Microsoft word - 2012 flexscripts formulary.docx

2012 FlexScripts Administrators Preferred Formulary List

The following is a list of the most commonly prescribed FORMULARY drugs only. It represents an
abbreviated version of the drug list (formulary) that is at the core of your pharmacy benefit program.
The list is not all-inclusive, does not guarantee coverage and is subject to change. In addition to
using this list, you are encouraged to ask your doctor to prescribe generic drugs, whenever
appropriate.
THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012 AND IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information.



SYMBOL KEY:
• [INJ] indicates that the drug is an Injectable.
• [OTC] Symbol indicates that the drug is available Over the Counter.
• [PA] indicates that the drug may require PRIOR AUTHORIZATION due to Step Therapy, FDA
Labeled Indication and/or Quantity Limit.
• [QL] indicates that the drug has a Quantity Limit per 30 Days or 90 Days.
• [*] indicates that the drug will become available as GENERIC in near future. BRAND will then
become Non-Formulary.
• [MAINT] indicates the drug is approved for maintenance 90 Day Supply. Available through ESI
Home Delivery upon member request & Compliance established.
-
To obtain via ESI Home Delivery member must establish a set dose & be compliant for 120
days.
• [SPEC] indicates the drug is approved for SPECIALTY USE as a 30 day supply and requires PRIOR
AUTHORIZATION. EXCLUSIVELY available at CuraScripts Specialty Pharmacy.
• CAPITAL letters indicate Brand name drug. Example: ADVAIR
• Lower case letters Generic name drug. Example: simvastatin

For the member: Generic medications contain the same active ingredients as their corresponding brand
name medications. Though they may look different in color or shape, they have been FDA-approved under
strict standards.
For the physician: Please prescribe preferred products & allow generic substitutions when appropriate.
ABILIFY (Excludes Discmelt & Soln) [MAINT] [PA] THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
AVANDIA, AVANDARYL, AVANAMET [MAINT] [*] chorionic gonadotropin [INJ] [SPEC] [PA] clindamycin and benzoyl peroxide topical [50gm only] THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
erythromycin,ethylsuccinate,-benzoyl peroxide,- glyburide,micronized,-metformin hcl [MAINT] HUMULIN 50-50,70-30,N, R [INJ]`[OTC][MAINT] HUMALOG,MIX 50-50,MIX 75-25 [INJ] [MAINT] I
indomethacin [MAINT]
isosorbide dinitrate,mononitrate [MAINT] THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
LEVITRA [PA] [QL of 4 per 30 Day Supply] THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
oxycodone hcl,-acetaminophen,-ibuprofen [PA] peg-3350 and electrolytes,with flavor packs S
SEASONIQUE
THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
sumatriptan oral, inj [PA- QL of 9 per fill] VIVOTIF [PA] [QL of 4 per 30 Day Supply] VOLTAREN GEL [PA] [QL of 100gm for 30 Days Supply] voriconazole [PA] VIVELLE-DOT [MAINT] ZOMIG,ZMT [PA- QL of 9 per fill, 18 per 30 DS] THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
_____________________________________________________________________________
FORMULARY ALTERNATIVES TO NON-FORMULARY MEDICATIONS (EXAMPLES)
NON FORMULARY
FORMULARY ALTERNATIVE
NON FORMULARY
FORMULARY ALTERNATIVE
risperidone, ABILIFY(regular tabs) , SEROQULE*/XR, risperidone, ABILIFY(regular tabs) , SEROQULE*/XR, lovastatin, pravastatin, atorvastatin, simvastatin, CRESTOR generic patches, ESTRADERM, VIVVELLE-DOT dextroamphetamine-amphetamine, methylphenidate, methylphenidate ER, VYVANSE 24 FE, LO LOESTRIN FE, NUVARING, LOSEASONIQUE, SEASONIQUE 24 FE, LO LOESTRIN FE, NUVARING, LOSEASONIQUE, SEASONIQUE peg- electrolytes, HALFLYTELY-BISACODYL, MOVIPREP THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

2012 FlexScripts Administrators Preferred Formulary List
NON FORMULARY
FORMULARY ALTERNATIVE
NON FORMULARY
FORMULARY ALTERNATIVE
ciprofloxacin/er, levofloxacin, ofoxacin GENOTROPIN, HUMATROPE, NUTROPIN/AQ, NUSPIN risperidone, ABILIFY (reg tabs), SEROQUEL*/XR GENOTROPIN, HUMATROPE, NUTROPIN/AQ, NUSPIN methylphenidate, methylphenidate ER, VYVANSE lovastatin, pravastatin, atorvastatin, simvastatin, CRESTOR THIS LIST IS EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012. IT IS SUBJECT TO
CHANGE. Visit www.flexscripts.com for more information. Updated 1-1-12

Source: http://www.rxconcepts.net/pdf/2012_FlexScripts_Formulary.pdf