2019 Walmart Associates Prescription Drug Formulary
2019 Walmart Associates Prescription Drug Formulary
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 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. Specific clinical rules and/or dispensing quantity limits may apply to certain medications. For more information contact Express Scripts Customer Service at 800.887.6194 or visit the My Benefits tab on or on the WIRE.
PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic version becomes available during the year. 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 prescription plan. For specific questions about your coverage, please call the phone number printed on your member ID card.
KEY
BD AUTOSHIELD
* Available at Walmart Stores DUO NEEDLES
[INJ] - Injectable Drug
BD ULTRAFINE
Brand-name drugs are listed INSULIN SYRINGES
in CAPITAL letters.
BD ULTRAFINE PEN NEEDLES
Generic drugs are listed
benazepril
in lower case letters.
benzonatate
BEPREVE
A
BETHKIS
BEVESPI AEROSPHERE
ABILIFY MAINTENA [INJ]
BIKTARVY
ACANYA
bisoprolol/hctz
acetaminophen/codeine
blisovi fe
ACTEMRA [INJ]
BOSULIF
acyclovir
BRILINTA
ADEMPAS
budesonide nebulization
AFSTYLA [INJ]
suspension
AKYNZEO
bupropion
albuterol nebulization
bupropion ext-release
solution
buspirone
allopurinol
butalbital/acetaminophen/
ALPHAGAN P 0.1%
caffeine
alprazolam
BYDUREON [INJ]
ALREX
BYETTA [INJ]
amiodarone
BYSTOLIC
AMITIZA
BYVALSON
amitriptyline
amlodipine
C
amlodipine/benazepril
amlodipine/valsartan
CABOMETYX
amoxicillin capsules
CANASA
amoxicillin/potassium
CARAC
clavulanate tablets
CARAFATE SUSPENSION
AMPYRA
carbidopa/levodopa
anastrozole
carvedilol
ANDRODERM
cefdinir
ANDROGEL 1.62%
cefuroxime axetil
ANORO ELLIPTA
celecoxib
APRISO
cephalexin capsules
ARCAPTA NEOHALER
CERDELGA
aripiprazole
CEREZYME [INJ]
ARMONAIR RESPICLICK
chlorhexidine gluconate
ASMANEX HFA
chlorthalidone
ASMANEX TWISTHALER
CIMDUO
atenolol
CIPRODEX
atenolol/chlorthalidone
ciprofloxacin
atomoxetine
(excluding 100 mg)
atorvastatin
citalopram
AVONEX [INJ]
clarithromycin tablets
AZASITE
CLENPIQ
azelastine nasal spray
clindamycin hcl
azithromycin tablets
clindamycin phosphate
topical
B
clindamycin phosphate/
benzoyl peroxide
baclofen
clobetasol propionate
BARACLUDE SOLUTION
clonazepam
clonidine clopidogrel clotrimazole/betamethasone
dipropionate COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COPAXONE 40 MG [INJ] CORLANOR COSENTYX [INJ] CREON CRINONE cyanocobalamin [INJ] cyclobenzaprine
D
DALIRESP DARAPRIM DAYTRANA DESCOVY desvenlafaxine succinate
ext-release dexamethasone dexmethylphenidate
ext-release dextroamphetamine/
amphetamine dextroamphetamine/
amphetamine ext-release diazepam tablets diclofenac sodium
delayed-release dicyclomine digoxin tablets diltiazem ext-release diphenoxylate/atropine
tablets divalproex delayed-release divalproex ext-release DIVIGEL donepezil doxazosin doxycycline hyclate doxycycline monohydrate DUAVEE DULERA DUPIXENT [INJ] DYMISTA
E
ELIDEL ELIQUIS EMVERM enalapril
ENBREL [INJ]
glyburide
enoxaparin [INJ]
GLYXAMBI
ENSTILAR
GRALISE
ENTRESTO
GRANIX [INJ]
EPCLUSA
GRASTEK
EPIDUO FORTE
guanfacine ext-release
EPINEPHRINE AUTO-INJECTOR
(by Mylan) [INJ]
H
EPIPEN, EPIPEN JR [INJ]
ergocalciferol
HARVONI
ERIVEDGE
HELIXATE FS [INJ]
ERLEADA
HUMALOG [INJ]
erythromycin eye ointment HUMIRA [INJ]
ESBRIET
HUMULIN [INJ]
escitalopram
hydralazine
estradiol
hydrochlorothiazide
estradiol patches
hydrocodone/acetaminophen
estradiol/norethindrone
hydrocodone/
acetate
chlorpheniramine polistirex
ESTRING
ext-release
eszopiclone
hydrocortisone topical
EVEKEO
hydromorphone
ezetimibe
hydroxychloroquine
ezetimibe/simvastatin
hydroxyzine hcl
hydroxyzine pamoate
F
(excluding 100 mg)
famotidine FARXIGA fenofibrate fenofibrate micronized fentanyl patches FINACEA finasteride FLECTOR fluconazole fluocinonide fluticasone nasal spray folic acid FOSRENOL FRAGMIN [INJ] furosemide FYCOMPA
I
ibandronate IBRANCE ibuprofen ILEVRO INCRUSE ELLIPTA indomethacin INLYTA INVOKAMET INVOKAMET XR INVOKANA irbesartan IRESSA isosorbide mononitrate
ext-release
G
gabapentin GELNIQUE gemfibrozil GENVOYA GILENYA GILOTRIF glimepiride glipizide glipizide ext-release GLUCAGEN [INJ] GLUCAGON [INJ]
J
JANUMET, JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR junel junel fe
K
KALBITOR [INJ]
(continued)
Go to 2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. For more information contact Express Scripts Customer Service at 800.887.6194 or visit the My Benefits tab on or on the WIRE.
? 2018 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 1
NP-A PRMT5067ANP-19 (09/05/18)
ketoconazole topical ketorolac KOGENATE FS [INJ] KOVALTRY [INJ] KYLEENA
L
labetalol lamotrigine LANTUS [INJ] latanoprost eye solution LATUDA LETAIRIS LEVEMIR [INJ] levetiracetam levofloxacin tablets levothyroxine sodium lidocaine patches LINZESS liothyronine LIPOFEN lisinopril lisinopril/hctz LO LOESTRIN FE lorazepam losartan losartan/hctz LOTEMAX lovastatin LUMIGAN LYRICA
M
MAKENA MULTIDOSE VIAL [INJ]
MAVYRET meclizine medroxyprogesterone meloxicam MESTINON SYRUP metformin metformin ext-release methimazole methocarbamol methotrexate methylphenidate methylprednisolone metoclopramide hcl
(non-ODT) metronidazole metronidazole topical metronidazole vaginal microgestin fe MINIVELLE minocycline MIRENA mirtazapine MIRVASO MITIGARE mometasone MONOVISC [INJ] montelukast MOVANTIK MOXEZA moxifloxacin eye solution mupirocin MYDAYIS MYRBETRIQ
N
PLEGRIDY [INJ]
polymyxin/trimethoprim
nabumetone
eye solution
NAMZARIC
POMALYST
naproxen, naproxen sodium pramipexole
tablets
pravastatin
NARCAN NASAL SPRAY
prednisolone acetate
NASCOBAL
eye suspension
neomycin/polymyxin/
PREMARIN CREAM
hydrocortisone ear solution PREMARIN TABLETS
NEVANAC
PREMPHASE
niacin ext-release
PREMPRO
nitrofurantoin macrocrystal PREPOPIK
NITYR
PROAIR HFA
nortriptyline capsules
PROAIR RESPICLICK
NOVOEIGHT [INJ]
PROCRIT [INJ]
NOVOFINE AUTOSHIELD
progesterone micronized
NEEDLES
PROLASTIN C [INJ]
NOVOFINE NEEDLES
PROLENSA
NOVOTWIST NEEDLES
promethazine
NUCALA [INJ]
promethazine/
NUEDEXTA
dextromethorphan
NUVARING
propranolol ext-release
NUWIQ [INJ]
capsules
nystatin
propranolol tablets
nystatin topical
PULMICORT FLEXHALER
PYLERA
O
Q
ODACTRA
OFEV
quetiapine
olanzapine
QUILLICHEW ER
olmesartan
QUILLIVANT XR
olmesartan/hctz
quinapril
olopatadine eye solution QVAR
omega-3 acid ethyl esters QVAR REDIHALER
OMNITROPE [INJ]
ondansetron
R
ondansetron orally
disintegrating tablets RAGWITEK
ONETOUCH KITS/METERS; raloxifene
ULTRA 2, ULTRAMINI,
ramipril
VERIO, VERIO FLEX,
RANEXA
VERIO IQ, VERIO SYNC ranitidine
ONETOUCH TEST STRIPS; RAPAFLO
ULTRA, VERIO
RASUVO [INJ]
ONEXTON
REBIF [INJ]
OPSUMIT
RECTIV
ORACEA
RELION GLUCOMETERS*
ORFADIN
RELION INSULIN 70/30 [INJ]*
ORTHOVISC [INJ]
RELION INSULIN N [INJ]*
oseltamivir
RELION INSULIN R [INJ]*
OTEZLA
RELION TEST STRIPS*
OTOVEL
RELISTOR [INJ]
oxcarbazepine
REMICADE [INJ]
oxybutynin ext-release
RESTASIS
oxycodone
REVLIMID
oxycodone/acetaminophen RHOPRESSA
OZEMPIC [INJ]
risperidone
rizatriptan
P
ropinirole
rosuvastatin
paroxetine hcl
RUCONEST [INJ]
PAZEO
penicillin v potassium tablets S
PENTASA
PERFOROMIST
SANCUSO
PHOSLYRA
SAVELLA
PICATO
SEGLUROMET
pioglitazone
SEREVENT DISKUS
sertraline simvastatin SKYLA SOLIQUA [INJ] SOLODYN SOMATULINE DEPOT [INJ] spironolactone sprintec SPRYCEL STEGLATRO STELARA SC [INJ] STIOLTO RESPIMAT STRENSIQ [INJ] STRIVERDI RESPIMAT SUBOXONE SL FILM sulfamethoxazole/
trimethoprim sumatriptan tablets SUPREP SUTENT SYMBICORT SYMFI SYMFI LO SYMLINPEN [INJ] SYMPROIC SYNJARDY, SYNJARDY XR
T
TACLONEX SUSPENSION tacrolimus topical tamoxifen tamsulosin ext-release TARCEVA TASIGNA TAYTULLA TAZORAC GEL TAZORAC 0.05% CREAM TECFIDERA TECHNIVIE TEKTURNA, TEKTURNA HCT terazosin terconazole vaginal THALOMID timolol maleate eye solution tizanidine TOBI PODHALER TOBRADEX OINTMENT TOBRADEX ST tobramycin eye solution tobramycin/dexamethasone
eye suspension topiramate TOUJEO [INJ] TOVIAZ TRACLEER TRADJENTA tramadol TRAVATAN Z trazodone TRELEGY ELLIPTA TREMFYA [INJ] TRESIBA [INJ] triamcinolone topical triamterene/hctz tablets tri-lo-marzia trinessa TRIPTODUR [INJ] tri-sprintec TRULANCE
TRULICITY [INJ] TUDORZA PRESSAIR TYMLOS [INJ]
U
UCERIS FOAM ULORIC UPTRAVI
V
valacyclovir valsartan valsartan/hctz VARUBI VASCEPA VELPHORO VELTASSA venlafaxine (non-ER) VENTOLIN HFA verapamil ext-release VESICARE VIBERZI VIEKIRA PAK VIEKIRA XR VIIBRYD VIMPAT VIOKACE VOSEVI VYVANSE
W
warfarin
X
XALKORI XARELTO XELJANZ, XELJANZ XR XIFAXAN XIGDUO XR XIIDRA XOLAIR [INJ] XTANDI XULTOPHY [INJ]
Y
YONSA yuvafem
Z
ZARXIO [INJ] ZENPEP zolpidem zolpidem ext-release ZONTIVITY ZOVIRAX CREAM ZYLET ZYTIGA
Go to 2019drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2019 THROUGH DECEMBER 31, 2019. THIS LIST IS SUBJECT TO CHANGE. For more information contact Express Scripts Customer Service at 800.887.6194 or visit the My Benefits tab on or on the WIRE.
? 2018 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 2
NP-A PRMT5067ANP-19 (09/05/18)
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