irbesartan/hctz, 49 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary IRESSA, 19 iron,carbonyl/vit c/vit b12/fa, 99 IRRITABLE BOWEL DRUGS, 71 ISENTRESS, 4 ISMO, 48 ISO GENTAMICIN 120 MG/100 ML, GENTAMICIN 120 MG/50 ML, GENTAMICIN 40 MG/100 ML, GENTAMICIN 40 MG/50 ML, 3 isocarboxazid, 34 ISOCHRON, 48 ISOLYTE H WITH DEXTROSE, 88 ISOLYTE M WITH DEXTROSE, 88 ISOLYTE P WITH DEXTROSE, 88 ISOLYTE S, 88 ISOLYTE S WITH DEXTROSE, 88 isonarif, 5 isoniazid injection, 5 isoniazid syrup, -tablet, 5 isoproterenol hcl, 50 ISOPTIN SR, 44 ISOPTO ATROPINE, 109 ISOPTO CARBACHOL, 105 ISOPTO CARPINE, 105 ISOPTO HOMATROPINE, 109 ISOPTO HYOSCINE, 109 ISORDIL, 48 ISORDIL TITRADOSE, 48 isosorb dinit/hydralazine hcl, 51 isosorbide dinitrate, 48 isosorbide mononitrate, 48 isotretinoin, 55 isradipine, 44 ISTALOL, 105 ISUPREL, 50 itraconazole, 8 itraconazole capsule, 8 ivermectin, 3 IXIARO, 77 JALYN, 115 jantoven, 91 JANUMET, 67 S7950_2011_DOC7aPC JANUVIA, 67 japanese encephalitis vaccine, 77 JE-VAX, 77 jolessa, 95 jolivette, 103 junel, 95 junel fe, 95 k effervescent, 92 KADIAN, 28 KALETRA 100-25 MG TABLET, 4 KALETRA 200-50 MG TABLET, -SOLUTION, 4 kalexate, 91 kanamycin sulfate, 3 KAOCHLOR, 92 kaon-cl 10, 92 KAPIDEX DR 30 MG CAPSULE, 74 KAPIDEX DR 60 MG CAPSULE, 74 kariva, 95 KAY CIEL, 92 KAYEXALATE, 91 kcl 20 meq in d5w solution, -20 meq/l iv solution, -40 meq in d5w solution, -40 meq/l iv solution, 92 kcl 20 meq in d5w-lact ringer, -40 meq in d5w-lact ringer, 92 kcl 40 meq in d5w-lact ringer, 88 KEFLEX, 6 kelnor 1-35, 95 KENALOG, 57 KENALOG-10, 64 KENALOG-40, 64 KEPIVANCE, 77 KEPPRA INJECTION, 34 KEPPRA SOLUTION, -TABLET, 34 KEPPRA XR, 34 KERAFOAM, 59 keratol 40, 59 keratol plus, 59 KERATOLYTIC DRUGS, 55 KERLONE, 43 KETEK, 8 ketoconazole, 12 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary ketoconazole cream, -shampoo, 12 ketoconazole tablet, 8 KETOLIDES, 8 ketoprofen capsule, -capsule 24hr sustained release pellets, 84 ketorolac, 85, 108 ketorolac tromethamine drops, 109 ketorolac tromethamine injection, 84 ketorolac tromethamine tablet, 84 KINERET, 79 KIONEX POWDER, 91 kionex suspension oral, 92 KLARON, 54 klor-con 10, 92 klor-con 20 meq packet, 92 KLOR-CON 25 MEQ PACKET, 92 klor-con 8, 92 klor-con m10, 92 klor-con m15, 92 klor-con m20, 92 klor-con-ef, 92 kolnatal dha, 100 K-PHOS M.F., 115 K-PHOS NEUTRAL, 92 K-PHOS NO.2, 115 K-PHOS ORIGINAL, 115 KRISTALOSE, 86 K-TAB, 92 KURIC, 12 KUVAN, 69 KYTRIL INJECTION, 26 KYTRIL TABLET, 26 labetalol, 43 labetalol hcl injection, 43 labetalol hcl tablet, 43 LAC-HYDRIN, 59 LACLOTION, 59 lacosamide, 34, 35 LACRISERT, 109 lactate, ammonium, 59 lactated ringers injection, 88 LACTOCAL-F, 100 S7950_2011_DOC7aPC lactulose, 86 LAMICTAL, 34 LAMICTAL (BLUE), 34 LAMICTAL (GREEN), 34 LAMICTAL (ORANGE), 34 LAMICTAL ODT, 34 LAMICTAL ODT (BLUE), 34 LAMICTAL ODT (GREEN), 34 LAMICTAL ODT (ORANGE), 34 LAMICTAL XR, 34 LAMICTAL XR (BLUE), 34 LAMICTAL XR (GREEN), 34 LAMICTAL XR (ORANGE), 34 LAMISIL PKT, 8 LAMISIL SOLUTION, 12 LAMISIL TABLET, 8 lamivudine, 4, 10 lamivudine/zidovudine, 4 lamotrigine, 34 LANOXIN INJECTION, 45 LANOXIN PEDIATRIC, 45 LANOXIN TABLET, 45 lanreotide acetate, 21 lansoprazole, 74 lansoprazole dr 15 mg capsule, 74 lansoprazole dr 30 mg capsule, 74 lansoprazole/amox tr/clarith, 73 lanthanum carbonate, 86 LANTUS, 65 LANTUS SOLOSTAR, 65 lapatinib ditosylate, 21 laronidase, 68 LASIX, 48 latanoprost, 105 LAXATIVES AND CATHARTICS, 71 leena, 95 leflunomide, 18, 19 lenalidomide, 20 lepirudin,recombinant, 91 LESCOL 20 MG CAPSULE, 46 LESCOL 40 MG CAPSULE, 46 LESCOL XL, 46 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary lessina, 95 LETAIRIS, 46 letrozole, 19 leucovorin calcium injection, 19 leucovorin calcium tablet, 19 LEUKERAN, 19 LEUKINE, 79 LEUKOTRIENE MODIFIERS, 111 leuprolide, 19, 104 leuprolide acetate, 104 levalbuterol, 111 LEVAQUIN INJECTION, 15 LEVAQUIN SOLUTION, -TABLET, 15 LEVATOL, 43 LEVEMIR, 65 levetiracetam, 34 levetiracetam injection, 34 levetiracetam solution, -tablet, 34 LEVLEN 28, 95 levobunolol, 104 levobunolol hcl, 105 levocarnitine, 93 levocarnitine injection, 93 levocarnitine solution, -tablet, 93 levocetirizine dihydrochlor, 111 levofloxacin, 15, 107 levonorgestrel, 96 levonorgestrel-ethin estradiol, 95, 96 levora-28, 95 levorphanol tartrate tablet, 28 levothroid, 69 levothyroxine, 70 levothyroxine sodium injection, 69 levothyroxine sodium tablet, 69 levoxyl, 69 LEVULAN, 59 LEXAPRO SOLUTION, 39 LEXAPRO TABLET, 39 LEXIVA SUSPENSION ORAL, 4 LEXIVA TABLET, 4 LIALDA, 73 LIDAMANTLE, 2 S7950_2011_DOC7aPC LIDAMANTLE HC, 57 lidazone hc, 57 lidocaine, 2, 63, 108 lidocaine hcl 0.5% vial, -1% abboject, -1% ampul, -1% syringe, -1% vial, -1.5% ampul, -2% abboject, -2% ampul, -2% luer-jet, -2% min-i-jet, -2% syringe, -2% vial, -20% vial, -4% ampul, 1 lidocaine hcl 10% vial, 49 lidocaine hcl cream, -jelly with prefilled applicator, -lotion, -ointment, -solution non-oral, 2 lidocaine hcl in 7.5% dextrose, 1 lidocaine hcl viscous, 2 lidocaine hcl-epinephrine, 1 lidocaine hydrochloride/epi, 2 lidocaine/prilocaine, 2 lidocaine/tetracaine, 2 lidocaine-hc, 57 lidocaine-hydrocortisone cream, -cream with applicator, -kit, -lotion, 57 lidocaine-prilocaine, 2 LIDODERM, 2 LIMBITROL, 35 LINCOCIN, 9 lincoject, 9 lincomycin, 9 LINDANE, 55 linezolid, 10 liothyronine, 69, 70 liothyronine sodium injection, 70 liothyronine sodium tablet, 70 liotrix, 70 LIPITOR, 46 LIPOFEN, 47 LIPOSYN II, 93 liposyn iii, 93 liquadd, 31 liqui-dualcitra, 92 liraglutide, 65 LISCO SPONGES, 80 lisdexamfetamine dimesylate, 31 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary lisinopril, 42 lisinopril tablet, 41 lisinopril/hctz, 50 lisinopril-hctz, 49 lisinopril-hydrochlorothiazide, 49 LITE TOUCH INSULIN PEN NEEDLES, 80 LITE TOUCH SYRINGE EMPTY DISPOSABLE, 80 lithium, 23 lithium carbonate, 23 lithium carbonate capsule, -tablet, -tablet sustained action, 23 lithium citrate, 23 LITHOBID, 23 LIVALO, 46 l-norgest-eth estr/ethin estr, 95, 96 LOCAL ANESTHETICS, 1 LOCOID, 57 LOCOID LIPOCREAM, 57 LODOSYN, 36 lodoxamide, 108 LOESTRIN, 95 LOESTRIN 24 FE, 95 LOESTRIN FE, 95 LOFIBRA, 47 LOKARA, 57 LOMOTIL, 70 lomustine, 18 lonox, 70 LOOP DIURETICS, 48 LO-OVRAL-28, 95 loperamide capsule, 70 LOPID, 47 LOPRESSOR HCT, 49 LOPRESSOR INJECTION, 43 LOPRESSOR TABLET, 43 LOPROX, 12 LORCET 10-650, 30 LORCET PLUS, 30 LORTAB, 30 losartan, 42 losartan /hctz, 49 S7950_2011_DOC7aPC losartan potassium, 42 losartan-hydrochlorothiazide, 49 LOSEASONIQUE, 95 LOTEMAX, 106 LOTENSIN, 41 LOTENSIN HCT, 49 loteprednol etabonate, 106 LOTREL, 50 LOTRISONE, 17 LOTRONEX, 71 lovastatin, 46 lovastatin 10 mg tablet, 46 lovastatin 20 mg tablet, -40 mg tablet, 46 lovastatin/niacin, 46 LOVAZA, 47 LOVENOX 100 MG PREFILLED SYR, -120 MG PREFILLED SYR, -150 MG PREFILLED SYR, -300 MG VIAL, -60 MG PREFILLED SYRN, 80 MG PREFILLED SYRN, 91 LOVENOX 30 MG PREFILLED SYRN, -40 MG PREFILLED SYRN, 91 low-ogestrel, 95 loxapine, 24 loxapine succinate, 24 LOXITANE, 24 lozi-flur, 90 lubiprostone, 71 LUCENTIS, 109 ludent fluoride, 90 LUER-LOK SYRINGE SYRINGE EMPTY DISPOSABLE, 80 LUFYLLIN, 112 LUMIGAN, 105 LUMIZYME, 69 LUNESTA, 38 LUPRON, 104 LUPRON DEPOT 11.25 MG 3MO KIT, -22.5 MG 3MO KIT, -3.75 MG KIT, -4 MONTH KIT, 104 LUPRON DEPOT 7.5 MG KIT, 104 LUPRON DEPOT-PED, 104 LURIDE, 90 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary lutera, 95 LUVOX CR, 39 LUXIQ, 57 LYBREL, 95 lymphocyte immune globulin, 76, 78 LYRICA, 34 LYSODREN, 19 LYSTEDA, 60 MACROBID, 17 MACRODANTIN, 17 mafenide acetate, 17 mag hydrox/alh/smc/dpha/lido, 63 MAGNACET, 28 magnesium sulfate injection, 88 magnesium sulfate/d5w, 88 MAGNESIUM SULFATE-D5W, 88 MALARONE, 15 malathion, 55 mannitol, 88, 89 mannitol injection, 88 MAO INHIBITORS, 33 maprotiline hcl, 35 maraviroc, 4 MARCAINE, 1 MARCAINE SPINAL, 1 MARCAINE WITH EPINEPHRINE, 1 MARCAINE-EPINEPHRINE, 1 margesic h, 30 MARINOL 10 MG CAPSULE, -5 MG CAPSULE, 26 MARINOL 2.5 MG CAPSULE, 26 marlexate, 92 MARPLAN, 34 maternity, 100 MATULANE, 19 MAVIK, 42 MAXAIR AUTOHALER, 111 MAXALT, 32 MAXALT MLT, 32 MAXIDEX, 106 MAXIDONE, 30 S7950_2011_DOC7aPC MAXIPIME 1 GM ADD-VANTAGE VL, -2 GM ADD-VANTAGE VL, -1 GRAM VIAL, -2 GRAM VIAL, 6 MAXIPIME 500 MG VIAL, 6 MAXITROL, 105 MAXZIDE, 51 MAXZIDE-25 MG, 51 measles vaccine,atten, 76 measles,mumps&rubella vaccine, 77 measles,mumps,rub,varicella, 77 mebendazole tablet chewable, 3 mecasermin, 78 mechlorethamine, 20 meclizine 12.5 mg tablet, -25 mg tablet, 26 meclizine hcl, 25 meclofenamate sodium capsule, 84 MEDICAL (MISCELLANEOUS) SUPPLIES, 80 MEDI-JECTOR NEEDLE-FREE SYR A, 81 MEDI-JECTOR NEEDLE-FREE SYR B, 81 MEDI-JECTOR NEEDLE-FREE SYR C, 81 MEDI-JECTOR VISION, 81 MEDROL, 64 medroxyprogesterone, 19, 103, 104 medroxyprogesterone acetate injection, 104 medroxyprogesterone acetate tablet, 104 mefenamic acid, 85 mefloquine hcl, 15 MEFOXIN, 6 MEGACE, 19 MEGACE ES, 19 megestrol, 19 megestrol acetate suspension oral, -tablet, 20 meloxicam, 84 meloxicam 15 mg tablet, -suspension oral, 84 meloxicam 7.5 mg tablet, 84 memantine hcl, 22 MENACTRA, 77 MENEST, 97 mening vac a,c,y,w-135 dip, 77 meningococcal vac a,c,y,w-135, 77 MENOMUNE-A-C-Y-W-135, 77 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary MENOSTAR, 97 MENTAX, 12 MENVEO A-C-Y-W-135-DIP, 77 mepenzolate, 70 meperidine, 28 meperidine hcl injection, 28 mepivacaine, 1, 2 meprobamate, 27 meprolone unipak, 64 MEPRON, 9 mercaptopurine, 20 mercaptopurine tablet, 20 meropenem, 9 MERREM IV 1 GM VIAL, 9 MERREM IV 500 MG VIAL, 9 MERUVAX II VACCINE W-DILUENT, 77 mesalamine, 72, 73 mesna, 20 MESNEX TABLET, 20 MESTINON SYRUP, -TABLET SUSTAINED ACTION, 37 MESTINON TABLET, 37 METADATE CD, 31 METADATE ER 10 MG TABLET SA, 31 metadate er 20 mg tablet, 31 METAGLIP, 67 metaproterenol sulfate syrup, -tablet, 111 metaxalone, 82, 83 metformin, 67 metformin hcl, 67 metformin hcl er, 67 methadex, 106 methadone, 28 methadone hcl injection, 28 methadone hcl solution, -tablet, -tablet soluble, 28 methadone intensol, 28 methadose, 28 methamphetamine, 31 methamphetamine hcl, 31 methazolamide, 105 methenamine hippurate, 17 S7950_2011_DOC7aPC methenamine mandelate, 17 METHERGINE INJECTION, 98 METHERGINE TABLET, 98 methimazole, 63 methimazole tablet, 63 METHITEST, 94 methocarbamol, 83 methocarbamol tablet, 82 methotrexate, 20 methotrexate injection, 20 methotrexate sodium, 21 methotrexate tablet, 20 methoxsalen, 55, 59 methscopolamine, 71 methscopolamine bromide, 70 methsuximide, 40 methyclothiazide tablet, 52 methyl aminolevulinate hcl, 59 METHYL XANTHINE DRUGS, 112 methyldopa, 45 methyldopa-hydrochlorothiazide, 50 methyldopate hcl, 45 methylergonovine, 98 METHYLIN 10 MG CHEWABLE TABLET, -2.5 MG CHEWABLE TAB, -5 MG CHEWABLE TABLET, -SOLUTION, 31 methylin 10 mg tablet, -20 mg tablet, -5 mg tablet, 31 methylin er, 31 methylnaltrexone bromide, 73 methylphenidate, 31 methylphenidate er, 31 methylphenidate hcl solution, -tablet, 31 methylphenidate sr, 31 methylprednisolone, 64 methylprednisolone acetate, 64 methylprednisolone acetate injection, 64 methylprednisolone sod succ, 64 methylprednisolone tablet, -tablet dose pack, 64 methyltestosterone, 94 metipranolol, 105 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary metoclopramide, 71 metoclopramide hcl injection, 70 metoclopramide hcl solution oral, -tablet, 70 metolazone, 52 metoprolol succinate, 43 metoprolol tartrate, 43 metoprolol tartrate injection, 43 metoprolol tartrate tablet, 43 metoprolol-hydrochlorothiazide, 50 METOZOLV ODT, 71 metro iv, 4 METROCREAM, 53 METROGEL, 53 METROGEL-VAGINAL, 98 METROLOTION, 53 metronidazole, 4, 53, 98 metronidazole capsule, -tablet, 4 metronidazole cream, -gel, -lotion, 53 metronidazole gel with applicator, 98 metronidazole injection, 4 metryl, 4 METVIXIA, 59 metyrosine, 45 MEVACOR, 46 mexiletine hcl capsule, 42 MIACALCIN AEROSOL SPRAY W/PUMP, 69 MIACALCIN INJECTION, 69 micafungin sodium, 13 MICARDIS, 42 MICARDIS HCT, 50 miconazole, 8 miconazole 3 200 mg vag supp, 17 miconazole nitrate/zinc oxide, 12 MICRHOGAM, 77 MICRHOGAM PLUS, 77 microgestin, 95 microgestin fe, 95 MICRO-K, 92 MICRONOR, 104 MICROZIDE, 52 MIDAMOR, 51 midodrine, 51 S7950_2011_DOC7aPC midodrine hcl, 50 migergot, 32 miglitol, 67 miglustat, 69 MIGRANAL, 32 MILLIPRED, 64 MILLIPRED DP, 64 milnacipran hcl, 35, 36 milrinone in 5% dextrose, 45 milrinone lactate, 45 mimvey, 98 MINERALOCORTICOID DRUGS, 66 MINIPRESS, 52 MINITRAN, 48 MINOCIN COMBINATION PACKAGE, -KIT, CAPSULE, 16 MINOCIN INJECTION, 16 minocycline, 16, 63 minocycline hcl capsule, -tablet, -tablet sustained release 24hr, 16 minoxidil tablet, 52 MIOSTAT, 105 MIRAPEX, 36 MIRAPEX ER, 36 MIRCETTE, 95 mirtazapine, 35 misc supp (dress,tape,gauze), 80, 82 MISCELLANEOUS DRUGS, 60 misoprostol, 72 mitotane, 19 mitoxantrone, 20 mitoxantrone hcl injection, 20 M-M-R II VACCINE, 77 MOBAN, 24 MOBIC 15 MG TABLET, -SUSPENSION ORAL, 84 MOBIC 7.5 MG TABLET, 84 modafinil, 31 MODICON, 95 moexipril, 42 moexipril hcl, 42 moexipril/hctz, 50 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary moexipril-hydrochlorothiazide, 50 molindone, 24 mometasone, 57, 62, 112, 113 mometasone furoat/ammonium l, 58 mometasone furoate, 58 mometasone/formoterol, 113 MOMEXIN, 58 MONODOX, 16 MONOJECT 0.5 ML SYRN 28GX1/2, 81 MONOJECT INSULIN SAFETY SYRNG, 81 MONOJECT INSULIN SYRINGE, 81 MONOKET, 48 mononessa, 95 MONOPRIL, 42 montelukast sodium, 111 MONUROL, 17 morphine, 27, 28, 29 morphine sulfate in dextrose, 28 morphine sulfate injection, 28 morphine sulfate solution, -suppository rectal, -tablet, 29 morphine sulfate tablet sustained action, 29 morphine sulfate/naltrexone, 28 MOTOFEN, 70 MOVIPREP, 73 MOXATAG, 14 moxifloxacin, 15, 107 MOZOBIL, 77 MS CONTIN, 29 MULTAQ, 49 multinatal plus, 100 multi-nate 30, 100 multi-nate 30 dha, 100 multi-nate dha extra, 100 mumps vaccine,live, 77 MUMPSVAX VACCINE W-DILUENT, 77 mupirocin, 16 mupirocin calcium, 16 mupirocin ointment, 16 muronab-cd3, 20 MUSCULOSKELETAL MEDICATIONS, 82 MUSTARGEN, 20 S7950_2011_DOC7aPC MYAMBUTOL, 5 MYCAMINE, 13 MYCOBUTIN, 5 mycophenolate mofetil, 18 mycophenolate mofetil capsule, 20 mycophenolate mofetil tablet, 20 mycophenolate sodium, 20 MYCOSTATIN, 8 MYDFRIN, 109 mydral, 109 MYDRIACYL, 109 MYELOID STIMULANTS, 79 MYFORTIC, 20 mynatal, 100 mynatal advance, 100 mynatal plus, 100 mynatal-z, 100 mynate 90 plus, 100 myochrysine, 85 MYOZYME, 69 MYSOLINE, 34 MYTELASE, 37 nabilone, 25 nabumetone, 84 nadolol, 43 nadolol-bendroflumethiazide, 50 nafarelin, 104 NAFCILL IN DEXTROSE, 14 nafcillin, 14 nafcillin sodium, 14 naftifine, 12 NAFTIN, 12 NAGLAZYME, 69 nalbuphine hcl, 22 NALFON, 84 NALLPEN, 14 NALLPEN IN DEXTROSE, 14 NALLPEN-ISO-OSMOTIC DEXTROSE, 14 naloxone hcl injection, 37 naltrexone, 37 naltrexone hcl tablet, 37 naltrexone microspheres, 37 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary NAMENDA, 22 NANO PEN NEEDLE, 81 naphazoline, 108 naphazoline hcl drops, 109 NAPRELAN, 84 NAPRELAN CR DOSE CARD, 84 NAPROSYN, 84 naproxen, 84 naproxen 250 mg tablet, -375 mg tablet, suspension oral, -tablet enteric coated, 85 naproxen 500 mg tablet, 85 naproxen sodium, 83, 84 naproxen sodium 275 mg tab, -550 mg tab, 85 naproxen/esomeprazole mag, 85 naratriptan, 31 naratriptan hcl, 32 NARDIL, 34 NAROPIN, 2 NASACORT AQ, 62 NASAREL, 62 NASONEX, 62 natacaps, 100 NATACHEW, 100 NATACYN, 109 NATAFORT, 100 natalcare pic forte, 100 natalcare plus, 100 natalizumab, 21 natamycin, 109 natatab, 100 NATAZIA, 95 nateglinide, 67 NATELLE, 100 NATELLE C, 100 NATELLE ONE, 100 NATELLE PLUS, 100 NATELLE PREFER, 100 NATELLE-EZ, 100 NATRECOR, 51 nature-throid, 70 NATURETIN-5, 52 S7950_2011_DOC7aPC NAVANE, 24 NEBCIN IN DEXTROSE, 3 nebivolol hcl, 43 necon, 95 nedocromil, 108 NEEVO, 100 nefazodone hcl, 35 nelfinavir mesylate, 5 neocidin, 107 NEO-FRADIN, 3 neofrin, 109 neomycin, 3 neomycin suf/polymy/buffers/hc, 61 neomycin sulfate tablet, 3 neomycin sulfate/colist sul/hc, 61 neomycin sulfate/polymyxin, 115 neomycin sulfate/polymyxin/hc, 61, 105 neomycin/bacitracin/poly/hc, 16 neomycin/colist sul/hc/thonz, 61 neomycin/gramicidin/polymyxin, 107 neomycin/polymyxin/dexameth, 105 neomycin/polymyxin/prednisol, 106 neomycin-bacitracin-poly-hc, 106 neomycin-bacitracin-polymyxin, 107 neomycin-polymyxin b, 115 neomycin-polymyxin-dexameth, 106 neomycin-polymyxin-gramicidin, 107 neomycin-polymyxin-hc solution, -solution non-oral, -suspension drops, 61 neomycin-polymyxin-hc suspension drops, 106 NEOPROFEN, 85 NEORAL, 20 NEOSPORIN DROPS, 107 NEOSPORIN G.U. IRRIGANT, 115 neostigmine bromide, 37 neostigmine methylsulfate, 37 nepafenac, 109 NEPHRAMINE, 88 NESACAINE, 2 NESACAINE-MPF, 2 nesiritide, 51 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary NEULASTA, 79 NEUMEGA, 79 NEUPOGEN, 79 NEURONTIN CAPSULE, -TABLET, 34 NEURONTIN SOLUTION, 34 NEUT, 88 neutragard advanced, 90 NEVANAC, 109 nevirapine, 5 NEXAVAR, 20 NEXIUM 10 MG PACKET, -20 MG CAPSULE, 20 MG PACKET, 74 NEXIUM 40 MG CAPSULE, -40 MG PACKET, 74 NEXIUM I.V., 74 next choice, 95 niacin, 47 niacin/simvastatin, 47 NIACOR, 47 NIASPAN, 47 nicardipine hcl capsule, 44 nicardipine hcl injection, 44 nicotine inhaler, 40 nicotine ns, 40 NICOTROL, 40 NICOTROL NS, 40 nifediac cc, 44 nifedical xl, 44 nifedipine, 43, 44 nifedipine capsule, 44 nifedipine er, 44 NILANDRON, 20 nilotinib hydrochloride, 21 nilutamide, 20 nimodipine, 44 NIMOTOP, 44 nisoldipine, 44 NISOLDIPINE ER 17 MG TABLET, -ER 25.5 MG TABLET, -ER 34 MG TABLET, -ER 8.5 MG TABLET, 44 nisoldipine er 20 mg tablet, -er 30 mg tablet, -er 40 mg tablet, 44 S7950_2011_DOC7aPC nitazoxanide, 8 nitisinone, 60 NITRATES, 48 nitro-bid, 48 NITRO-DUR, 48 nitrofurantoin, 17 nitrofurantoin capsule, 17 nitrofurantoin macrocrystal, 17 nitrofurantoin mono-macro, 17 nitrofurantoin/nitrofuran mac, 17 nitroglycerin, 48 nitroglycerin in d5w, 48 nitroglycerin injection, 48 nitroglycerin patch, 48 nitroglycerin tablet sublingual, 48 NITROLINGUAL, 48 NITROMIST, 48 nitroquick, 48 NITROSTAT, 48 nizatidine, 71 NIZORAL, 12 NON-STEROIDAL ANTIINFLAMMATORY AGENTS, 83 nora-be, 104 NORCO, 30 NORDETTE-28, 95 NORDIPEN 15, 81 NORDIPEN 5, 81 NORDITROPIN, 75 NORDITROPIN FLEXPRO, 75 NORDITROPIN NORDIFLEX, 75 norepinephrine bitartrate, 50 noreth a-et estra/fe fumarate, 95 noreth-ethinyl estradiol/iron, 95 norethindrone, 104 norethindrone acetate, 103 norethindrone acetate tablet, 104 norethindrone a-e estradiol, 95, 98 norethindrone-ethin estradiol, 94, 95, 96 norethindrone-mestranol, 95 NORFLEX, 82 norfloxacin, 15 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary norgestimate-ethinyl estradiol, 96 norgestrel-ethiny estra, 95 norgestrel-ethinyl estradiol, 95 NORINYL 1+35, 95 NORINYL 1+50, 95 NORITATE, 53 NORMOSOL-M AND DEXTROSE, 88 NORMOSOL-R, 88 NORMOSOL-R AND DEXTROSE, 88 NORMOSOL-R PH 7.4, 88 NOROXIN, 15 NORPRAMIN, 38 NOR-Q-D, 104 northyx, 63 nortrel, 96 nortriptyline, 38 nortriptyline hcl capsule, -solution, 38 NORVASC, 44 NORVIR CAPSULE, -TABLET, 4 NORVIR SOLUTION, 4 NOVAMINE, 88 NOVANATAL, 100 NOVANTRONE, 20 NOVASTART, 100 NOVOCAIN, 2 NOVOFINE 32, 81 NOVOFINE AUTOCOVER, 81 NOVOLIN 70-30 100 UNIT/ML VIAL, -U100 CARTRIDGE, 65 NOVOLIN 70-30 INNOLET, 66 NOVOLIN N 100 UNIT/ML INNOLET, -100 UNITS/ML CARTRDG, -100 UNITS/ML VIAL, 66 NOVOLIN R 100 UNIT/ML CARTRIDG, -100 UNIT/ML INNOLET, -100 UNITS/ML VIAL, 66 NOVOLOG, 66 NOVOLOG MIX 70-30, 66 NOVOPEN 3, 81 NOVOPEN JR, 81 NOXAFIL, 8 NUCYNTA, 29 S7950_2011_DOC7aPC NULYTELY WITH FLAVOR PACKS, 73 NUMORPHAN, 29 nutrilyte, 88 nutrilyte ii, 88 nutrinate, 100 nutrispire, 100 NUTRITION,BLOOD MODIFIERS,ELECTROLYTES, 86 NUTROPIN, 75 NUTROPIN AQ, 75 NUTROPIN AQ NUSPIN, 75 NUVARING, 96 NUVIGIL, 31 nyamyc, 12 nystatin, 8 nystatin 100,000 unit/gm powd, -cream, ointment, 12 nystatin 150,000,000 units pwd, -50,000,000 units pwd, -500,000,000 units pwd, suspension oral, -tablet, 8 nystatin tablet, 17 nystatin-triamcinolone, 17 nystop, 12 ob + dha, 100 ob 90 + dha, 100 OB/GYN TOPICAL ANTIINFECTIVES, 98 ob-natal one, 100 OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS, 94 OBTREX, 100 O-CAL FA, 100 O-CAL PRENATAL, 100 ocella, 96 OCL, 73 OCTAGAM, 77 octreotide, 20, 21 octreotide 1,000 mcg/ml vial, -acet 100 mcg/ml amp, -acet 100 mcg/ml vl, -acet 200 mcg/ml vl, -acet 500 mcg/ml amp, acet 500 mcg/ml vl, 20 octreotide acet 50 mcg/ml amp, -acet 50 mcg/ml vial, 20 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary OCUFEN, 109 OCUFLOX, 107 ofloxacin, 15, 61, 107 ofloxacin drops, 61, 107 ofloxacin tablet, 15 OGEN, 97 ogestrel, 96 olanzapine, 25 olanzapine pamoate, 25 olanzapine/fluoxetine hcl, 25 OLEPTRO ER, 35 olmesartan med/amlodipine/hct, 50 olmesartan medoxomil, 42 olmesartan medoxomil/hctz, 49 olopatadine hcl, 62, 109 olsalazine, 72 OLUX, 58 OLUX-E, 58 OLUX-OLUX-E, 58 omalizumab, 114 omega-3 acid ethyl esters, 47 omeprazole, 74 omeprazole dr 10 mg capsule, 74 omeprazole dr 20 mg capsule, -dr 40 mg capsule, 74 omeprazole magnesium-legend, 74 omeprazole/sodium bicarbonat, 74 omeprazole-bicarb 20-1,100 cap, 74 omeprazole-bicarb 40-1,100 cap, 74 OMNARIS, 62 OMNICEF, 6 OMNIPRED, 106 OMNITROPE, 75 ondansetron, 27 ondansetron hcl 24 mg tablet, 26 ondansetron hcl 4 mg tablet, -8 mg tablet, 26 ondansetron hcl in dextrose, 26 ondansetron hcl injection, 26 ondansetron hcl solution, 26 ondansetron odt, 26 ONGLYZA, 67 S7950_2011_DOC7aPC ONSOLIS, 29 OPANA, 29 OPANA ER, 29 OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS, 105 OPHTHALMIC CORTICOSTEROID DRUGS, 106 OPHTHALMIC MEDICATIONS, 104 OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS, 107 OPHTHALMIC TOPICAL ANTIVIRAL DRUGS, 108 OPHTHETIC, 109 opium, 29 OPIUM, 29 oprelvekin, 79 OPTINATE, 100 OPTIPRANOLOL, 105 OPTIVAR, 109 ORACEA, 16 ORACIT, 92 ORAL ANTICOAGULANTS, VITAMIN K, 91 ORAL ANTIFUNGAL DRUGS, 8 ORAL DERMATOLOGICAL DRUGS, 55 ORAL HYPOGLYCEMICS AND COMBOS, 66 ORALONE, 63 ORAMORPH SR, 29 ORAP, 24 ORAPRED, 64 ORAPRED ODT, 64 ORASEP, 63 ORAVIG, 8 oraxyl, 63 ORENCIA, 20 ORFADIN, 60 orphenadrine, 82 orphenadrine citrate injection, 82 orphenadrine citrate tablet sustained action, 82 orphenadrine compound, 82 orphenadrine compound forte, 82 ORSINI INSULIN SYRINGE, 81 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary ORTHO EVRA, 96 ORTHO TRI-CYCLEN, 96 ORTHO TRI-CYCLEN LO, 96 ORTHO-CEPT, 96 ORTHOCLONE OKT-3, 20 ORTHO-CYCLEN, 96 ORTHO-EST, 97 ORTHO-NOVUM, 96 oseltamivir phosphate, 11 OSMITROL, 88 OSMOPREP, 72 OTHER ANTIARRHYTHMICS, 48 OTHER ANTICONVULSANTS, 34 OTHER ANTIDEPRESSANTS, 35 OTHER ANTIHYPERTENSIVES, 49 OTHER ANTIINFECTIVE DRUGS, 8 OTHER ANTIPARKINSON DRUGS, 36 OTHER ANTIULCER DRUGS, 72 OTHER ANTIVIRAL DRUGS, 10 OTHER CARDIOVASCULAR DRUGS, 50 OTHER CNS/AUTONOMIC DRUGS, 37 OTHER DRUGS AFFECTING COAGULATION, 91 OTHER DRUGS FOR ARTHRITIS, 85 OTHER DRUGS FOR ASTHMA, 112 OTHER ENDOCRINE DRUGS, 68 OTHER GENITOURINARY PRODUCTS, 115 OTHER GI DRUGS, 72 OTHER MACROLIDES, 11 OTHER OPHTHALMIC DRUGS, 108 OTHER RESPIRATORY DRUGS, 114 OTHER TOPICAL ANTIFUNGALS, 12 OTHER VASODILATING DRUGS, 51 otic edge, 61 oticin hc ear solution, -suspension drops, 61 otocidin, 61 otomycet-hc, 61 OVCON-35, 96 OVCON-50, 96 OVIDE, 55 oxacillin, 13, 14 S7950_2011_DOC7aPC oxacillin 1 gm add-vantage vl, -10 gm vial, -2 gm add-vantage vl, -2 gm vial, 14 oxacillin 1 gm vial, 14 OXANDRIN 10 MG TABLET, 94 OXANDRIN 2.5 MG TABLET, 94 oxandrolone, 94 oxaprozin, 84, 85 oxcarbazepine, 27 oxiconazole, 12 OXISTAT, 12 OXSORALEN, 59 OXSORALEN-ULTRA, 55 oxybutynin, 114 oxybutynin chloride syrup, -tablet, 114 oxybutynin cl er 10 mg tablet, -cl er 15 mg tablet, 114 oxybutynin cl er 5 mg tablet, 114 oxycodone, 28, 29 oxycodone hcl, 29 oxycodone hcl-acetaminophen, 29 oxycodone hcl-ibuprofen, 29 oxycodone/acetaminophen, 28, 29 oxycodone/aspirin, 29 oxycodone/ibuprofen, 28 oxycodone-acetaminophen, 29 oxycodone-aspirin, 29 OXYCONTIN, 29 oxymetholone, 94 oxymorphone, 29 oxytetracycline, 16 oxytetracycline hcl/polymyxin, 107 OXYTOCICS, 98 oxytocin, 98 oxytocin injection, 98 OXYTROL, 114 PACERONE 100 MG TABLET, -400 MG TABLET, 41 pacerone 200 mg tablet, 41 palgic, 111 palifermin, 77 paliperidone, 24 palivizumab, 77 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary palonosetron hcl, 25 PAMELOR, 38 pamidronate disodium, 68, 69 PAMINE, 71 PAMINE FORTE, 71 PANCREAZE, 73 PANCRELIPASE 5,000, 73 PANDEL, 58 PANHEMATIN, 60 PANLOR DC, 30 PANLOR SS, 30 PANRETIN, 59 pantoprazole, 74 pantoprazole sod dr 20 mg tab, 74 pantoprazole sod dr 40 mg tab, 74 PARAFON FORTE DSC, 82 parcaine, 109 PARCOPA, 36 paregoric, 70 PARENTERAL ANTIFUNGALS, 13 paricalcitol, 93 PARLODEL, 36 PARNATE, 34 paromomycin sulfate, 3 paroxetine, 39 paroxetine hcl 10 mg tablet, -40 mg tablet, 39 paroxetine hcl 20 mg tablet, -30 mg tablet, tablet sustained release 24hr, 39 paroxetine hcl suspension oral, 39 paroxetine mesylate, 39 PASER, 5 PATADAY, 109 PATANASE, 62 PATANOL, 109 PAXIL 10 MG TABLET, -40 MG TABLET, 39 PAXIL 20 MG TABLET, -30 MG TABLET, 39 PAXIL CR, 39 PAXIL SUSPENSION ORAL, 39 pazopanib, 21 PCE, 7 PEDIADERM HC, 58 S7950_2011_DOC7aPC PEDIAPRED, 64 PEDIARIX, 77 pedi-dri, 12 PEDIOTIC, 61 PEDVAXHIB, 77 peg 3350-electrolyte, 73 peg-3350 and electrolytes, 73 peg-3350 with flavor packs, 73 pegademase bovine, 60 PEGANONE, 33 PEGASYS 180 MCG/0.5 ML CONV.PK, 78 PEGASYS 180 MCG/ML VIAL, 79 pegfilgrastim, 79 peginterferon alfa-2a, 78, 79 peginterferon alfa-2b, 79 PEGINTRON 120 MCG KIT, -150 MCG KIT, 80 MCG KIT, 79 PEGINTRON 50 MCG KIT, 79 PEGINTRON REDIPEN, 79 pegvisomant, 69 pemetrexed disodium, 18 pemirolast potassium, 108 PEN 12MM 29G NEEDLES, -31GX3/16, 31GX5/16, -6MM 31G, -8MM 31G NEEDLES, -AURORA 6MM 31G, -AURORA S 12MM 29G, -AURORA S 8MM 31G, -BD 29GX1/2, -BD 29GX3/16, -BD 29GX5/16, BD MINI 31GX3/16, -BD ORIG 29GX1/2, BD SHORT 31GX5/16, -LIVE BETTER 6MM 31G, -LIVE B, 81 pen g pot/dextrose-water, 14 pen g procaine/pen g benz, 13 PEN NEEDLES, 81 penbutolol, 43 penciclovir, 10 penicillamine, 85 penicillin g benzathine, 13 penicillin g potassium, 14 PENICILLIN G POTASSIUM IN D5W, 14 penicillin g procaine, 14 penicillin g sodium, 14 PENICILLIN GK-ISO-OSM DEXTROSE, 14 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary penicillin v potassium, 14 PENICILLINS, 13 PENLAC, 12 PENNSAID, 56 PENTACEL, 77 PENTAM 300, 9 pentamidine, 9 pentamidine isethionate, 9 PENTASA, 73 pentazocine, 22 pentopak, 50 pentosan polysulfate sodium, 115 pentoxifylline, 51 pentoxifylline tablet sustained action, 50 pentoxil, 50 PEPCID INJECTION, 71 PEPCID SUSPENSION ORAL, -TABLET, 71 PERANEX HC PADS MEDICATED, 58 PERCOCET, 29 PERCODAN, 29 perindopril erbumine, 41, 42 perio med, 90 periogard, 63 PERIOSTAT, 63 perisol, 63 permethrin, 55 permethrin cream, 55 perphenazine, 24 perphenazine-amitriptyline, 35 PERSANTINE, 86 PEXEVA 10 MG TABLET, -40 MG TABLET, 39 PEXEVA 20 MG TABLET, -30 MG TABLET, 39 PFIZERPEN, 14 phenadoz, 26 phenelzine, 34 PHENERGAN, 111 phenoxybenzamine, 45 phentolamine, 46 PHENTOLAMINE MESYLATE INJECTION, 46 phenylephrine hcl, 109 phenylephrine hcl drops, 109 PHENYTEK, 33 S7950_2011_DOC7aPC phenytoin, 33 phenytoin sodium, 33 phenytoin sodium extended, 33 phenytoin sodium injection, 33 phenytoin suspension oral, 33 PHISOHEX, 17 PHOS-FLUR, 90 PHOSLO, 93 phospha 250 neutral, 92 PHOSPHOLINE IODIDE, 105 phosphorus, 92 physostigmine salicylate injection, 37 pilocarpine hcl, 63, 105 pilocarpine hcl drops, 105 pilocarpine hcl tablet, 63 PILOPINE HS, 105 pimecrolimus, 58 pimozide, 24 pindolol, 43 pioglitazone hcl, 66 pioglitazone hcl/metformin hc, 66 pioglitazone/glimepiride, 67 piperacillin, 14 piperacillin/tazobactam sodium, 14 piperacillin-tazobactam, 14 PIPRACIL IN DEXTROSE, 14 pirbuterol, 111 piroxicam, 84 piroxicam capsule, 85 pitavastatin calcium, 46 PITOCIN, 98 PLAN B, 96 PLAN B ONE-STEP, 96 PLAQUENIL, 15 PLASBUMIN-25, 88 PLASMA-LYTE 148, 88 PLASMA-LYTE 148 IN DEXTROSE, 88 PLASMA-LYTE 56, 88 PLASMA-LYTE 56 IN DEXTROSE, 88 PLASMA-LYTE A PH 7.4, 88 PLASMA-LYTE R, 89 PLASMODICIDES, 14 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary PLAVIX, 86 plerixafor, 77 PLETAL, 86 PLEXION, 53 pnv-dha, 100 pnv-iron, 100 pnv-omega, 100 pnv-select, 101 podofilox, 55 poliomyelitis vac,killed, 77 POLOCAINE, 2 poly iron pn, 101 POLY IRON PN FORTE, 101 polycin-b, 107 poly-dex, 106 polyethylene glycol 3350, -pkt, -powd, 72 polymyxin b, 9 polymyxin b sulfate injection, 9 POLYMYXIN B SULFATE POWDER, 9 polymyxin b sulfate/tmp, 107 polymyxin b sul-trimethoprim, 107 POLY-PRED, 106 POLYTRIM, 107 PONSTEL, 85 portia, 96 posaconazole, 8 pot acid phos/sod acid phos, 115 potassium acetate injection, 92 potassium acid phosphate, 115 potassium bicarb/ca, 92 potassium bicarbonate tablet effervescent, 92 potassium chl-normal saline, 89 potassium chloride, 92 potassium chloride capsule sustained action, -cl 20 meq tab er, -cl er 10 meq tablet, -cl er 20 meq tablet, -cl er 8 meq tablet, solution, 93 potassium chloride injection, 93 potassium chloride-nacl, 89 potassium citrate tablet sustained action, 115 potassium citrate-citric acid, 115 S7950_2011_DOC7aPC potassium cl 10 meq tab sa, -tablet effervescent, 93 POTASSIUM REMOVING RESINS, 91 POTASSIUM SPARING DIURETICS, 51 POTASSIUM SUPPLEMENTS, 92 povidone-iodine, 108 pr natal 430, 101 pr natal 430 ec, 101 pr natal 440 ec, 101 pr otic solution, 61 pralidoxime chloride, 60 pramipexole, 36 pramipexole dihydrochloride, 36 pramlintide acetate, 65 PRAMOTIC, 61 pramoxine hcl/chloroxylenol, 61 PRANDIMET, 67 PRANDIN, 67 prascion, 53 prascion fc, 54 prascion ts, 54 prasugrel, 86 PRAVACHOL, 46 pravastatin, 46 pravastatin sodium, 47 praziquantel, 3 prazosin, 52 prazosin hcl, 52 PRECISION SYRINGE EMPTY DISPOSABLE, 81 PRECOSE, 67 PRED FORTE, 106 PRED MILD, 106 PRED-G, 106 prednicarbate, 57, 58 prednisol, 106 prednisolone, 64 prednisolone acetate, 106 prednisolone acetate suspension drops, 106 prednisolone sod phosphate, 64 prednisolone sodium phosphate drops, 106 prednisolone sodium phosphate solution, 64 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary prednisolone solution oral, 64 prednisone, 64 prednisone intensol, 64 prednisone solution, -tablet, -tablet dose pack, 64 PREFERA-OB, 101 PREFERA-OB ONE, 101 PREFERA-OB PLUS DHA, 101 PREFEST, 98 pregabalin, 34 PRELONE, 64 PREMARIN CREAM WITH APPLICATOR, TABLET, 97 PREMARIN INJECTION, 97 PREMASOL, 89 PREMPHASE, 98 PREMPRO, 98 prenacare, 101 prenafirst, 101 prenaplus, 101 prenatabs fa, 101 prenatabs obn, 101 prenatabs rx, 101 prenatal 19, 101 prenatal ad, 101 prenatal formula tablet, 101 prenatal low iron, 101 prenatal mr 90 fe, 101 prenatal multivitamin w-iron, 101 prenatal plus, 101 prenatal rx 1, 101 prenatal vit( = or > 1mg fa), 99, 100, 101, 102, 103 PRENATAL VITAMINS, 99 prenatal vitamins (< 1mg fa), 100, 101 prenatal z, 101 prenatal-u, 101 PRENATE DHA, 101 PRENATE ELITE, 101 PRENATE ESSENTIAL, 101 prenate plus, 101 PRENEXA, 101 S7950_2011_DOC7aPC PREPIDIL, 104 PREQUE 10, 101 PREVACID 30 MG CAPSULE DR, -30 MG SOLUTAB, -DR 30 MG CAPSULE, 74 PREVACID DR 15 MG CAPSULE, -15 MG SOLUTAB, 74 prevalite, 47 PREVIDENT, 90 PREVIDENT 5000, 90 PREVIDENT 5000 PLUS, 90 PREVIDENT 5000 SENSITIVE, 90 previfem, 96 previt+dha, 101 previte rx, 101 PREVPAC, 73 PREZISTA 150 MG TABLET, -300 MG TABLET, -75 MG TABLET, 4 PREZISTA 400 MG TABLET, -600 MG TABLET, 4 PRIALT, 22 PRIFTIN, 5 PRILOSEC DR 10 MG CAPSULE, -DR 20 MG CAPSULE, 74 PRILOSEC DR 40 MG CAPSULE, -PKT, 74 PRIMALEV, 29 primaquine, 15 PRIMAQUINE, 15 PRIMAXIN 250 MG VIAL, 9 PRIMAXIN 500 MG VIAL, 9 PRIMAXIN I.M., 9 primidone, 34 PRIMLEV, 29 PRIMSOL, 17 PRINIVIL, 42 PRINZIDE, 50 PRISTIQ, 35 PRIVIGEN, 77 PROAIR HFA, 111 PROAMATINE, 51 probenecid, 83 probenecid-colchicine, 83 procainamide, 42 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary procainamide hcl injection, 42 procaine, 2 PROCALAMINE, 89 procarbazine, 19 PROCARDIA, 44 PROCARDIA XL, 44 PROCENTRA, 31 PROCHIEVE, 104 prochlorperazine edisylate, 25, 26 prochlorperazine maleate suppository rectal, -tablet, 26 PROCRIT 10,000 UNITS/ML VIAL, -2,000 UNITS/ML VIAL, -3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 77 PROCRIT 20,000 UNITS/ML VIAL, -40,000 UNITS/ML VIAL, 77 PROCTOCORT, 73 PROCTOCREAM-HC, 73 procto-pak, 73 proctosol-hc, 73 proctozone-hc, 73 PRODIGY INSULIN SYRINGE, 81 PRODIGY PEN NEEDLE, 81 progesterone, 103, 104 progesterone in oil, 104 progesterone injection, 104 PROGESTIN DRUGS, 103 PROGLYCEM, 65 PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE, 20 PROGRAF 5 MG CAPSULE, 20 PROGRAF INJECTION, 20 PROLASTIN, 114 PROLEUKIN, 79 PROLIA, 69 PROMACTA, 79 promethazine, 111 promethazine hcl injection, 111 promethazine hcl suppository rectal, 26 promethazine hcl syrup, -tablet, 111 promethazine vc, 110 promethegan, 26 S7950_2011_DOC7aPC PROMETRIUM, 104 PRONESTYL, 42 propafenone, 42 propafenone hcl, 42 propantheline bromide, 71 proparacaine, 108, 109 proparacaine hcl, 109 PROPINE, 105 propranolol, 43 propranolol hcl cap sa, -solution, -tablet, 43 propranolol hcl injection, 43 propranolol-hydrochlorothiazid, 50 propylthiouracil, 63 PROQUAD, 77 PROQUIN XR, 15 PROSCAR, 115 PROSOL, 89 PROSTIGMIN, 37 PROSTIN E2 VAGINAL SUPPOSITORY, 94 PROSTIN VR PEDIATRIC, 51 protamine, 90 PROTAMINE SULFATE, 90 PROTON PUMP INHIBITORS, 73 PROTONIX DR 20 MG TABLET, 74 PROTONIX DR 40 MG TABLET, -PKT, 74 PROTONIX IV, 74 PROTOPAM CHLORIDE, 60 PROTOPIC, 59 protriptyline, 38 protriptyline hcl, 38 PROVENTIL HFA, 111 PROVERA, 104 PROVIGIL, 31 PROZAC 10 MG PULVULE, 39 PROZAC 20 MG PULVULE, -SOLUTION, 39 PROZAC 40 MG PULVULE, 39 PROZAC WEEKLY, 39 PRUDOXIN, 59 pruet dha, 101 pruet dha ec, 101 pse/acrivas, 110 pse/desloratadine, 110 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary pse/fexofenadine, 109, 110 PULMICORT 180 MCG FLEXHALER, 113 PULMICORT 90 MCG FLEXHALER, 114 PURINETHOL, 20 PYLERA, 73 pyrazinamide, 5 pyridostigmine, 37 pyridostigmine bromide, 37 pyrimethamine, 14 pyrimethamine/sulfadoxine, 14 QUALAQUIN, 15 quasense, 96 QUESTRAN, 47 QUESTRAN LIGHT, 47 quetiapine fumarate, 25 quinapril, 41 quinapril hcl, 42 quinapril/hctz, 49 quinapril-hydrochlorothiazide, 50 quinaretic, 50 quinidine gluconate injection, 42 quinidine gluconate tablet sustained action, 42 quinidine sulfate tablet, -tablet sustained action, 42 quinine sulfate, 15 QUINOLONES, 15 quinupristin/dalfopristin, 9 QUIXIN, 107 QVAR, 114 RABAVERT, 77 rabeprazole sodium, 73 rabies immune globulin, 76 rabies vac,pf chick-emb cell, 77 rabies vaccine,human diploid, 77 raloxifene, 69 raltegravir potassium, 4 ramelteon, 38 ramipril, 41, 42 RANEXA, 51 ranibizumab, 109 RANICLOR, 6 S7950_2011_DOC7aPC ranitidine, 71 ranitidine 150 mg tablet, -300 mg tablet, capsule, -syrup, 71 ranitidine hcl injection, 71 ranolazine, 51 RAPAFLO, 115 RAPAMUNE, 20 rapiflux 20 mg tablet, 39 RAPTIVA, 20 rasagiline mesylate, 36 rasburicase, 19 RAZADYNE, 22 RAZADYNE ER, 23 REBETOL SOLUTION, -CAPSULE, 10 REBIF 22 MCG/0.5 ML SYRINGE, -44 MCG/0.5 ML SYRINGE, 79 REBIF TITRATION PACK, 79 RECLAST, 69 reclipsen, 96 RECOMBIVAX HB, 77 REFLUDAN, 91 REGLAN INJECTION, 71 REGLAN TABLET, 71 REGONOL, 37 REGRANEX, 59 RELAGARD, 98 RELENZA, 10 RELION NOVOLIN 70-30 VIAL, -RELION VIAL, 66 RELION NOVOLIN N 100 UNITS/ML, -RELION 100 UNITS/ML, 66 RELION NOVOLIN R 100 UNITS/ML, 66 RELISTOR, 73 RELPAX, 33 REMERON, 35 remeven, 59 REMICADE, 20 remifentanil, 22 REMODULIN, 51 RENACIDIN, 115 renaf, 90 RENAGEL, 86 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary RENAMIN, 89 re-nata 29, 101 re-nata 29 ob, 101 renate, 101 renate dha, 101 renate dha extra, 101 RENVELA, 86 REOPRO, 86 repaglinide, 67 repaglinide/metformin hcl, 67 reprexain, 30 REQUIP, 36 REQUIP XL, 36 RESCRIPTOR, 4 RESECTISOL, 89 reserpine, 50 RESPIRATORY MEDICATIONS, 109 RESTASIS, 109 retapamulin, 16 RETIN-A, 54 RETIN-A MICRO, 54 RETIN-A MICRO PUMP, 54 RETISERT, 106 RETROVIR CAPSULE, -SYRUP, -TABLET, 4 RETROVIR INJECTION, 4 re-u40, 59 revatio (sildenafil citrate), 51 REVATIO INJECTION, 51 REVATIO TABLET, 51 REVIA, 37 REVLIMID, 20 revonto, 83 REYATAZ, 4 R-GENE 10, 89 RHEUMATREX, 20 RHINOCORT AQUA, 62 rho(d) immune globulin, 76, 77, 78 RHOGAM, 77 RHOGAM PLUS, 77 RHOPHYLAC, 77 ribapak, 10 ribasphere 200 mg tablet, 10 S7950_2011_DOC7aPC ribasphere 400 mg tablet, -600 mg tablet, capsule, 10 RIBATAB, 11 ribavirin, 10, 11 ribavirin 200 mg tablet, 11 ribavirin 400 mg tablet, -600 mg tablet, capsule, 11 RIDAURA, 85 rifabutin, 5 RIFADIN CAPSULE, 5 RIFADIN INJECTION, 5 RIFAMATE, 5 rifampin, 5 rifampin capsule, 5 rifampin injection, 5 rifampin/inh/pyrazinamide, 5 rifampin/isoniazid, 5 rifapentine, 5 RIFATER, 5 rifaximin, 10 rilonacept, 79 RILUTEK, 83 riluzole, 83 rimantadine, 10 rimantadine hcl, 11 rimexolone, 106 RIMSO-50, 115 ringers injection, 89 RIOMET, 67 risedron sod/calcium carbona, 68 risedronate, 68 RISPERDAL CONSTA 12.5 MG SYR, -25 MG SYR, 24 RISPERDAL CONSTA 37.5 MG SYR, -50 MG SYR, 24 RISPERDAL M-TAB, 24 RISPERDAL SOLUTION, 24 RISPERDAL TABLET, 24 risperidone, 24 risperidone m-tab, 24 risperidone odt, 24 risperidone solution, 24 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary risperidone tablet, 25 RITALIN, 31 RITALIN LA, 31 RITALIN-SR, 31 ritonavir, 4 ritonavir/lopinavir, 4 RITUXAN, 20 rituximab, 20 rivastigmine, 23 rivastigmine tartrate, 22 rizatriptan benzoate, 32 ROBAXIN INJECTION, 83 ROBAXIN TABLET, 83 ROBAXIN-750, 83 ROBINUL FORTE, 71 ROBINUL INJECTION, 71 ROBINUL TABLET, 71 ROCALTROL, 93 ROCEPHIN, 6 ROMAZICON, 37 romycin, 107 ropinirole, 36 ropinirole hcl, 36 ropivacaine, 2 rosaderm cleanser, 54 rosiglitazone maleate, 66 rosiglitazone maleate/glimepir, 66 rosiglitazone/metformin hcl, 66 rosuvastatin calcium, 46 ROTARIX, 77 ROTATEQ, 77 rotavirus vac, live att, 89-12, 77 rotavirus vac, live pentav, 77 rovin-nv, 102 rovin-nv dha, 102 ROWASA, 73 ROXICET SOLUTION, 29 roxicet tablet, 29 ROXICODONE, 29 ROXICODONE INTENSOL, 29 ROZEREM, 38 rubella vaccine, 77 S7950_2011_DOC7aPC rufinamide, 34 RYBIX ODT, 22 RYTHMOL, 42 RYTHMOL SR, 42 RYZOLT, 22 SABRIL, 34 SAFESNAP INSULIN SYRINGE, 81 SAFETYGLIDE INSULIN SYRINGE, 81 SAFETYGLIDE SYRINGE SYRINGE EMPTY DISPOSABLE, 81 SAIZEN, 75 SALAGEN, 63 SALICYLATES AND RELATED DRUGS, 85 salmeterol, 111 salmeterol/fluticasone, 112 salsalate, 85 SAMSCA, 69 SANCTURA, 114 SANCTURA XR, 114 SANCUSO, 26 SANDIMMUNE CAPSULE, -SOLUTION, 20 SANDIMMUNE INJECTION, 20 SANDOSTATIN, 20 SANDOSTATIN LAR 10 MG KIT, -30 MG KIT, 20 SANDOSTATIN LAR 20 MG KIT, 21 SANTYL, 59 SAPHRIS, 25 sapropterin dihydrochloride, 69 saquinavir mesylate, 4 SARAFEM 10 MG TABLET, 39 SARAFEM 15 MG TABLET, 40 SARAFEM 20 MG TABLET, 40 sargramostim, 79 SAVELLA 100 MG TABLET, -12.5 MG TABLET, -25 MG TABLET, -50 MG TABLET, 35 SAVELLA TITRATION PACK, 36 saxagliptin hydrochloride, 67 SCABICIDES, 55 SCALACORT, 58 scopolamine, 26, 71, 109 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary SCOPOLAMINE HYDROBROMIDE INJECTION, 71 SEASONALE, 96 SEASONIQUE, 96 seb-prev 10% cream, -10% gel, 54 se-care, 102 se-care conceive, 102 se-care gesture, 102 SECONDARY AMINES, 37 SECTRAL, 43 SEDATIVE/HYPNOTIC DRUGS, 38 SELECTIVE SEROTONIN REUPTAKE INHIBITORS, 38 SELECT-OB, 102 SELECT-OB + DHA, 102 selegiline, 33, 36, 37 selegiline hcl capsule, -tablet, 36 selenium sulfide, 54, 55 selenium sulfide 2.25% shampoo, -2.5% lotion, -sulf 2.5% shampoo, 54 selenos, 54 selfemra 10 mg capsule, 40 selfemra 20 mg capsule, 40 SELSEB, 54 SELZENTRY, 4 SEMPREX-D, 110 se-natal 19, 102 se-natal 90, 102 se-natal one, 102 SENSIPAR, 69 SENSORCAINE, 2 SENSORCAINE WITH DEXTROSE, 2 SENSORCAINE WITH EPINEPHRINE, 2 SENSORCAINE-MPF, 2 SENSORCAINE-MPF EPINEPHRINE, 2 se-plete dha, 102 SEPTRA, 15 SEPTRA DS, 15 SEREVENT DISKUS, 111 SEROMYCIN, 5 S7950_2011_DOC7aPC SEROQUEL 100 MG TABLET, -200 MG TABLET, -25 MG TABLET, -50 MG TABLET, 25 SEROQUEL 300 MG TABLET, -400 MG TABLET, 25 SEROQUEL XR 150 MG TABLET, -200 MG TABLET, 25 SEROQUEL XR 300 MG TABLET, -400 MG TABLET, -50 MG TABLET, 25 SEROSTIM, 75 sertaconazole nitrate, 12 sertraline, 40 sertraline hcl 100 mg tablet, -50 mg tablet, 40 sertraline hcl 25 mg tablet, 40 sertraline hcl solution, 40 se-tan dha, 102 setonet, 102 setonet-ec, 102 sevelamer, 86 sevelamer carbonate, 86 sf, 90 sf 5000 plus, 90 SFROWASA, 73 silodosin, 115 SILVADENE, 17 silver sulfadiazine, 17 SIMCOR 1,000-20 MG TABLET, -750-20 MG TABLET, 47 SIMCOR 500-20 MG TABLET, 47 SIMPONI, 21 SIMULECT, 21 simvastatin, 47 simvastatin tablet, 47 sinecatechins, 59 SINEMET 10-100, 36 SINEMET 25-100, 36 SINEMET 25-250, 36 SINEMET CR, 36 SINGLE USE SWAB, 81 SINGULAIR, 111 sirolimus, 20 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary sitagliptin phos/metformin hcl, 67 sitagliptin phosphate, 67 SKELAXIN, 83 SKELID, 69 SMOKING CESSATION PRODUCTS, 40 sodium acetate, 89 sodium benzoate/na ph-acetate, 60 sodium bicarbonate, 88 sodium bicarbonate injection, 89 sodium chloride 0.45% irrig, -0.9% irrig., sterile saline 0.9% irr, 89 sodium chloride 0.45% soln, -0.45% solnexcel con, -0.9% soln, -0.9% soln., -0.9% soln-excel cont, -0.9% solution, -3% iv soln, -4 meq/ml vl, -5% iv soln, -cl 2.5 meq/ml vial, 89 sodium citrate & citric acid, 93 sodium citrate/citric acid, 92 SODIUM EDECRIN, 48 sodium fluoride, 89, 90 sodium fluoride drops, -solution non-oral, tablet, -tablet chewable, 90 sodium fluoride/pot nitrate, 90 sodium lactate, 89 sodium oxybate, 37 sodium phenylbutyrate, 60 sodium phosphate injection, 89 sodium phosphate/na biphos, 72 sodium polystyrene sulfonate, 91, 92 sodium sulfacetamide-sulfur cleanser, -foam, -pads medicated, -sulfacetamide-sulfur lotn, -sulf-sulfur wash, -suspensions, (not oral), 54 sodium tetradecyl sulfate, 60 sodium/calcium/mag/potassium, 108 SOLARAZE, 59 solia, 96 solifenacin succinate, 115 SOLODYN, 16 SOLU-CORTEF, 64 SOLU-CORTEF (PF), 64 SOLU-MEDROL, 64 S7950_2011_DOC7aPC SOLU-MEDROL (PF), 64 SOMA, 83 somatropin, 75 SOMATULINE DEPOT, 21 SOMAVERT, 69 SONATA 10 MG CAPSULE, 38 SONATA 5 MG CAPSULE, 38 sorafenib tosylate, 20 SORIATANE, 55 SORIATANE CK 10 MG KIT, 55 SORIATANE CK 25 MG KIT, 55 sorine, 49 sotalol, 48, 49 sotalol af, 49 SOTALOL HCL, 49 SOTRADECOL, 60 sotret, 55 SPECIALIZED OB/GYN DRUGS, 104 SPECTRACEF, 6 SPIRIVA, 114 spironolactone, 51 spironolactone tablet, 51 spironolactone/hctz, 51 spironolactone-hctz, 51 SPORANOX CAPSULE, 8 SPORANOX SOLUTION, 8 sprintec, 96 SPRYCEL, 21 sps, 92 sronyx, 96 ssd, 17 ssd af, 17 stagesic, 30 STALEVO 100, 36 STALEVO 125, 36 STALEVO 150, 36 STALEVO 200, 37 STALEVO 50, 37 STALEVO 75, 37 stanimax, 90 stannous fluoride, 90 stannous fluoride solution, 90 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary STARLIX, 67 stavudine, 4, 5 STAVZOR, 41 STELARA, 21 STERAPRED, 64 STERAPRED DS, 64 STIMATE, 69 STRATTERA, 37 streptomycin, 5 STREPTOMYCIN SULFATE INJECTION, 5 STRIANT, 94 STROMECTOL, 3 sublimaze, 29 SUBOXONE, 30 SUBUTEX, 30 succimer, 60 SUCCINIMIDES, 40 succinylcholine, 83 sucralfate, 72 sucralfate suspension oral, -tablet, 72 sufenta, 22 sufentanil citrate injection, 22 SULAR, 44 sulconazole nitrate, 12 sulfac, 107 sulfacetamide sodium, 54, 107 sulfacetamide sodium drops, 107 sulfacetamide sodium lotion, -suspension topical, 55 sulfacetamide/prednisolone ac, 105 sulfacetamide/sulfur, 53, 54 sulfacetamide-prednisolone, 106 sulfadiazine tablet, 15 sulfamethoxazole/trimethoprim, 15 sulfamethoxazole-trimethoprim injection, 15 sulfamethoxazole-trimethoprim suspension oral, -tablet, 15 sulfamide, 107 SULFAMYLON, 17 sulfanilamide, 98 sulfasalazine, 72 sulfasalazine dr, 73 S7950_2011_DOC7aPC sulfasalazine tablet, 73 sulfatol c, 54 sulfatrim, 15 sulfazine, 73 sulfazine ec, 73 sulfisoxazole acetyl, 15 SULFONAMIDES, 15 sulfuric acid/sulf phenol, 63 sulindac, 83 sulindac tablet, 85 sulzee, 54 sumatriptan, 32, 33 SUMATRIPTAN 20 MG NASAL SPRAY, 33 sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml kit, -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng, 33 sumatriptan 4 mg/0.5 ml vial, -6 mg/0.5 ml vial, 33 SUMATRIPTAN 5 MG NASAL SPRAY, 33 sumatriptan suc/naproxen sod, 33 sumatriptan succinate tablet, 33 SUMAXIN, 54 sunitinib malate, 21 SUPPRELIN LA, 104 SUPRAX, 7 SURE COMFORT, 81 SURE COMFORT ALCOHOL, 81 SURE-FINE PEN NEEDLES, 81 SURE-JECT INSULIN SYRINGE, 81 SURE-PREP ALCOHOL PREP PADS, 81 SURMONTIL, 40 SUSTIVA, 4 SUTENT, 21 SYMBICORT, 114 SYMBYAX, 25 SYMLIN, 65 SYMLINPEN 120, 65 SYMLINPEN 60, 65 SYNAGIS, 77 SYNALGOS-DC, 30 SYNAREL, 104 SYNERA, 2 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary SYNERCID, 9 SYNTHROID, 70 SYPRINE, 85 TACLONEX, 55 TACLONEX SCALP, 55 tacrine, 22 tacrolimus, 20, 59 tacrolimus 0.5 mg capsule, -1 mg capsule, 21 tacrolimus 5 mg capsule, 21 TALWIN INJECTION, 22 TAMBOCOR, 42 TAMIFLU 30 MG GELCAP, 11 TAMIFLU 45 MG GELCAP, -75 MG GELCAP, 11 TAMIFLU SUSPENSION, 11 tamoxifen citrate tablet, 21 tamsulosin, 115 tamsulosin hcl, 115 TANDEM DHA, 102 TANDEM OB, 102 TAPAZOLE, 63 tapentadol hcl, 29 TARCEVA, 21 TARGRETIN, 21 TARKA, 50 taron a prenatal, 102 taron ec calcium, 102 taron-c dha, 102 taron-ec cal, 102 taron-prex prenatal, 102 TASIGNA, 21 TASMAR, 37 tazarotene, 55 TAZICEF, 7 TAZORAC, 55 taztia xt, 44 TEGRETOL, 27 TEGRETOL XR 100 MG TABLET, 27 TEGRETOL XR 200 MG TABLET, -400 MG TABLET, 27 TEKTURNA, 50 TEKTURNA HCT, 50 S7950_2011_DOC7aPC telavancin, 9 telbivudine, 11 telithromycin, 8 telmisartan, 42 telmisartan/amlodipine, 50 telmisartan/hctz, 50 TEMOVATE, 58 TEMOVATE EMOLLIENT, 58 TENEX, 45 tenofovir disproxil fumarate, 5 TENORETIC 100, 50 TENORETIC 50, 50 TENORMIN, 43 TERAZOL 3 80 MG SUPPOSITORY, 17 TERAZOL 3 CREAM, 18 TERAZOL 7, 18 terazosin 1 mg capsule, -2 mg capsule, -5 mg capsule, 52 terazosin 10 mg capsule, 52 terbinafine, 8, 12 terbinafine hcl, 8 terbinafine/hydroxy chitosan, 8 TERBINEX, 8 terbutaline sulfate injection, 111 terbutaline sulfate tablet, 111 terconazole, 17, 18 terconazole 0.4% cream, 18 terconazole 0.8% cream, 18 terconazole 80 mg suppository, 18 teriparatide, 69 TERRAMYCIN, 16 TERRAMYCIN IM, 16 TERRAMYCIN WITH POLYMYXIN, 107 TERSI FOAM, 55 TERTIARY AMINES, 40 TERUMO INSULIN SYRINGE, 81 TERUMO SURGUARD, 81 TESTIM, 94 TESTOPEL, 94 testosterone, 94 testosterone cypionate, 94 testosterone cypionate injection, 94 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary testosterone enanthate, 94 testosterone propionate, 94 TESTRED, 94 TETANUS DIPHTHERIA TOXOIDS, 77 tetanus immune globulin, 76 tetanus toxoid adsorbed, 77 tetanus,diphtheria toxoid, 76, 77, 78 TETANUS-DIPHTERIA-DECAVAC, 78 tetrabenazine, 37 tetracyc hcl/bis ss/metronid, 73 tetracycline hcl capsule, 16 TETRACYCLINES, 16 tetrahydrozoline, 62 TEVETEN, 42 TEVETEN HCT, 50 TEV-TROPIN, 75 TEXACORT, 58 thalidomide, 60 THALITONE, 52 THALOMID, 60 THEO-24, 112 theochron, 112 theophylline, 112 theophylline anhydrous tablet sustained release 12hr, 112 THERACYS, 21 THERAPEUTIC VITAMINS AND MINERALS, 93 thermazene, 17 THIAZIDE AND RELATED DRUGS, 51 THINPRO INSULIN SYRINGE, 82 thioguanine, 21 THIOGUANINE, 21 thioridazine hcl, 25 thiothixene, 24, 25 THROMBATE III, 91 THROMBOPOIETIC AGENTS, 79 THYMOGLOBULIN, 78 thyroid, 69 THYROID SUPPLEMENTS, 69 thyroid tablet, 70 THYROLAR-1, 70 THYROLAR-1/2, 70 S7950_2011_DOC7aPC THYROLAR-1/4, 70 THYROLAR-2, 70 THYROLAR-3, 70 tiagabine, 34 TIAZAC, 44 ticarcillin/k clavulanate, 14 TICE BCG, 78 ticlopidine hcl, 86 TIGAN CAPSULE, 26 TIGAN INJECTION, 26 tigecycline, 9 TIKOSYN, 49 tilia fe, 96 tiludronate, 69 TIMENTIN, 14 timolol, 104, 105 timolol maleate drops, -gel-forming solution, 105 timolol maleate tablet, 43 TIMOPTIC, 105 TIMOPTIC OCUDOSE, 105 TIMOPTIC-XE, 105 tinzaparin sodium, porcine, 91 tiotropium bromide, 114 tipranavir/vitamin e tpgs, 4 tirofib hc m-hyd/na chlor, 86 TIROSINT, 70 tizanidine, 83 tizanidine hcl, 83 TOBRADEX, 106 tobramycin, 3, 107 tobramycin sulfate drops, 107 tobramycin sulfate in ns, 3 tobramycin sulfate injection, 3 tobramycin sulfate/dexameth, 106 tobramycin/lotepred etab, 106 tobramycin-dexamethasone, 106 tobrasol, 107 TOBREX, 107 tocilizumab, 79 TOFRANIL, 41 TOFRANIL-PM, 41 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary tolazamide, 67 tolbutamide, 67 tolcapone, 37 tolmetin sodium, 85 tolterodine tartrate, 114 tolvaptan, 69 TOPAMAX, 34 TOPCARE CLICKFINE, 82 TOPCARE ULTRA COMFORT, 82 TOPICAL ANESTHETICS, 2 TOPICAL ANTIBACTERIAL DRUGS, 16 TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB., 17 TOPICAL ANTI-INFLAMMATORY DRUGS, 56 TOPICAL CORTICOSTEROID DRUGS, 56 TOPICAL DERMATOLOGICAL DRUGS, 58 TOPICORT, 58 TOPICORT LP, 58 topiragen, 34 topiramate, 34 topiramate capsule sprinkle, -tablet, 34 topisulf, 54 TOPROL XL, 43 TORADOL, 85 toremifene, 19 torsemide, 48 torsemide injection, 48 torsemide tablet, 48 TOTACILLIN-N, 14 TOVIAZ, 115 TPN ELECTROLYTES, 89 TPN ELECTROLYTES II, 89 TRACLEER, 46 tramadol, 22 tramadol hcl tablet, 22 tramadol hcl tablet sustained release 24hr, 22 tramadol hcl-acetaminophen, 22 tramadol/apap, 22 TRANDATE, 43 trandolapril, 42 trandolapril/verapamil, 50 S7950_2011_DOC7aPC trandolapril-verapamil, 50 tranexamic acid, 60 TRANSDERM-SCOP, 26 tranylcypromine, 34 tranylcypromine sulfate, 34 TRAVASOL, 89 TRAVASOL WITH DEXTROSE, 89 TRAVASOL WITH ELECTROLYTES, 89 TRAVATAN, 105 TRAVATAN Z, 105 travoprost, 105 trazodone, 35 trazodone hcl tablet, 36 treagan otic, 61 TRECATOR, 5 TRELSTAR 11.25 MG SYRINGE, -3.75 MG SYRINGE, 21 TRELSTAR 22.5 MG SYRINGE, -22.5 MG VIAL, 21 TRELSTAR DEPOT, 21 TRELSTAR LA, 21 TRENTAL, 51 treprostinil sodium, 51 tretinoin, 21, 52, 53, 54 tretinoin 0.025% cream, -0.05% cream, 0.1% cream, -gel, 54 tretinoin capsule, 21 tretinoin/emol cmb9/skin cln1, 54 TRETIN-X, 54 TREXALL, 21 TREXIMET, 33 trezix, 30 tri rx, 102 triadvance, 102 triamcinolone acetonide, 57, 62, 63, 64, 106, 113 triamcinolone acetonide cream, -lotion, ointment, 58 triamcinolone acetonide injection, 64 triamcinolone acetonide paste, 63 triamcinolone hexacetonide, 63 triamterene, 51 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary triamterene-hctz, 51 TRIBENZOR, 50 TRICARE, 102 TRICARE PRENATAL DHA ONE, 102 tricitrates, 115 TRICOR, 47 triderm, 58 TRIDESILON, 58 trientine, 85 TRIESENCE, 106 trifera ob, 102 trifluoperazine hcl, 25 trifluridine, 108 TRIGLIDE, 47 trihexyphenidyl hcl, 23 TRIHIBIT, 78 tri-legest fe, 96 TRILEPTAL, 27 TRILIPIX, 47 tri-lo-sprintec, 96 trilyte with flavor packets, 73 trimesis rx, 102 trimethobenzamide, 26 trimethobenzamide hcl capsule, 26 trimethobenzamide hcl injection, 26 trimethoprim, 17 trimethoprim tablet, 17 trimipramine, 40 trimipramine maleate, 41 trinatal rx 1, 102 trinate, 102 trinessa, 96 TRI-NORINYL, 96 TRIOSTAT, 70 TRIPEDIA, 78 tripohist, 111 tri-previfem, 96 triprolidine hcl syrup, 111 triptorelin pamoate, 21 tri-sprintec, 96 triveen-one, 102 triveen-prx rnf, 102 S7950_2011_DOC7aPC triveen-u, 102 trivora-28, 96 TRIZIVIR, 5 TROPHAMINE, 89 tropicacyl, 109 tropicamide, 109 trospium chloride, 114 TRUSOPT, 105 TRUVADA, 5 TWINJECT, 114 TWINRIX, 78 TWYNSTA, 50 TYGACIL, 9 TYKERB, 21 TYLENOL-CODEINE NO.3, 30 TYLENOL-CODEINE NO.4, 30 TYLOX, 29 TYPHIM VI, 78 typhoid vaccine, 78 TYSABRI, 21 TYZEKA, 11 TYZINE, 62 U-CORT, 58 u-kera e urea emollient, 59 ULESFIA, 55 ULORIC, 83 ULTICARE NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE, 82 ULTIGUARD 30GX0.5 ML SYRINGE, -30GX1 ML SYRINGE, -SYRINGE EMPTY DISPOSABLE, 82 ULTILET ALCOHOL SWAB, 82 ULTILET INSULIN SYRINGE, 82 ULTILET PEN NEEDLE, 82 ultimatecare advantage, 102 ultimatecare one, 102 ultimatecare one nf, 102 ULTIVA, 22 ULTRA COMFORT, 82 ULTRACET, 22 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary ULTRACOMFORT DISPOSABLE SYRINGE, NEEDLE DISPOSABLE, -SYRINGE EMPTY DISPOSABLE, 82 ULTRAM, 22 ULTRAM ER, 22 ULTRAVATE, 58 ULTRAVATE PAC, 58 UMECTA, 59 UMECTA PD, 59 UNASYN, 14 UNIFINE PENTIPS, 82 UNIPHYL, 112 UNIRETIC, 50 unithroid, 70 UNIVASC, 42 URAMAXIN, 59 urea, 58, 59 urea 40, 59 urea 40% cream, -40% nail film susp, -45% cream, -50% cream, -50% nail stick, -50% nailstik, -foam, -gel, -kit, -lotion, ointment, -towelette, 59 urealac cream, -gel, -lotion, -soln, top, 59 URECHOLINE, 115 URINARY ANTIINFECTIVES, 17 UROLOGICAL MEDICATIONS, 114 UROQID-ACID NO.2, 17 UROXATRAL, 115 URSO, 73 URSO FORTE, 73 ursodiol, 72, 73 ursodiol capsule, -tablet, 73 ustekinumab, 21 utac, 17 VAGIFEM, 97 VAGINAL ANTIFUNGALS, 17 valacyclovir, 11 VALCYTE, 11 valganciclovir, 11 valproate sodium, 41 valproate sodium injection, 41 valproic acid, 41 S7950_2011_DOC7aPC VALPROIC ACID AND DERIVATIVES, 41 valproic acid capsule, -syrup, 41 valsartan, 42 VALTREX, 11 VALTURNA, 50 VANCOCIN HCL, 9 vancomycin, 9 vancomycin 1 gm add-van vial, -1 gm vial, 10 gm vial, -5 gm vial, -500 mg a/v vial, 500 mg vial, -750 mg vial, 9 VANCOMYCIN HCL 1G/200 ML BAG, 9 VANCOMYCIN-D5W, 9 vandazole, 98 VANISHPOINT SYRINGE EMPTY DISPOSABLE, 82 VANOS, 58 VANTAS, 21 VANTIN, 7 VAQTA, 78 varenicline tartrate, 40 varicella vacc/pf, 78 varicella virus vaccine live, 78 VARIVAX VACCINE, 78 VASERETIC, 50 VASODILATOR ANTIHYPERTENSIVES, 52 VASOTEC, 42 VECTICAL, 55 velaglucerase alfa, 69 VELCADE, 21 velivet, 96 venlafaxine, 35, 36 venlafaxine hcl, 36 venlafaxine hcl er capsule sustained release 24 hr, 36 VENLAFAXINE HCL ER TAB SA, 36 VENTOLIN HFA, 111 VERAMYST, 63 verapamil, 43, 44, 45 verapamil 360 mg cap pellet, 44 verapamil er, 44 verapamil hcl capsule 24hr sustained release pellets, -er 120 mg capsule, -er 180 mg © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary capsule, -er 240 mg capsule, -tablet, tablet sustained action, 45 verapamil hcl injection, 45 VERDESO, 58 VEREGEN, 59 VERELAN, 45 VERELAN PM, 45 veripred 20, 64 VERSALON ALL PURPOSE SPONGE, 82 verteporfin, 109 VESANOID, 21 VESICARE, 115 VEXOL, 106 VFEND, 8 VFEND IV, 13 VIBATIV, 9 VIBRAMYCIN 50 MG CAPSULE, 16 VIBRAMYCIN SUSPENSION, -SYRUP, -100 MG CAPSULE, 16 VIBRA-TABS, 16 VICODIN, 30 VICODIN ES, 30 VICODIN HP, 30 VICOPROFEN, 30 VICTOZA 2-PAK, 65 VICTOZA 3-PAK, 65 VIDAZA, 21 VIDEX, 5 VIDEX EC, 5 vigabatrin, 34 VIGAMOX, 107 VIMOVO, 85 VIMPAT INJECTION, 34 VIMPAT SOLUTION, -TABLET, 35 vinacal, 102 vinate az, 102 vinate az extra, 102 vinate c, 102 vinate calcium, 102 vinate care, 103 vinate gt, 103 vinate ic, 103 S7950_2011_DOC7aPC vinate ii, 103 vinate iii, 103 vinate one, 103 vinate pn care, 103 vinate ultra, 103 vinate-m, 103 VIRACEPT, 5 VIRAMUNE, 5 VIRAZOLE, 11 VIREAD, 5 VIROPTIC, 108 VISICOL, 72 vis-phos n, 93 visqid a-a, 17 VISTARIL, 54 VISTIDE, 11 VISUDYNE, 109 vitafol-ob, 103 VITAFOL-OB+DHA, 103 vitafol-pn, 103 VITAMINS AND MINERALS AND RELATED PRODUCTS, 93 vitanatal ob + dha, 103 vitaphil, 103 vitaphil + dha, 103 vitaphil + dha 90, 103 vitaphil aide, 103 vitaspire, 103 vitazol, 54 VITRASERT, 109 VIVACTIL, 38 VIVAGLOBIN, 78 VIVELLE, 97 VIVELLE-DOT, 98 VIVITROL, 37 VOL-TAB RX, 103 VOLTAREN DROPS, 109 VOLTAREN GEL, 56 VOLTAREN TABLET ENTERIC COATED, 85 VOLTAREN-XR, 85 VOLUVEN, 60 VOPAC, 30 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary voriconazole, 8, 13 vorinostat, 21 VOSOL, 61 VOSOL HC, 61 VOSPIRE ER, 111 VOTRIENT, 21 VPRIV, 69 VUSION, 12 vynatal-fa, 103 VYTORIN 10-10 MG TABLET, 47 VYTORIN 10-20 MG TABLET, -10-40 MG TABLET, -10-80 MG TABLET, 47 VYVANSE, 31 warfarin sodium, 91 WEBCOL, 82 WELCHOL, 47 WELLBUTRIN, 36 WELLBUTRIN SR, 36 WELLBUTRIN XL, 36 WESTCORT, 58 westhroid, 70 WINRHO SDF, 78 XALATAN, 105 XENAZINE, 37 XERAC AC, 59 XIAFLEX, 60 XIBROM, 109 XIFAXAN 200 MG TABLET, 10 XIFAXAN 550 MG TABLET, 10 XODOL 10-300, 30 XODOL 5-300, 30 XODOL 7.5-300, 30 XOLAIR, 114 XOLEGEL, 12 XOLOX, 29 XOPENEX HFA, 111 x-viate, 59 XYLOCAINE 2% VIAL, 63 XYLOCAINE 2% VIAL, -0.5% VIAL, -1% VIAL, 2 XYLOCAINE IV, 2 XYLOCAINE IV FOR CARDIAC, 2 S7950_2011_DOC7aPC XYLOCAINE JEL, -SOLUTION NON-ORAL, 2 XYLOCAINE WITH EPINEPHRINE, 2 XYLOCAINE-MPF, 2 XYLOCAINE-MPF WITH EPINEPHRINE, 2 XYREM, 37 XYZAL SOLUTION, 111 XYZAL TABLET, 111 YASMIN 28, 96 YAZ, 96 yellow fever vaccine, 78 YF-VAX, 78 zafirlukast, 111 zaleplon, 38 zaleplon 10 mg capsule, 38 zaleplon 5 mg capsule, 38 zamicet, 30 ZANAFLEX, 83 zanamivir, 10 ZANTAC 25, 71 ZANTAC INJECTION, 71 ZANTAC SYRUP, -TABLET, 71 ZARONTIN, 40 ZAROXOLYN, 52 zatean-pn, 103 zatean-pn dha, 103 zatean-pn plus, 103 ZAVESCA, 69 ZAZOLE 0.8% VAGINAL CREAM, 18 ZAZOLE 80 MG VAGINAL SUPP, 18 ZAZOLE VAGINAL 0.4% CREAM, 18 ZEBETA, 43 ZEGERID 20 MG CAPSULE, 74 ZEGERID 20 MG PACKET, 74 ZEGERID 40 MG CAPSULE, 74 ZEGERID 40 MG PACKET, 74 ZELAPAR, 37 ZEMAIRA, 114 zema-pak, 65 ZEMPLAR CAPSULE, 93 ZEMPLAR INJECTION, 93 ZENAPAX, 79 zenchent, 96 © Express Scripts, Inc. All Rights Reserved 2011 MEDICARE NATIONAL PREFERRED ENHANCED FORMULARY Open Comprehensive Formulary ZENPEP, 73 ZERIT, 5 ZERLOR, 30 ZESTORETIC, 50 ZESTRIL, 42 ZETIA, 47 ZIAC, 50 ZIAGEN, 5 ZIANA, 54 ziconotide acetate, 22 zidovudine, 4, 5 zidovudine/lamivudine/abacavir, 5 zileuton, 111 ZINACEF, 7 ZINACEF IN ISO-OSMOTIC WATER, 7 ZINACEF ISO-OSMOTIC DEXTROSE, 7 ziprasidone, 24 ZIPSOR, 85 ZIRGAN, 109 ZITHRANOL-RR, 55 ZITHROMAX 100 MG/5 ML SUSP, 11 ZITHROMAX 200 MG/5 ML SUSP, 11 ZITHROMAX 250 MG TABLET, -250 MG ZPAK TABLET, 12 ZITHROMAX 500 MG TABLET, 12 ZITHROMAX INJECTION, 12 ZITHROMAX PACKET, -600 MG TABLET, 12 ZITHROMAX TRI-PAK, 12 ZMAX, 12 ZMAX ADULT-PEDIATRIC, 12 ZMAX PEDIATRIC, 12 ZOCOR, 47 ZOFRAN INJECTION, 27 ZOFRAN ODT, 27 ZOFRAN SOLUTION, 27 ZOFRAN TABLET, 27 ZOLADEX, 21 zoledronic acid, 69 ZOLINZA, 21 zolmitriptan, 33 ZOLOFT 100 MG TABLET, -50 MG TABLET, 40 S7950_2011_DOC7aPC ZOLOFT 25 MG TABLET, 40 ZOLOFT SOLUTION, 40 zolpidem, 38 zolpidem tartrate, 38 ZOMETA, 69 ZOMIG SPRAY NON-AEROSOL, 33 ZOMIG TABLET, 33 ZOMIG ZMT, 33 ZONALON, 59 ZONEGRAN, 35 zonisamide, 35 ZORBTIVE, 75 ZORPRIN, 85 ZORTRESS 0.25 MG TABLET, 21 ZORTRESS 0.5 MG TABLET, -0.75 MG TABLET, 21 ZOSTAVAX, 78 ZOSYN, 14 zovia 1-35e, 96 zovia 1-50e, 96 ZOVIRAX CAPSULE, -SUSPENSION ORAL, TABLET, 11 ZOVIRAX CREAM, -OINTMENT, 11 ZUPLENZ, 27 ZYBAN, 40 ZYCLARA, 59 ZYDONE, 30 ZYFLO, 111 ZYFLO CR, 111 ZYLET, 106 ZYLOPRIM, 83 ZYMAR, 107 ZYMAXID, 107 ZYPREXA INJECTION, 25 ZYPREXA RELPREVV, 25 ZYPREXA TABLET, 25 ZYPREXA ZYDIS, 25 ZYVOX INJECTION, 10 ZYVOX SUSPENSION RECONSTITUTED ORAL, -TABLET, 10 © Express Scripts, Inc. All Rights Reserved Express Scripts Prescription Drug Plan is a standalone 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. Quantity limitations and restrictions may apply. This document is available in alternate formats or languages. For more information contact Customer Service at the number listed on the back of your ID card.