Prmtckyanp-12.anp.110805

The following is a list of the most commonly prescribed drugs. It representsan abbreviated version of the drug list (formulary) that is at the core ofyour prescription-drug benefit plan. The list is not all-inclusive and doesnot guarantee coverage. In addition to using this list, you are encouragedto ask your doctor to prescribe generic drugs whenever appropriate.
2012 Express Scripts
PLEASE NOTE: The symbol * next to a drug signifies that it is subject to
National Preferred Formulary
nonformulary status when a generic is available throughout the year.
For specific questions about your coverage, please call the phone
For Kentucky Employees’ Health Plan
number printed on your ID card.
A
B
G
MULTICLIX, SOFT TOUCH, BETASERON [INJ] [PA] [QLL] donepezil, odt O
CURVE, COMPACT DRUM budesonide neb susp [QLL] doxepin H
M
E
C
I
P
J
K
F
N
L
naproxen, naproxen sodium potassium chloride, er D
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2012 Express Scripts, Inc.
PRMTCKYANP-12 (08/05/11)
All Rights Reserved
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
R
ciprofloxacin/er, levofloxacin, ofloxacin, U
V
ciprofloxacin/er, levofloxacin, ofloxacin, S
Detrol/LA* [ST], Enablex [ST], Toviaz [ST], ciprofloxacin/er, levofloxacin, ofloxacin, W
X
simvastatin [QLL] or Crestor [QLL] [ST] or Z
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
T
The symbol [PA] next to a drug name indicates that Prior Authorization is required.
The symbol [QLL] next to a drug name indicates that quantity or therapy limits exist.
The symbol [ST] next to a drug name indicates that Step Therapy applies.
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.
Generic drugs are listed in lower case letters.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our website at www.express-scripts.com.
2012 Express Scripts, Inc.
PRMTCKYANP-12 (08/05/11)
All Rights Reserved

Source: http://www.madison.k12.ky.us/userfiles/1176/Health%20Benefits/2012%20Formulary%20List.pdf