2020 Express Scripts Drug List for the NYC PICA Plan

2020 Express Scripts Drug List for the New York City PICA Program

The following is a list of the drugs included in the NYC PICA prescription 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: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. For specific questions about your coverage, please call the phone number printed on your member ID card.

INJECTABLES

BUPRENEX

buprenorphine hydrochloride

NOTE: Coverage based on benefit butorphanol tartrate

design.

CABLIVI [PA] [SP]

caffeine & sodium benzoate

ABILIFY MAINTENA

calcium disodium versenate

ACTEMRA [PA] [SP]

CAPASTAT SULFATE

ACTEMRA ACTPEN [PA] [SP]

CARBOCAINE

ADAGEN

CAVERJECT [PA]

adrenalin chloride

cefazolin sodium

a-hydrocort

cefepime hcl

AIMOVIG [PA]

CEFOTAN

AJOVY [PA]

cefotaxime sodium

ALFENTA

cefotetan

alfentanil hydrochloride

ceftazidime

amikacin sulfate

ceftriaxone

ampicillin sodium

cefuroxime sodium

ampicillin/sulbactam

CELESTONE

AMYTAL SODIUM

CEREBYX

AQUASOL A

CETROTIDE [FER]

ARCALYST [PA] [SP]

chloroprocaine hcl

ARISTADA

chlorpromazine hcl

ARISTADA INITIO

CLAFORAN

ARISTOSPAN

CLEOCIN PHOSPHATE

ARIXTRA [SP]

clindamycin phosphate

ascorbic acid

COGENTIN

ATIVAN

colistimethate sodium

ATROPEN

COLY-MYCIN M PARENTERAL

atropine sulfate

COPAXONE [PA] [SP]

AVEED [PA]

CORTROSYN

AVONEX [PA] [SP]

COSENTYX [PA] [SP]

AZACTAM

cosyntropin

aztreonam

CRYSVITA [SP]

baci-im

cyanocobalamin

bacitracin

D.H.E.45

BAL IN OIL

DDAVP

b-complex

DELESTROGEN

BENLYSTA [SP]

DEMEROL

BENTYL

DEPO-ESTRADIOL

benztropine mesylate

DEPO-MEDROL

betamethasone acet and na phos DEPO-PROVERA

betamethasone acetate-sod phos DEPO-SUBQ PROVERA

betamethasone sod phos-water DEPO-TESTOSTERONE [PA]

BETASERON [PA] [SP]

desmopressin acetate

BICILLIN C-R

dexamethasone acetate la

BICILLIN L-A

dexamethasone acetate-sod

BOTOX [PA] [SP]

phos

bumetanide

dexamethasone sodium

bupivacaine hcl

phosphate

bupivacaine hcl-epinephrine diazepam

bupivacaine w/dextrose

dicyclomine hcl

bupivacaine-dexamethasone sod dihydroergotamine mesylate

bupivacaine-ketorolac-ketamine DILAUDID

diphenhydramine hcl droperidol duramorph EDEX [PA] EGRIFTA [SP] EGRIFTA SV EMGALITY [PA] ENBREL [PA] [SP] enoxaparin sodium [SP] ephedrine sulfate epinephrine auto-injector ertapenem estradiol valerate fentanyl citrate FIRAZYR [PA] [SP] fluphenazine decanoate fluphenazine hcl folic acid fondaparinux sodium [SP] FORTAZ FORTEO [PA] [SP] fosphenytoin sodium FRAGMIN [SP] FULPHILA [PA] [SP] furosemide FUZEON [SP] GENOTROPIN [PA] [SP] gentamicin sulfate gentamicin-sodium citrate GEODON glatiramer acetate [PA] [SP] glatopa [PA] [SP] glycopyrrolate GLYRX-PF GONAL-F/RFF [FER] H.P. ACTHAR [PA] [SP] HAEGARDA [PA] [SP] HALDOL HALDOL DECANOATE haloperidol haloperidol decanoate haloperidol lactate HEMABATE HEMLIBRA [PA] [SP] heparin sodium HUMIRA [PA] [SP] HUMIRA PEDIATRIC [PA] [SP] hydralazine hcl hydromorphone hcl hydromorphone hcl-water hydroxocobalamin hydroxyzine hcl hyoscyamine sulfate

icatibant [PA] [SP] IFE-BIMIX 30/1 IFE-PG20 INCRELEX [PA] [SP] infed INFUMORPH INVANZ INVEGA SUSTENNA INVEGA TRINZA isoniazid isoproterenol hcl ISUPREL KENALOG KETALAR ketamine hcl ketamine hcl-ns ketamine hcl-water ketorolac tromethamine KEVZARA [PA] [SP] LEUKINE [SP] LEVSIN lidocaine hcl lidocaine hcl w/epinephrine lidocaine hcl-ns LINCOCIN lincomycin hcl lorazepam LUPRON DEPOT-PED [PA] [SP] magnesium chloride MARCAINE MARCAINE WITH EPINEPHRINE MAXIPIME medroxyprogesterone acetate MENOPUR [FER] meperidine hcl methadone hcl methocarbamol methylergonovine maleate methylprednisolone methylprednisolone acetate methylprednisolone sod succ methylprednisolone-bupivacaine MIACALCIN midazolam hcl MITIGO morphine sulfate morphine sulfate/ns MOZOBIL [SP] MYALEPT MYOBLOC [PA] [SP] nafcillin sodium nalbuphine hcl NAROPIN

NATPARA [PA] NEMBUTAL SODIUM NESACAINE NESACAINE-MPF NEULASTA [PA] [SP] NEXAVIR NIVESTYM [PA] [SP] NORDITROPIN FLEXPRO [PA] [SP] NOVAREL [FER] NUTROPIN [SP] [ST] NUTROPIN AQ [SP] [ST] octreotide acetate [SP] olanzapine orphenadrine citrate OTREXUP [ST] OVIDREL [FER] oxacillin sodium PALYNZIQ [PA] [SP] papaverine hcl papaverine-alprostadil papaverine-phentolamine papaverine-phentolmn-alprostdl PEGASYS [PA] [SP] PEGASYS PROCLICK [PA] [SP] PEG-INTRON [PA] [SP] PEG-INTRON REDIPEN [PA] [SP] penicillin g procaine PENTAM 300 pentamidine isethionate pentobarbital sodium PERSERIS PHENERGAN phenobarbital sodium PHENTOLAMINE-ALPROSTADIL phenylephrine hcl physostigmine salicylate PHYTONADIONE PLEGRIDY [PA] [SP] polocaine polymyxin b sulfate PRALUENT [PA] prochlorperazine edisylate PROCRIT [PA] [SP] progesterone [FER] promethazine hcl PROTOPAM CHLORIDE pyridoxine hcl quinidine gluconate R.E.C.K. (ROPIV-EPI-CLON-

KETOR) ranitidine hcl RASUVO [ST] REBIF [PA] [SP]

(continued) Costs for covered alternatives may vary. Log on to covered to compare drug prices. THIS DOCUMENT LIST IS EFFECTIVE MARCH 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-.

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

Page 1

APNA ANP PRMTPICA-20 (02/11/20)

REBIF REBIDOSE RELISTOR REMODULIN REPATHA [PA] RETACRIT [PA] [SP] REVCOVI RISPERDAL CONSTA ROBAXIN ROBINUL ropivacaine hcl/pf ropivacaine hcl-ns ropivacaine-clonidine-ketorolc ropivacaine-ketorolac-ketamine SANDOSTATIN [SP] SAXENDA [PA] SENSORCAINE SENSORCAINE WITH DEXTROSE SENSORCAINE WITH

EPINEPHRINE SENSORCAINE-MPF SEROSTIM [SP] SKYRIZI (2 SYRINGES) KIT

[PA] [SP] SOLU-CORTEF SOLU-MEDROL SOMATULINE DEPOT [SP] SOMAVERT [PA] [SP] STELARA [PA] [SP] STRENSIQ [SP] STREPTOMYCIN SULFATE sumatriptan succinate SUMAVEL DOSEPRO SUSTOL SYMJEPI TAKHZYRO [PA] [SP] TALWIN TAZICEF TEGSEDI [PA] [SP] terbutaline sulfate testosterone cypionate [PA] testosterone enanthate [PA] tetracaine hcl ticarcillin disod-clavulanate TIGAN tobramycin sulfate TREMFYA [PA] [SP] treprostinil [SP] triamcinolone acet-bupivacaine triamcinolone acetonide triamcinolone diacetate tricitrasol TRIPTODUR [SP] TYMLOS [SP]

UDENYCA [PA] [SP] UNASYN vancomycin hcl VAZCULEP vitamin k XGEVA XYLOCAINE XYLOCAINE WITH EPINEPHRINE XYOSTED [PA] ZANTAC RX ZARXIO [SP] [ST] ZEMBRACE SYMTOUCH ZINACEF ZINBRYTA [PA] [SP] ZORBTIVE ZYPREXA

CHEMOTHERAPY

abiraterone acetate [PA] [SP] ACTIMMUNE [INJ] [SP] AFINITOR [PA] [SP] AFINITOR DISPERZ [PA] [SP] ALDARA ALECENSA [PA] [SP] ALFERON N ALKERAN ALUNBRIG [PA] [SP] AMELUZ anastrozole ANZEMET aprepitant AROMASIN azacitidine BALVERSA [PA] [SP] bexarotene bicalutamide bleo 15k bleomycin sulfate [INJ] BOSULIF [PA] [SP] BRAFTOVI [PA] [SP] BRUKINSA [PA] [SP] CABOMETYX [PA] [SP] CALQUENCE [PA] [SP] capecitabine [SP] CAPRELSA [PA] [SP] CARAC CASODEX COMETRIQ [PA] [SP] COMPAZINE compro COPIKTRA [PA] [SP] COTELLIC [PA] [SP]

CYCLOPHOSPHAMIDE

LYNPARZA [PA] [SP]

cytarabine [INJ]

LYSODREN

DAURISMO [PA] [SP]

MARINOL

diclofenac sodium

MATULANE [SP]

dronabinol

MEGACE

DROXIA

megestrol acetate

EFUDEX

MEKINIST [PA] [SP]

ELIGARD [INJ] [PA] [SP]

MEKTOVI [PA] [SP]

EMCYT

melphalan hcl

ERIVEDGE [PA] [SP]

mercaptopurine

ERLEADA [PA] [SP]

MESNEX

erlotinib hcl [PA] [SP]

methotrexate

ERWINAZE

methotrexate sodium [INJ]

etoposide

metoclopramide hcl

everolimus [PA] [SP]

metoclopramide hcl odt

exemestane

MUSTARGEN

FARESTON

MYLERAN

FARYDAK [PA] [SP]

NERLYNX [PA] [SP]

FASLODEX [INJ]

NEXAVAR [PA] [SP]

FEMARA

NILANDRON

FIRMAGON [INJ] [PA] [SP]

nilutamide

floxuridine

NINLARO [PA] [SP]

FLUOROPLEX

NUBEQA [PA] [SP]

flutamide

ODOMZO [PA] [SP]

fulvestrant [PA] [SP]

ONCASPAR [INJ]

GILOTRIF [PA] [SP]

ondansetron hcl

GLEOSTINE

ondansetron odt

granisetron hcl

PANRETIN

HERCEPTIN HYLECTA [SP]

PICATO

HEXALEN

POMALYST [SP]

HYCAMTIN

prochlorperazine maleate

HYDREA

PURIXAN [SP]

hydroxyurea

REGLAN

IBRANCE [PA] [SP]

REVLIMID [PA] [SP]

ICLUSIG [PA] [SP]

RITUXAN HYCELA [PA] [SP]

IDHIFA [PA] [SP]

ROZLYTREK [PA] [SP]

imatinib mesylate [PA] [SP]

RUBRACA [PA] [SP]

IMBRUVICA [PA] [SP]

RYDAPT [PA] [SP]

imiquimod

SANCUSO

IMLYGIC [SP]

SOLARAZE [PA]

INLYTA [PA] [SP]

SOLTAMOX

INTRON A [INJ] [SP]

SPRYCEL [PA] [SP]

IRESSA [PA] [SP]

STIVARGA [PA] [SP]

JAKAFI [PA] [SP]

SUTENT [PA] [SP]

LENVIMA [PA] [SP]

SYLATRON [SP]

letrozole

SYNDROS

leucovorin calcium

SYNRIBO

LEUKERAN

TABLOID

leuprolide acetate [INJ] [PA] [SP] TAFINLAR [PA] [SP]

LEVULAN

TAGRISSO [PA] [SP]

LONSURF [SP]

TALZENNA [PA] [SP]

LORBRENA [PA] [SP]

tamoxifen citrate

LUPRON DEPOT [INJ] [SP] [ST] TARCEVA [PA] [SP]

TARGRETIN [SP] TASIGNA [PA] [SP] TAZVERIK [PA] [SP] TEMODAR [PA] [SP] temozolomide [PA] [SP] TEPADINA THALOMID [PA] [SP] thiamine hcl [INJ] thiotepa TIBSOVO [PA] [SP] TIGAN [INJ] TOLAK toremifene citrate TRELSTAR [ST] TRELSTAR LA [ST] tretinoin trexall trimethobenzamide hcl TURALIO [PA] [SP] TYKERB [PA] [SP] UVADEX VALCHLOR [SP] VANTAS [SP] VARUBI VELCADE [INJ] [SP] VENCLEXTA [SP] VENCLEXTA STARTING PACK [SP] VERZENIO [PA] [SP] VIDAZA [SP] VISTOGARD [SP] VITRAKVI [PA] [SP] VIZIMPRO [PA] [SP] VOTRIENT [PA] [SP] XALKORI [PA] [SP] XELODA [SP] XERMELO [PA] [SP] XOSPATA [PA] XTANDI [PA] [SP] YONSA [PA] [SP] ZEJULA [PA] [SP] ZELBORAF [PA] [SP] ZOFRAN ZOFRAN ODT ZOLADEX [INJ] [SP] ZOLINZA [SP] ZUPLENZ ZYDELIG [PA] [SP] ZYKADIA [PA] [SP]

KEY [FER] - fertility medication in which there is a lifetime limit of 3 cycles of therapy per drug class when covered; available through Freedom Fertility Pharmacy (800.660.4283) [INJ] - injectable medication [PA] - Prior Authorization is required for coverage [SP] - available through Accredo Specialty Pharmacy (800.467.2006) [ST] - Step Therapy may apply to certain indications or some or all strengths of the drug

For the member: 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. For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.

Brand-name drugs are listed in CAPITAL letters. Generic drugs are listed in lower case letters.

Costs for covered alternatives may vary. Log on to covered to compare drug prices. THIS DOCUMENT LIST IS EFFECTIVE MARCH 1, 2020 THROUGH DECEMBER 31, 2020. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-.

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

Page 2

APNA ANP PRMTPICA-20 (02/11/20)

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download