Prmtnmmanp-13.anp.130405

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit 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.
2013 Express Scripts
PLEASE NOTE: The symbol * next to a drug signifies that it is subject to nonformulary status
when a generic is available throughout the year. Not all the drugs listed are covered by all
National Preferred Formulary
prescription-drug benefit programs; check your benefit materials for the specific drugs
covered and the copayments for your prescription-drug benefit program. For specific
For University of New Mexico
questions about your coverage, please call the phone number printed on your ID card.
A
D
B
G
GENOTROPIN [INJ] [PA] [SP] lisinopril, /hctz O
H
HUMATROPE [INJ] [PA] [SP] M
E
C
I
P
J
F
K
N
naproxen, naproxen sodium potassium chloride, er L
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2013 THROUGH DECEMBER 31, 2013. THIS LIST IS SUBJECT TO CHANGE.
If your drug is not listed visit our website at www.express-scripts.com for a complete and updated listing.
2013 Express Scripts Holding Company
All Rights Reserved
PRMTNMMANP-13 (04/05/13)
Examples of Nonformulary Medications With Selected Formulary Alternatives
The following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary.
Column 1 lists examples of nonformulary medications.
Column 2 lists some alternatives that can be prescribed.
Nonformulary
Formulary Alternative
Nonformulary
Formulary Alternative
Q
balsalazide, Asacol/HD, Delzicol, Lialda, Genotropin [PA][SP], Humatrope [PA][SP], R
U
ciprofloxacin/er, levofloxacin, ofloxacin, V
Genotropin [PA][SP], Humatrope [PA][SP], ciprofloxacin/er, levofloxacin, ofloxacin, S
Genotropin [PA][SP], Humatrope [PA][SP], ciprofloxacin/er, levofloxacin, ofloxacin, 80 MG, 105 MG, 115 MG W
FLOVENT DISKUS, HFA Asmanex, Pulmicort Flexhaler, Qvar Genotropin [PA][SP], Humatrope [PA][SP], X
Z
The symbol ^ next to a drug name indicates it has a zero dollar copay.
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
The symbol [PA] next to a drug name indicates that a Prior Authorization is required for coverage.
The symbol [SP] next to a drug name indicates it is a CuraScript specialty medication and is a Tier 4 copay.
T
The symbol [ST] next to a drug name indicates that Step Therapy may apply to some or all strengths of the drug.
For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications,
although they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate. Thank you.
Brand-name drugs are listed in CAPITAL letters and are Tier 2 copays.
Generic drugs are listed in lower case letters and are Tier 1 copays.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2013 THROUGH DECEMBER 31, 2013. THIS LIST IS SUBJECT TO CHANGE.
If your drug is not listed visit our website at www.express-scripts.com for a complete and updated listing.
2013 Express Scripts Holding Company
All Rights Reserved
PRMTNMMANP-13 (04/05/13)

Source: http://hr.unm.edu/docs/benefits/covered-medications-(express-scripts-formulary).pdf