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Prmtjquhp-09.hp.090701.vs2

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan.
The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.
2009 Express Scripts
PLEASE NOTE: The symbol * next to a drug signifies that it is subject to nonformulary status
when a generic is available throughout the year. Not all the drugs listed are covered by all

High Performance Formulary
prescription-drug benefit programs; check your benefit materials for the specific drugs
covered and the copayments for your prescription-drug benefit program. For specific

For Carolina Crescent
questions about your coverage, please call the phone number printed on your ID card.
ANTIINFECTIVES
CARDIOVASCULAR
Drugs to Treat Multiple
ENDOCRINE MEDICATIONS
MEDICATIONS
Sclerosis
Antivirals
Amylin Analogues
NOTE: All brand oral antiviral ACE Inhibitors + HCT Combos oxcarbazepine
Sedative/Hypnotics
Dipeptidyl Peptidase IV
IMMUNOLOGICALS
Inhibitors
Antidementia Drugs
Glucocorticoids
Selective Serotonin
Reuptake Inhibitors
Growth Hormones
Cephalosporins
Antidepressants
Angiotensin II Receptor
Glucose Elevating Drugs
Antagonists + HCT Combos
Tertiary Amines
Incretin Mimetics
Beta-Adrenergic Antagonists venlafaxine
Insulins
Erythroid Stimulants
Macrolides
Antiparkinson Drugs
DERMATOLOGICAL
MEDICATIONS
Interferons
Oral Antifungals
Antipsychotic Drugs
Insulin Sensitizers
Antiacne Drugs
Pegylated Interferons/
Oral Ribavirin Agents
Oral Hypoglycemics
Calcium Antagonists
Penicillins
MUSCULOSKELETAL
Antivertigo & Antiemetics
Antipsoriasis & Antieczema metformin, er
MEDICATIONS
Quinolones
HMG-CoA Reductase
Drugs
Inhibitors
CNS Muscle Relaxants
Thyroid Supplements
Topical Antifungals
Corticosteroid Drugs
HMG-CoA Combinations
Class II Narcotics
Other Endocrine Drugs
Hypolipoproteinemics
Inj. Drugs for Arthritis
Urinary Antiinfectives
ANTINEOPLASTIC/IMMUNO-
Class III Narcotics
Miscellaneous
GASTROINTESTINAL
Non-Steroidal Anti-
SUPPRESSANT DRUGS
Dermatologicals
MEDICATIONS
Inflammatory Agents
Antispasmodics/Drugs
Nitrates
Affecting GI Motility
considered formulary, unless isosorbide mononitrate CNS Stimulants
EAR-NOSE MEDICATIONS
Thiazide & Related Drugs
Drugs Affecting The Ear
Proton Pump Inhibitors
Salicylates & Related Drugs
Other Antihypertensives
Other GI Drugs
Other Drugs For ADHD
AUTONOMIC & CNS
Drugs Affecting The Nose
NUTRITION & BLOOD
MEDICATIONS
MODIFIERS
Drugs To Prevent & Treat
Anticonvulsants
Headaches
Antiplatelet Drugs
THIS DOCUMENT LIST IS EFFECTIVE JULY 1, 2009 THROUGH DECEMBER 31, 2009. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our web site at www.express-scripts.com.
2009 Express Scripts, Inc.
PRMTJQUHP-09 (07/01/09 Vs2)
All Rights Reserved
RESPIRATORY MEDICATIONS
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary.
Blood Detoxicants
Antihistamines
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Antihistamine/Decongestants
Oral and Inj. Anticoagulants promethazine w/codeine
LOVENOX* [INJ] [PA]
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
Therapeutic Vitamins &
Minerals
Antitussive & Expectorants
OBSTETRICAL &
Beta-2 Adrenergics
GYNECOLOGICAL
MEDICATIONS
Androgen Drugs
Contraceptives
Leukotriene Modifiers
Methyl Xanthines
Other Drugs For Asthma
Estrogen Drugs
flunisolide, fluticasone, Nasacort AQ [ST] Estrogen/Progestin
flunisolide, fluticasone, Nasacort AQ [ST] Combinations
ORTHO TRI-CYCLEN LO Generic oral contraceptive flunisolide, fluticasone, Nasacort AQ [ST] Prenatal Vitamins
UROLOGICAL MEDICATIONS
Progestin Drugs
Anticholinergic
medroxyprogesterone acetate Antispasmodics
fluoxetine (daily), citalopram, paroxetine Drugs Used For BPH
Specialized OB/GYN Drugs
flunisolide, fluticasone, Nasacort AQ [ST] OPHTHALMIC MEDICATIONS
WEIGHT MANAGEMENT
Antibacterial Drugs
Appetite Suppressants
Other Weight Loss Products
DIABETIC SUPPLIES
Antiglaucoma Drugs
flunisolide, fluticasone, Nasacort AQ [ST] Meters & Strips
Corticosteroid Drugs
Miscellaneous Supplies
Other Ophthalmic Drugs
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [PA] next to a drug name indicates that Prior Authorization may apply to some or all strengths of the drug.
The symbol [SNRI] stands for Serotonin-Norepinephrine Reuptake Inhibitor.
The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths of the drug.
For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although
they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JULY 1, 2009 THROUGH DECEMBER 31, 2009. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our web site at www.express-scripts.com.
2009 Express Scripts, Inc.
PRMTJQUHP-09 (07/01/09 Vs2)
All Rights Reserved

Source: http://www.carolinachp.com/uploads/Carolina_Crescent_Abridged_PDL.pdf

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