Comp2053a-14.basic-a.13110

2014 Express Scripts Basic Formulary List
The 2014 Basic Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan. Inclusion on the list does notguarantee coverage.
The following list is not a complete list of over-the-counter [OTC] products and prescription medical supplies that are on the formulary. The only OTC products andprescription medical supplies that appear on the list are in contracted classes.
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 drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For
specific questions about your coverage, please call the phone number printed on your member ID card.
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
Brand-name drugs are listed in CAPITAL letters. Example: CELEBREX substitutions when medically appropriate.
Generic drugs are listed in lower-case letters. Example: ibuprofen A
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
#2053 BASIC-A
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B
C
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
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clotrimazole/betamethasone dipropionate DAUNOXOME [INJ] desloratadine orally disintegrating tablets donepezil E
D
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
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G
F
H
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
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hyoscyamine orally disintegrating tablets isotretinoin I
J
M
K
medroxyprogesterone (contraceptive) [INJ] ipratropium bromide nebulization solution ipratropium/albuterol sulfate nebulization L
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
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O
ondansetron orally disintegrating tablets N
mirtazapine orally disintegrating tablets Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
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PRECISION XTRA B-KETONE STRIPS [OTC] promethazine/phenylephrine P
Q
peg 3350/electrolytes powder for 4000 mL polysaccharide iron forte R
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
#2053 BASIC-A
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T
risperidone orally disintegrating tablets rizatriptan orally disintegrating tablets S
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
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COMP2053A-14 (11/01/13)
Y
Z
V
zolmitriptan orally disintegrating tablets W
water for injection, bacteriostatic [INJ] X
#
U
Created 11/1/2013. Please note that this document is subject to change. Any changes/updates to this document can be viewed at Express-Scripts.com.
2014 Express Scripts
#2053 BASIC-A
All Rights Reserved
COMP2053A-14 (11/01/13)

Source: http://www.txhealthpool.org/Comprehensive%20Basic%20Alpha%20COMP2053A-14.131101.pdf