Prmtmdcap-12.ap.110715

The following is a list of the most commonly prescribed drugs. It representsan abbreviated version of the drug list (formulary) that is at the core of yourprescription-drug benefit plan. The list is not all-inclusive and does notguarantee coverage. In addition to using this list, you are encouraged to askyour doctor to prescribe generic drugs whenever appropriate.
2012 Express Scripts
Medicare
PLEASE NOTE: Not all the drugs listed are covered by all prescription-drug
benefit programs; check your benefit materials for the specific drugs
covered and the copayments for your prescription-drug benefit program.
Formulary
For specific questions about your coverage, please call the phone
number printed on your ID card.
A
C
B
D
amox tr-potassium clavulanate baclofen KEY
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [P] indicates that prior authorization may apply.
The symbol [Q] indicates that quantities dispensed may be limited.
The symbol [S] indicates that step therapy may apply.
For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications,
although they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case, italicized letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
Prime- S7950_2012_ DOC7P
All Rights Reserved
PRMTMDCAP-12 (07/15/11)
J
K
E
G
L
N
H
F
I
M
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
Prime- S7950_2012_ DOC7P
All Rights Reserved
PRMTMDCAP-12 (07/15/11)
O
V
Q
T
R
P
W
X
Z
S
U
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
Prime- S7950_2012_ DOC7P
All Rights Reserved
PRMTMDCAP-12 (07/15/11)
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on theformulary.
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
lansoprazole/odt [Q] [S], omeprazole [Q], citalopram [Q], fluoxetine [Q], paroxetine/er [Q], sertraline [Q], lovastatin [Q], pravastatin [Q], lovastatin [Q], pravastatin [Q], fenofibrate, TRICOR [S], TRILIPIX [S] fenofibrate, TRICOR [S], TRILIPIX [S] lovastatin [Q], pravastatin [Q], fluoxetine [Q], fluvoxamine [Q], paroxetine/er [Q], sertraline [Q] MAXAIR AUTOHALER PROAIR HFA [Q], PROVENTIL HFA [Q] dorzolamide, ALPHAGAN P 0.1% DROPS, lansoprazole/odt [Q] [S], omeprazole [Q], fenofibrate, TRICOR [S], TRILIPIX [S] fenofibrate, TRICOR [S], TRILIPIX [S] fenofibrate, TRICOR [S], TRILIPIX [S] lovastatin [Q], pravastatin [Q], lansoprazole/odt [Q] [S], omeprazole [Q], KEY
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [P] indicates that prior authorization may apply.
The symbol [Q] indicates that quantities dispensed may be limited.
The symbol [S] indicates that step therapy may apply.
For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications,
although they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case, italicized letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
Express Scripts Prescription Drug Plan is a stand-alone prescription drug plan with a Medicare Contract.
All beneficiaries must use their plan sponsor's network pharmacies to access their prescription drug benefit,
except under non-routine circumstances. This document is available in alternate formats or languages.
2012 Express Scripts, Inc.
Prime- S7950_2012_ DOC7P
All Rights Reserved
PRMTMDCAP-12 (07/15/11)

Source: https://www.ohprs.org/ohprs/downloads/miscDocs/2012ESIMedicarePrimeFormulary.pdf