Express Scripts 2020 National Preferred Formulary Exclusions

2020 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

Take action to avoid paying full price. If you're currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card.

Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans.

Drug Class

ANTIINFECTIVES Antibiotics Antifungal Agents (Oral) Antivirals (Oral) AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Anticonvulsants Anti-Migraine Therapy

Antiparkinsonism Agents

Antispasmodic Agents

Duchenne Muscular Dystrophy (DMD) Agents

Long-Acting Opioid Oral Analgesics

Multiple Sclerosis (Beta Interferons) Multiple Sclerosis (Oral)

Narcotic Analgesics & Combinations

Narcotic Antagonists Neuropathic Agents Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants Tardive Dyskinesia Therapy Transmucosal Fentanyl Analgesics

Miscellaneous Antidepressants

CARDIOVASCULAR ACE Inhibitors Anticoagulants

Beta Blockers & Combinations

Calcium Channel Blockers Calcium Channel Blockers & Combinations HMG & Cholesterol Inhibitor Combinations

Excluded Medications

DOXYCYCLINE HYCLATE DR 80 MG TOLSURA SITAVIG

LUCEMYRA TOPIRAMATE ER CAPSULES ONZETRA XSAIL GOCOVRI ER, OSMOLEX ER XADAGO OZOBAX EMFLAZA EXONDYS 51, VYONDYS 53 EMBEDA, OXYCODONE ER

EXTAVIA AUBAGIO APADAZ, BENZHYDROCODONE/ACETAMINOPHEN BUTRANS EVZIO LYRICA CR DRIZALMA SPRINKLE INGREZZA ABSTRAL, FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS

SPRAVATO

EPANED QBRELIS PRADAXA, SAVAYSA KAPSPARGO SPRINKLE DUTOPROL, METOPROLOL SUCCINATE/HCTZ ER KATERZIA CONSENSI

ALTOPREV, EZALLOR SPRINKLE, SIMVASTATIN SUSPENSION

Preferred Alternatives

doxycycline hyclate dr

itraconazole acyclovir oral or cream, famciclovir, valacyclovir

clonidine

topiramate tablets, QUDEXY XR sumatriptan nasal spray, ZOMIG NASAL SPRAY amantadine capsules, amantadine tablets, amantadine oral solution rasagiline, selegiline baclofen, tizanidine prednisone solution, prednisone tablets No alternatives recommended hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE GILENYA, MAYZENT, TECFIDERA hydrocodone/acetaminophen buprenorphine patches, BELBUCA naloxone syringes, NARCAN NASAL SPRAY gabapentin, pregabalin

desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA

AUSTEDO

fentanyl citrate lozenges

olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline enalapril lisinopril ELIQUIS, XARELTO metoprolol succinate metoprolol tartrate/hydrochlorothiazide, metoprolol succinate er plus hydrochlorothiazide amlodipine amlodipine benzoate plus celecoxib atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (03/01/2020)

Drug Class

DERMATOLOGICAL Oral Agents for Acne Rosacea Agents (Oral) Topical Acne/Antibiotic Combinations

Topical Agents for Actinic Keratosis Topical Antifungals

Topical Corticosteroids

Vitamin D Analogs (Topical)

Miscellaneous Topical Dermatological Agents

DIABETES Blood Glucose Meters & Test Strips

Dipeptidyl Peptidase-4 Inhibitors & Combinations

Glucagon-Like Peptide-1 Agonists Insulins EAR/NOSE Nasal Steroids Otic Fluoroquinolone Antibiotics ENDOCRINE (OTHER) Combination Patches Estrogen and Estrogen Modifiers for Vaginal Symptoms Growth Hormones Somatostatin Analogs Topical Estrogen Gels GASTROINTESTINAL Antiemetics (Oral) Corticosteroids (Rectal Formulations) Inflammatory Bowel Agents

Excluded Medications

MINOLIRA DOXYCYCLINE 40 MG CAPSULES AKTIPAK, VELTIN

FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA LULICONAZOLE, SULCONAZOLE CLOCORTOLONE

TOPICORT SPRAY, VERDESO FOAM CALCIPOTRIENE FOAM CALCIPOTRIENE/BETAMETHASONE SUSPENSION ALCORTIN A LIDOCAINE/TETRACAINE

ASCENSIA (BREEZE, CONTOUR) ROCHE (ACCU-CHEK) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

ALOGLIPTIN, NESINA, ONGLYZA ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR ALOGLIPTIN/PIOGLITAZONE ADLYXIN, VICTOZA NOVOLIN, RELION NOVOLIN ADMELOG, APIDRA, FIASP, INSULIN ASPART, INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG

BECONASE AQ, OMNARIS, ZETONNA

CETRAXAL CIPROFLOXACIN/FLUOCINOLONE OTIC

CLIMARA PRO

FEMRING HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON SANDOSTATIN LAR DEPOT, SIGNIFOR LAR ESTROGEL AKYNZEO CAPSULES EMEND POWDER PACKETS CORTIFOAM DIPENTUM

Preferred Alternatives

minocycline er

ORACEA clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream, CARAC, PICATO ciclopirox, econazole, ketoconazole, naftifine, oxiconazole betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment calcipotriene, calcitriol calcipotriene/betamethethasone ointment, ENSTILAR, TACLONEX SUSPENSION hydrocortisone, mupirocin lidocaine cream, lidocaine/prilocaine cream

FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, VERIO FLEX ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS JANUVIA, TRADJENTA JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR pioglitazone plus JANUVIA or TRADJENTA BYDUREON, BYETTA, OZEMPIC, TRULICITY HUMULIN

HUMALOG

budesonide, flunisolide, fluticasone, mometasone, QNASL

ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEX, OTOVEL CIPRODEX, OTOVEL

COMBIPATCH

estradiol patches, estradiol tablets, yuvafem, ESTRING, PREMARIN CREAM, PREMARIN TABLETS

GENOTROPIN, NORDITROPIN FLEXPRO

SOMATULINE DEPOT DIVIGEL granisetron, ondansetron, aprepitant, VARUBI TABLETS aprepitant, VARUBI TABLETS hydrocortisone enema, UCERIS FOAM balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (03/01/2020)

Drug Class

GASTROINTESTINAL (continued) Pancreatic Enzymes Proton Pump Inhibitors HEMATOLOGICAL Antiplatelet Agents Chelating Agents Erythropoiesis-Stimulating Agents Factor VIII Recombinant Products Granulocyte Colony Stimulating Factors Sickle Cell Disease Agents

Thrombocytopenia Agents HEPATITIS Hepatitis C

HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.

MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

OBSTETRICAL & GYNECOLOGICAL Human Chorionic Gonadotropin Ovulatory Stimulants (Follitropins) Vaginal Progesterones ONCOLOGY Breast Cancer Agents Multiple Myeloma Agents Myelofibrosis Agents OPHTHALMIC Antiglaucoma Drugs (Beta-Adrenergic Blockers) Antiglaucoma Drugs (Ophthalmic Prostaglandins)

Ophthalmic Anti-Allergic

Ophthalmic Anti-Inflammatory

Excluded Medications

PANCREAZE, PERTZYE ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, PROTONIX SUSPENSION, RABEPRAZOLE DR SPRINKLE ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR JADENU, JADENU SPRINKLE ARANESP, EPOGEN, MIRCERA NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE GRANIX, NEUPOGEN OXBRYTA SIKLOS MULPLETA LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI ATRIPLA, DELSTRIGO COMPLERA PIFELTRO PREZCOBIX STRIBILD COLCHICINE ZURAMPIC FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES

RELAFEN DS

TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX DICLOFENAC EPOLAMINE PATCHES PENNSAID CHORIONIC GONADOTROPIN, PREGNYL FOLLISTIM AQ ENDOMETRIN KISQALI, KISQALI FEMARA CO-PACK, PIQRAY

XPOVIO INREBIC TIMOPTIC OCUDOSE

XELPROS

ALOCRIL, ALOMIDE

FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

Preferred Alternatives

CREON, ZENPEP

esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM PACKETS aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole deferasirox PROCRIT, RETACRIT ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT NIVESTYM, ZARXIO hydroxyurea, ADAKVEO, DROXIA DROXIA DOPTELET

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ ODEFSEY efavirenz, EDURANT atazanavir, ritonavir, KALETRA TABLETS, PREZISTA BIKTARVY, GENVOYA COLCRYS, MITIGARE allopurinol, probenecid fenoprofen calcium tablets, diclofenac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen nabumetone, diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, piroxicam diclofenac, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam FLECTOR PATCHES diclofenac sodium topical, FLECTOR PATCHES

NOVAREL, OVIDREL

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT CRINONE 8% GEL

IBRANCE, VERZENIO

DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE JAKAFI betaxolol drops, levobunolol drops, timolol drops, ALPHAGAN P 0.1%, COMBIGAN bimatoprost drops, latanoprost drops, travoprost drops, LUMIGAN, ZIOPTAN azelastine drops, cromolyn drops, olopatadine drops, ALREX, BEPREVE, PAZEO dexamethasone drops, fluorometholone drops, loteprednol drops, prednisolone drops, INVELTYS, LOTEMAX

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (03/01/2020)

Drug Class

OPHTHALMIC (continued) Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

OSTEOARTHRITIS Hyaluronic Acid Derivatives

OSTEOPOROSIS Bone Modifiers RENAL DISEASE Phosphate Binders RESPIRATORY Epinephrine Auto-Injector Systems Immunological Agents for Asthma Long-Acting Beta Agonist Inhalers Long-Acting Muscarinic Antagonist Inhalers Long-Acting Muscarinic Antagonist/ Long-Acting Beta-Agonist Combination Inhalers

Pulmonary Anti-Inflammatory Inhalers

Pulmonary Anti-Inflammatory/ Beta-Agonist Combination Inhalers

Short-Acting Beta2-Agonist Inhalers

WEIGHT LOSS Weight Loss Agents MISCELLANEOUS AGENTS Hereditary Angioedema Immunosuppressant Agents Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis Potassium Binders

Excluded Medications

Preferred Alternatives

ACUVAIL, NEVANAC

bromfenac drops, diclofenac drops, ketorolac drops, ILEVRO, PROLENSA

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3

EVENITY, PROLIA

FOSRENOL POWDER PACKETS

EUFLEXXA, MONOVISC, ORTHOVISC

alendronate, ibandronate, risedronate, zoledronic acid, FORTEO, TYMLOS lanthanum, sevelamer carbonate, sevelamer hcl, PHOSLYRA, VELPHORO

AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX)

epinephrine auto-injector (by Mylan), EPIPEN, EPIPEN JR

CINQAIR

FASENRA, NUCALA

STRIVERDI RESPIMAT

SEREVENT DISKUS

SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, TUDORZA PRESSAIR INCRUSE ELLIPTA

DUAKLIR PRESSAIR, STIOLTO RESPIMAT

ANORO ELLIPTA, BEVESPI AEROSPHERE

ALVESCO

ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR REDIHALER

BUDESONIDE/FORMOTEROL

ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT

ALBUTEROL SULFATE HFA, LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA

PROAIR HFA/RESPICLICK, VENTOLIN HFA

QSYMIA

benzphetamine, diethylpropion, phentermine

NOCTIVA BERINERT XATMEP

ONPATTRO

desmopressin tablets RUCONEST methotrexate

No alternatives recommended

VELTASSA

LOKELMA

Indication Based Management

Drug Class

Excluded Medications

Preferred Alternatives

INFLAMMATORY CONDITIONS

TALTZ

COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC, TREMFYA

Drug Class

Nonpreferred Medications

Preferred Alternatives

INFLAMMATORY CONDITIONS

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred medications is required prior to initiating therapy with a Nonpreferred medication. A formulary exception may be granted for patients already established on therapy with a Nonpreferred medication.

ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, RINVOQ ER, SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), SKYRIZI, STELARA SC, TREMFYA, XELJANZ, XELJANZ XR

Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (03/01/2020)

Excluded Medications/Products at a Glance

ABILIFY^ ABSTRAL ACIPHEX^ ACIPHEX SPRINKLE ACUVAIL ADCIRCA^ ADDERALL^ ADLYXIN ADMELOG AKTIPAK AKYNZEO CAPSULES ALBUTEROL SULFATE HFA ALCORTIN A ALOCRIL ALOGLIPTIN ALOGLIPTIN/METFORMIN ALOGLIPTIN/PIOGLITAZONE ALOMIDE ALTOPREV ALVESCO AMBIEN^, AMBIEN CR^ AMPYRA^ AMRIX^ ANDROGEL 1%^ ANUSOL-HC^ APADAZ APIDRA ARANESP ARIMIDEX^ ASACOL HD^ ASCENSIA (BREEZE, CONTOUR) ASPIRIN/OMEPRAZOLE DR ATACAND^, ATACAND HCT^ ATRIPLA AUBAGIO AUVI-Q AVALIDE^, AVAPRO^ AVODART^ AZOR^ BARACLUDE TABLETS^ BECONASE AQ BENICAR^, BENICAR HCT^ BENZHYDROCODONE/ACETAMINOPHEN BERINERT BRISDELLE^ BUDESONIDE/FORMOTEROL BUPAP^ BUTRANS CALCIPOTRIENE FOAM CALCIPOTRIENE/BETAMETHASONE

SUSPENSION CELEBREX^ CELEXA^ CETRAXAL CHORIONIC GONADOTROPIN CIALIS^ CINQAIR CIPROFLOXACIN/FLUOCINOLONE OTIC CLIMARA PRO CLOCORTOLONE COLCHICINE COMPLERA CONSENSI COREG^ CORTIFOAM COSOPT^ COZAAR^, HYZAAR^ CRESTOR^ CUPRIMINE^ CYMBALTA^ CYTOMEL^ DELSTRIGO DELZICOL^ DETROL^, DETROL LA^ DICLOFENAC EPOLAMINE PATCHES DIOVAN^, DIOVAN HCT^

DIPENTUM DOXYCYCLINE 40 MG CAPSULES DOXYCYCLINE HYCLATE DR 80 MG DRIZALMA SPRINKLE DUAKLIR PRESSAIR DUROLANE DUTOPROL EFFEXOR XR^ ELIDEL^ EMBEDA EMEND CAPSULES^, TRIFOLD PACK^ EMEND POWDER PACKETS EMFLAZA ENDOMETRIN EPANED EPINEPHRINE AUTO-INJECTOR (BY IMPAX) EPOGEN ESTROGEL EVENITY EVZIO EXFORGE^, EXFORGE HCT^ EXJADE^ EXONDYS 51 EXTAVIA EZALLOR SPRINKLE FEMRING FENOPROFEN CAPSULES FENORTHO FENTANYL CITRATE BUCCAL TABLETS FENTORA FIASP FLUOROURACIL 0.5% CREAM FML FORTE, FML S.O.P. FOCALIN^, FOCALIN XR^ FOLLISTIM AQ FOSRENOL CHEWABLE TABLETS^ FOSRENOL POWDER PACKETS GANIRELIX ACETATE^ GEL-ONE GELSYN-3 GENVISC 850 GLEEVEC^ GLUCOPHAGE^, GLUCOPHAGE XR^ GLUMETZA^ GOCOVRI ER GRANIX HUMATROPE HYALGAN HYMOVIS IMIQUIMOD 3.75% CREAM PUMP IMITREX^ INDERAL LA^ INGREZZA INREBIC INSULIN ASPART, INSULIN ASPART PROTAMINE INSULIN LISPRO INTUNIV^ ISTALOL^ JADENU, JADENU SPRINKLE KAPSPARGO SPRINKLE KATERZIA KAZANO KEPPRA^, KEPPRA XR^ KISQALI, KISQALI FEMARA CO-PACK KOMBIGLYZE XR LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ LAZANDA LEDIPASVIR/SOFOSBUVIR LEVALBUTEROL HFA LEXAPRO^ LIBRAX^ LIDOCAINE/TETRACAINE LIDODERM^ LIPITOR^ LOESTRIN^, LOESTRIN FE^ LOTREL^

LOVENOX^

SIGNIFOR LAR

LUCEMYRA

SIKLOS

LULICONAZOLE

SIMVASTATIN SUSPENSION

LUNESTA^

SINGULAIR^

LYRICA^

SITAVIG

LYRICA CR

SODIUM HYALURONATE

MAVYRET

SOFOSBUVIR/VELPATASVIR

MAXALT^, MAXALT MLT^

SOVALDI

MAXIDEX

SPIRIVA HANDIHALER, SPIRIVA RESPIMAT

METOPROLOL SUCCINATE/HCTZ ER

SPRAVATO

MICARDIS^, MICARDIS HCT^

STIOLTO RESPIMAT

MINASTRIN 24 FE^

STRATTERA^

MINOLIRA

STRIBILD

MIRCERA

STRIVERDI RESPIMAT

MULPLETA

SUBSYS

NALFON CAPSULES

SULCONAZOLE

NAMENDA XR^

SUPARTZ FX

NASONEX^

SYNVISC, SYNVISC-ONE

NESINA

TALTZ

NEUPOGEN

TESTIM^

NEURONTIN^

TIKOSYN^

NEVANAC

TIMOPTIC OCUDOSE

NOCTIVA

TIVORBEX

NORCO^

TOBI SOLUTION^

NORVASC^

TOLSURA

NOVOLIN

TOPAMAX^

NOVOLOG

TOPICORT SPRAY

NUTROPIN AQ NUSPIN

TOPIRAMATE ER CAPSULES

NUVIGIL^

TRIBENZOR^

NUWIQ

TRICOR^

OMNARIS

TRILEPTAL^

OMNITROPE

TRILURON

ONGLYZA

TRIVIDIA (TRUETEST, TRUETRACK)

ONPATTRO

TRIVISC

ONZETRA XSAIL

TUDORZA PRESSAIR

ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ UROXATRAL^

OSMOLEX ER

VAGIFEM^

OXBRYTA

VALIUM^

OXYCODONE ER

VALTREX^

OZOBAX

VELTASSA

PANCREAZE

VELTIN

PATADAY^

VERDESO FOAM

PENNSAID

VIAGRA^

PERTZYE

VICTOZA

PIFELTRO

VISCO-3

PIQRAY

VIVELLE-DOT^

PLAQUENIL^

VIVLODEX

PLAVIX^

VYONDYS 53

PRADAXA

VYTORIN^

PRAVACHOL^

WELLBUTRIN SR^

PRED MILD

XADAGO

PREGNYL

XALATAN^

PREVACID^, PREVACID SOLUTAB^

XANAX^, XANAX XR^

PREZCOBIX

XATMEP

PRILOSEC SUSPENSION

XELPROS

PRISTIQ^

XENAZINE^

PROLIA

XOPENEX HFA

PROTONIX^

XPOVIO

PROTONIX SUSPENSION

XYNTHA, XYNTHA SOLOFUSE

PROVENTIL HFA

YASMIN^

PROVIGIL^

YOSPRALA DR

PROZAC^

ZAVESCA^

PULMICORT RESPULES^

ZEGERID^

QBRELIS

ZETIA^

QSYMIA

ZETONNA

RABEPRAZOLE DR SPRINKLE

ZIPSOR

RAPAFLO^

ZOCOR^

RECOMBINATE

ZOLOFT^

RELAFEN DS

ZOMACTON

RELION NOVOLIN

ZOMIG TABLETS^, ZOMIG ZMT^

RENAGEL^

ZONEGRAN^

ROCHE (ACCU-CHEK)

ZORVOLEX

SAIZEN, SAIZENPREP

ZURAMPIC

SANDOSTATIN LAR DEPOT

ZYCLARA

SAVAYSA

ZYFLO CR^

SEROQUEL^, SEROQUEL XR^

ZYTIGA 250 MG^

^ Multisource brand exclusion ? The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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