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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