Prmt-22157 - alphn.p.0310.qxd

2004 The following is a list of the most commonly prescribed drugs. It represents an abbreviated
version of the drug list (formulary) that is at the core of your pharmacy benefit plan. The listis not all-inclusive and does not guarantee coverage. In addition to using this list, you are Express Scripts
encouraged to ask your doctor to prescribe generic drugs whenever appropriate.
PLEASE NOTE: The symbol * next to a drug signifies subject to non-formulary status
National Preferred
when generic is available throughout the year. Not all the drugs listed are covered by
all pharmacy benefit programs, check your benefit materials for the specific drugs
Formulary
covered and the copay information for your pharmacy benefit program. For specific
questions about your coverage, please call the phone number printed on your ID card.
A
M
O
B
H
C
E
I
N
P
F
K
L
D
G
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2004 THROUGH DECEMBER 31, 2004. THIS LIST IS SUBJECT TO CHANGE.
The symbol [G] next to a drug name signifies that a generic is available for at least one or more strengths of the brand medication. Most generics are available at the lowest copay.
You can get more information and updates to this document at our web site at www.express-scripts.com.
2004 Express Scripts, Inc.
PRMT-22157 (10/03)
All Rights Reserved
Examples of Non-Formulary Medications
with Selected Formulary Alternatives
The following is a list of some non-formulary brand medications with examples of selected alternatives that are on the Column 1 lists examples of non-formulary medications.
Column 2 lists some alternatives that can be prescribed. Non-Formulary
Formulary Alternative
Non-Formulary
Formulary Alternative
enalapril, lisinopril, Altace, Lotensin * enalapril, lisinopril, Altace, Lotensin * enalapril, lisinopril, Altace, Lotensin * U
V
Q
W
R
X
Y
S
Z
Abilify, Risperdal (non M-Tab), Seroquel, albuterol inh, Maxair Auto, Proventil HFA T
enalapril, lisinopril, Altace, Lotensin * KEY
The symbol [G] next to a drug name indicates that a generic is available for at least one or more strengths of the brand medication.
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, 2004 THROUGH DECEMBER 31, 2004. THIS LIST IS SUBJECT TO CHANGE.
The symbol [G] next to a drug name signifies that a generic is available for at least one or more strengths of the brand medication. Most generics are available at the lowest copay.
You can get more information and updates to this document at our web site at www.express-scripts.com.
2004 Express Scripts, Inc.
PRMT-22157 (10/03)
All Rights Reserved

Source: http://www.959trusts.com/html/frm01150.pdf