Prmt22157-09.anp.09070

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan.
The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.
PLEASE NOTE: The symbol * next to a drug signifies that it is subject to nonformulary status
2009 Express Scripts
when a generic is available throughout the year. Not all the drugs listed are covered by all
prescription-drug benefit programs; check your benefit materials for the specific drugs
National Preferred Formulary
covered and the copayments for your prescription-drug benefit program. For specific
questions about your coverage, please call the phone number printed on your ID card.
A
bisoprolol fumarate/hctz dextroamphetamine G
GANIRELIX ACETATE [INJ] LEVEMIR, FLEXPEN [INJ] nizatidine C
O
E
H
M
I
P
F
J
K
N
B
L
D
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 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.
PRMT22157-09 (07/01/09)
All Rights Reserved
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary.
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
Q
U
R
V
S
W
fluoxetine (daily), citalopram, paroxetine, amlodipine, felodipine er, nifedipine er, ciprofloxacin, ofloxacin, Vigamox, Zymar* X
Y
Z
ciprofloxacin, ofloxacin, Avelox, Levaquin SYMLIN, SYMLINPEN [INJ] zolpidem tartrate T
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [SNRI] stands for Serotonin-Norepinephrine Reuptake Inhibitor.
For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although
they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 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.
PRMT22157-09 (07/01/09)
All Rights Reserved

Source: http://bvsd.org/benefits/Documents/ESI%20-%20National%20Preferred%20Formulary.pdf