2020 Express Scripts Basic Formulary
2023 Express Scripts Basic 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.
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 DIABETES SYRINGES
[INJ] - Injectable Drug
BELBUCA
Brand-name drugs are listed benazepril
in CAPITAL letters.
benzonatate
Generic drugs are listed
betaine anhydrous
in lower case letters.
BETASERON [INJ]
BEVESPI AEROSPHERE
A
BIKTARVY
bisoprolol/hctz
ABILIFY MAINTENA [INJ]
BOSULIF
acetaminophen/codeine
BREO ELLIPTA
ACTEMRA [INJ]
BREZTRI AEROSPHERE
acyclovir
BRILINTA
ADBRY [INJ]
budesonide nebulization
ADEMPAS
suspension
ADVAIR HFA
buprenorphine/naloxone
ADVATE [INJ]
bupropion
ADYNOVATE [INJ]
bupropion ext-release
AFSTYLA [INJ]
buspirone
AIMOVIG [INJ]
butalbital/acetaminophen/
AJOVY [INJ]
caffeine
albuterol nebulization solution BYDUREON BCISE [INJ]
albuterol sulfate hfa
BYETTA [INJ]
(by Cipla, Civica, Exelan,
Lupin, Par, Perrigo, Sandoz, C
Teva & West-Ward)
ALECENSA
CABOMETYX
alendronate
CALQUENCE
allopurinol
carbidopa/levodopa
alprazolam
carvedilol
ALUNBRIG
cefdinir
amiodarone
cefuroxime axetil
amitriptyline
celecoxib
amlodipine
cephalexin
amlodipine/benazepril
CERDELGA
amlodipine/valsartan
CEREZYME [INJ]
amoxicillin
CETROTIDE [INJ]
amoxicillin/potassium
chlorhexidine gluconate
clavulanate
chlorthalidone
anastrozole
CIBINQO
ANDRODERM
CIMDUO
ANORO ELLIPTA
ciprofloxacin
ARALAST NP [INJ]
citalopram
ARANESP [INJ]
clarithromycin
ARIKAYCE
CLENPIQ
aripiprazole
clindamycin hcl
ARISTADA [INJ]
clindamycin phosphate
ARMOUR THYROID
topical
ARNUITY ELLIPTA
clindamycin phosphate/
ASMANEX HFA
benzoyl peroxide
ASMANEX TWISTHALER
clobetasol propionate
atenolol
clomiphene citrate
atomoxetine
clonazepam
atorvastatin
clonidine
AUBAGIO
clopidogrel
AUSTEDO
clotrimazole/betamethasone
AVONEX [INJ]
dipropionate
AZASITE
colchicine tablets
azelastine nasal spray
COMBIPATCH
azithromycin
COMBIVENT RESPIMAT
COMETRIQ
B
CORLANOR
CREON
baclofen
cyanocobalamin [INJ]
BAFIERTAM
cyclobenzaprine
BAQSIMI
cyclosporine eye solution
BARACLUDE SOLUTION
BAXDELA
BD DIABETES PEN NEEDLES
D
esomeprazole magnesium G
delayed-release
DALIRESP
ESPEROCT [INJ]
gabapentin
DAYTRANA
estradiol
GAMMACORE
deferiprone
estradiol patches
GELNIQUE
DESCOVY
estradiol vaginal inserts gemfibrozil
desloratadine
estradiol/norethindrone
GENOTROPIN [INJ]
desvenlafaxine succinate
acetate
GENVOYA
ext-release
ESTRING
GILENYA
dexamethasone
eszopiclone
GLASSIA [INJ]
DEXCOM: RECEIVER, SENSOR, ethinyl estradiol/desogestrel glimepiride
TRANSMITTER
ethinyl estradiol/drospirenone glipizide
dexmethylphenidate
ethinyl estradiol/
glipizide ext-release
ext-release
drospirenone/levomefolate GLUCAGON EMERGENCY KIT
dextroamphetamine/
ethinyl estradiol/ethynodiol (by Eli Lilly) [INJ]
amphetamine
ethinyl estradiol/etonogestrel glyburide
dextroamphetamine/
vaginal ring
GLYXAMBI
amphetamine ext-release ethinyl estradiol/
GONAL-F, GONAL-F RFF,
diazepam
levonorgestrel
GONAL-F RFF
diclofenac sodium
ethinyl estradiol/
REDI-JECT [INJ]
delayed-release
norelgestromin patches GRANIX [INJ]
dicyclomine
ethinyl estradiol/
GRASTEK
digoxin
norethindrone
guanfacine ext-release
diltiazem ext-release
ethinyl estradiol/
GVOKE [INJ]
dimethyl fumarate
norethindrone acetate
diphenoxylate/atropine
ethinyl estradiol/
H
divalproex delayed-release
norethindrone/iron
divalproex ext-release
ethinyl estradiol/norgestimate halcinonide
DIVIGEL
ethinyl estradiol/norgestrel HARVONI
donepezil
EUFLEXXA [INJ]
HUMALOG [INJ]
DOPTELET
ezetimibe
HUMATROPE [INJ]
DOVATO
ezetimibe/simvastatin
HUMIRA [INJ]
doxazosin
HUMULIN [INJ]
doxycycline hyclate
F
hydralazine
doxycycline monohydrate
hydrochlorothiazide
DUAVEE
famotidine
hydrocodone/acetaminophen
DULERA
FARXIGA
hydrocodone/
duloxetine delayed-release FASENRA [INJ]
chlorpheniramine polistirex
DUPIXENT [INJ]
fenofibrate
ext-release
DYANAVEL XR
fenofibric acid
hydrocortisone topical
delayed-release
hydromorphone
E
fentanyl patches
hydroxychloroquine
FETZIMA
hydroxyzine hcl
EDARBI
FINACEA FOAM
hydroxyzine pamoate
EDARBYCLOR
finasteride
HYSINGLA ER
ELIQUIS
FLECTOR
ELOCTATE [INJ]
FLOVENT DISKUS
I
EMGALITY [INJ]
FLOVENT HFA
EMPAVELI [INJ]
fluconazole
ibandronate
emtricitabine/tenofovir
fluocinonide
IBRANCE
disoproxil fumarate
fluoxetine
ibuprofen
EMVERM
fluticasone nasal spray
INBRIJA
enalapril
folic acid
INCRUSE ELLIPTA
ENBREL [INJ]
FORTEO [INJ]
indomethacin
ENDOMETRIN
FRAGMIN [INJ]
INFLECTRA [INJ]
enoxaparin [INJ]
FREESTYLE KITS/METERS: INLYTA
ENSTILAR
FREESTYLE FREEDOM, INVOKAMET
ENTRESTO
FREESTYLE FREEDOM LITE, INVOKAMET XR
ENTYVIO [INJ]
FREESTYLE INSULINX,
INVOKANA
EPCLUSA
FREESTYLE LITE
irbesartan
EPIDIOLEX
FREESTYLE LIBRE:
isosorbide mononitrate
epinephrine auto-injector
READER, SENSOR
ext-release
(by Mylan, Teva) [INJ]
FREESTYLE TEST STRIPS: isotretinoin
EPIPEN, EPIPEN JR [INJ]
FREESTYLE,
ergocalciferol
FREESTYLE INSULINX, J
ERIVEDGE
FREESTYLE LITE
ERLEADA
FULPHILA
JAKAFI
erythromycin eye ointment furosemide
JANUMET, JANUMET XR
escitalopram
FYCOMPA
JANUVIA
(continued)
Costs for covered alternatives may vary. Log on to covered to compare drug prices. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2023 THROUGH DECEMBER 31, 2023. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-.
? 2022 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 1
CRP2205_0016033.1 #2225 BASIC-A PRMT2225A-23 (09/02/2022)
JARDIANCE JENTADUETO JENTADUETO XR JIVI [INJ] JULUCA
K
KANJINTI [INJ] KERENDIA KESIMPTA [INJ] ketoconazole topical ketorolac KITABIS PAK KLOXXADO KOGENATE FS [INJ] KOVALTRY [INJ] KYLEENA KYNMOBI
L
labetalol lamotrigine lansoprazole delayed-release LANTUS [INJ] latanoprost eye solution LATUDA LEVEMIR [INJ] levetiracetam levocetirizine levofloxacin levothyroxine sodium levoxyl LICART lidocaine patches LINZESS liothyronine lisinopril lisinopril/hctz LIVALO LO LOESTRIN FE LOKELMA lorazepam LORBRENA losartan losartan/hctz loteprednol eye suspension lovastatin LUCEMYRA LUPANETA PACK [INJ] LUPRON DEPOT
3.75 MG, 11.25 MG [INJ] LUPRON DEPOT-PED [INJ] LYNPARZA LYUMJEV [INJ]
M
MAYZENT meclizine medroxyprogesterone meloxicam metaxalone metformin metformin ext-release methimazole methocarbamol methotrexate methylphenidate methylphenidate ext-release methylprednisolone metoclopramide metoprolol succinate
ext-release metoprolol tartrate metronidazole metronidazole topical metronidazole vaginal minocycline MIRENA mirtazapine MIRVASO MITIGARE
mometasone MONOVISC [INJ] montelukast morphine sulfate ext-release MOUNJARO [INJ] MOVANTIK moxifloxacin eye solution mupirocin MUSE MYDAYIS MYFEMBREE MYRBETRIQ
N
nabumetone NAMZARIC naproxen, naproxen sodium NARCAN NASAL SPRAY NASCOBAL NATESTO NAYZILAM nebivolol neomycin/polymyxin/
hydrocortisone ear solution NEULASTA [INJ] NEUPOGEN [INJ] NEXLETOL NEXLIZET niacin ext-release nifedipine ext-release NINLARO nitrofurantoin macrocrystal NITYR NIVESTYM [INJ] NORDITROPIN [INJ] norethindrone nortriptyline NOVAREL [INJ] NOVO NORDISK PEN NEEDLES NOVOEIGHT [INJ] NUBEQA NUCALA [INJ] NUEDEXTA NURTEC ODT nystatin nystatin topical NYVEPRIA [INJ]
O
OCREVUS [INJ] ODACTRA ODEFSEY ODOMZO OFEV ofloxacin olanzapine olmesartan olmesartan/hctz OLUMIANT omega-3 acid ethyl esters omeprazole delayed-release OMNIPOD 5 OMNIPOD DASH ondansetron ondansetron orally
disintegrating tablets ONETOUCH KITS/METERS:
ULTRA 2, ULTRAMINI, VERIO, VERIO FLEX ONETOUCH TEST STRIPS: ULTRA, VERIO ONEXTON OPSUMIT ORALAIR ORIAHNN ORILISSA ORTHOVISC [INJ] oseltamivir OTEZLA OTREXUP [INJ] OVIDREL [INJ] oxcarbazepine
oxybutynin ext-release oxycodone oxycodone/acetaminophen OXYCONTIN OZEMPIC [INJ]
P
PANCREAZE pantoprazole delayed-release paroxetine hcl penicillin v potassium PENTASA 250 MG CAPSULES PHOSLYRA pioglitazone PLEGRIDY [INJ] polymyxin/trimethoprim
eye solution PONVORY potassium chloride
ext-release pramipexole pravastatin PRECISION XTRA:
METERS, TEST STRIPS, B-KETONE STRIPS prednisolone acetate eye suspension prednisolone sodium phosphate prednisone pregabalin PREMARIN CREAM PREMARIN TABLETS PREMPHASE PREMPRO prenatal vitamins PROCRIT [INJ] progesterone micronized PROLASTIN C [INJ] promethazine promethazine/ dextromethorphan propranolol propranolol ext-release PULMICORT FLEXHALER
Q
QNASL quetiapine QUILLICHEW ER QUILLIVANT XR quinapril QULIPTA QVAR REDIHALER
R
rabeprazole delayed-release RADICAVA ORS RAGWITEK raloxifene ramipril RASUVO [INJ] REBIF [INJ] RECTIV RELISTOR [INJ] RELISTOR TABLETS REMICADE [INJ] REPATHA [INJ] RESTASIS REVLIMID RHOPRESSA RINVOQ ER risperidone rizatriptan ropinirole rosuvastatin ROZLYTREK RUBRACA RUCONEST [INJ] RUXIENCE [INJ] RYBELSUS
S
SAVELLA SEGLUROMET SEREVENT DISKUS sertraline SEVENFACT [INJ] sildenafil SIMPONI 100 MG [INJ] simvastatin SKYLA SKYRIZI [INJ] SOLIQUA [INJ] SOLOSEC SOMATULINE DEPOT [INJ] SOMAVERT [INJ] SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone SPRYCEL STEGLATRO STEGLUJAN STELARA SC [INJ] STIOLTO RESPIMAT STIVARGA STRENSIQ [INJ] STRIVERDI RESPIMAT SUBLOCADE [INJ] sulfamethoxazole/
trimethoprim sumatriptan SUNOSI SUPREP SUTAB SYMBICORT SYMFI SYMFI LO SYMJEPI [INJ] SYMLINPEN [INJ] SYMPROIC SYMTUZA SYNJARDY, SYNJARDY XR
T
tacrolimus topical tadalafil TAGRISSO TAKHZYRO [INJ] TALICIA TALTZ [INJ] TALZENNA tamoxifen tamsulosin ext-release TASIGNA TAVALISSE TEGSEDI [INJ] TEKTURNA HCT telmisartan TEMIXYS terazosin terconazole vaginal testosterone cypionate [INJ] thyroid timolol maleate eye solution tizanidine TOBI PODHALER tobramycin eye solution tobramycin/dexamethasone
eye suspension topiramate topiramate ext-release TOUJEO [INJ] TRACLEER SUSPENSION TRADJENTA tramadol travoprost eye solution TRAZIMERA [INJ] trazodone TRELEGY ELLIPTA TREMFYA [INJ] treprostinil [INJ] TRESIBA [INJ] tretinoin
triamcinolone topical triamterene/hctz TRIJARDY XR TRIPTODUR [INJ] TRIUMEQ TRULANCE TRULICITY [INJ] TYMLOS [INJ]
U
UBRELVY UCERIS FOAM UDENYCA [INJ] UPTRAVI TABLETS
V
valacyclovir valsartan valsartan/hctz varenicline tartrate VARUBI VASCEPA VELPHORO VELTASSA venlafaxine venlafaxine ext-release VENTOLIN HFA verapamil ext-release VERQUVO VERZENIO VGO VIBERZI VICTOZA [INJ] VIIBRYD vilazodone VIOKACE VITRAKVI VIZIMPRO VOSEVI VUMERITY VYVANSE
W
warfarin WEGOVY [INJ]
X
XALKORI XARELTO XELJANZ, XELJANZ XR XIFAXAN XIGDUO XR XIIDRA XOLAIR [INJ] XTANDI XULTOPHY [INJ] XYREM XYWAV
Y
YONSA YUPELRI
Z
ZARXIO [INJ] ZEJULA ZENPEP ZEPATIER ZEPOSIA ZIEXTENZO [INJ] ZIRABEV [INJ] zolpidem zolpidem ext-release ZOMIG NASAL ZTLIDO ZUBSOLV
Costs for covered alternatives may vary. Log on to covered to compare drug prices. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2023 THROUGH DECEMBER 31, 2023. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-.
? 2022 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 2
CRP2205_0016033.1 #2225 BASIC-A PRMT2225A-23 (09/02/2022)
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