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THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.

You can get more information and updates to this document at our web site at http://hr.osu.edu/benefits/hb_prescription.aspx.
(continued)
ANTIINFECTIVES
Antivirals
acyclovir
INCIVEK
TAMIFLU
valacyclovir
VICTRELIS
VIRAMUNE XR
Cephalosporins
cefdinir
cefprozil
cefuroxime
cephalexin
Macrolides
azithromycin
clarithromycin
Oral Antifungals
fluconazole
nystatin
Penicillins
amoxicillin
amoxicillin/potassium
clavulanate
penicillin v potassium
Quinolones
AVELOX
ciprofloxacin
levofloxacin
Tetracyclines
doxycycline hyclate
doxycycline monohydrate
minocycline
SOLODYN 55 MG, 65 MG,
80 MG, 105 MG, 115 MG
Topical Antibacterials
mupirocin
Topical Antifungals
clotrimazole/betamethasone
dipropionate
ketoconazole
nystatin
nystatin/triamcinolone
Urinary Antiinfectives
nitrofurantoin macrocrystal
Other Antiinfective Drugs
clindamycin hcl
hydroxychloroquine
metronidazole
sulfamethoxazole/
trimethoprim
XIFAXAN
ANTINEOPLASTIC/IMMUNO-
SUPPRESSANT DRUGS
anastrozole
azathioprine
ENBREL [INJ]
HUMIRA [INJ]
methotrexate
ORENCIA [INJ]
SOMATULINE DEPOT [INJ]
tamoxifen
ZYTIGA
CARDIOVASCULAR
MEDICATIONS
ACE Inhibitors +
HCT Combos
benazepril
benazepril/
hydrochlorothiazide
enalapril
lisinopril
lisinopril/hydrochlorothiazide
quinapril
ramipril
Angiotensin II Receptor
Antagonists + HCT Combos
BENICAR, BENICAR HCT
candesartan
DIOVAN
irbesartan
losartan
losartan/hydrochlorothiazide
valsartan/
hydrochlorothiazide
Anti-Arrhythmic Drugs
amiodarone
sotalol
Beta Blockers
atenolol
atenolol/chlorthalidone
bisoprolol/
hydrochlorothiazide
BYSTOLIC
carvedilol
COREG CR
labetalol hcl
metoprolol succinate
ext-release
metoprolol tartrate
nadolol
propranolol
propranolol ext-release
Calcium Channel Blockers
amlodipine
diltiazem ext-release
(24 hour)
nifedipine ext-release
verapamil ext-release
Diuretics
chlorthalidone
furosemide
hydrochlorothiazide
spironolactone
triamterene/
hydrochlorothiazide
HMG-CoA Reductase
Inhibitors
atorvastatin
CRESTOR
lovastatin
pravastatin
simvastatin
Other Blood Pressure Drugs
amlodipine/benazepril
AMTURNIDE
AZOR
clonidine
doxazosin
EXFORGE, EXFORGE HCT
hydralazine
TARKA
TEKAMLO
TEKTURNA, TEKTURNA HCT
terazosin
TRIBENZOR
Other Cardiovascular Drugs
ADCIRCA
digoxin
isosorbide mononitrate
ext-release
LETAIRIS
NITROLINGUAL PUMPSPRAY
RANEXA
TRACLEER
Other Cholesterol Lowering
Drugs
fenofibrate
fenofibrate micronized
gemfibrozil
LIPOFEN
LIPTRUZET
LOVAZA
SIMCOR
VASCEPA
VYTORIN
WELCHOL
ZETIA
AUTONOMIC & CNS
MEDICATIONS
Anticonvulsants
clonazepam
divalproex sodium
ext-release
gabapentin
GRALISE
LAMICTAL ODT
lamotrigine
levetiracetam
LYRICA
oxcarbazepine
POTIGA
topiramate
VIMPAT
Antidementia Drugs
donepezil
EXELON PATCHES
NAMENDA, NAMENDA XR
Antidepressants
bupropion
bupropion ext-release
(12 hour)
bupropion ext-release
(24 hour)
mirtazapine
PRISTIQ
trazodone hcl
venlafaxine
venlafaxine ext-release
Antiparkinson Drugs
AZILECT
carbidopa/levodopa
pramipexole
ropinirole
Antipsychotic Drugs
ABILIFY, ABILIFY DISCMELT
LATUDA
lithium carbonate
olanzapine
quetiapine
risperidone
SEROQUEL XR
Antivertigo & Antiemetics
meclizine hcl
ondansetron
ondansetron orally
disintegrating tablets
SANCUSO
Anxiolytics
alprazolam
buspirone
diazepam
lorazepam
Class II Narcotics
fentanyl citrate
FENTORA
hydromorphone
methadone
morphine sulfate ext-release
NUCYNTA, NUCYNTA ER
OPANA ER
oxycodone
oxycodone/acetaminophen
OXYCONTIN
Class III Narcotics
acetaminophen/codeine
BUTRANS
hydrocodone/acetaminophen
hydrocodone/ibuprofen
SUBOXONE SL FILM
CNS Stimulants
amphetamine salt combo
amphetamine salt combo
ext-release
DAYTRANA
FOCALIN XR
methylphenidate
methylphenidate ext-release
modafinil
QUILLIVANT XR
VYVANSE
Drugs to Prevent & Treat
Headaches
butalbital/acetaminophen/
caffeine
RELPAX
rizatriptan
rizatriptan orally
disintegrating tablets
sumatriptan
SUMAVEL DOSEPRO [INJ]
TREXIMET
zolmitriptan
zolmitriptan orally
disintegrating tablets
ZOMIG NASAL
Drugs to Treat Multiple
Sclerosis
AMPYRA
AVONEX [INJ]
COPAXONE [INJ]
EXTAVIA [INJ]
GILENYA
REBIF, REBIF REBIDOSE [INJ]
TECFIDERA
Non-Narcotic Analgesics
tramadol
tramadol/acetaminophen
Sedative/Hypnotics
LUNESTA
temazepam
zolpidem
zolpidem ext-release
Selective Serotonin
Reuptake Inhibitors
citalopram
escitalopram
fluoxetine
paroxetine
sertraline
VIIBRYD
Tertiary Amines
amitriptyline
doxepin
nortriptyline
Other Autonomic/CNS Drugs
NUEDEXTA
SAVELLA
Other Drugs For ADHD
INTUNIV
STRATTERA
DERMATOLOGICAL
MEDICATIONS
Antiacne Drugs
ACANYA
ACZONE
ATRALIN
BENZACLIN PUMP
clindamycin phosphate
DIFFERIN 0.3% GEL,
0.1% LOTION
EPIDUO
FINACEA, FINACEA PLUS
ORACEA
tretinoin
VELTIN
ZIANA
Antipsoriasis & Antieczema
Drugs
calcipotriene
TACLONEX
TAZORAC
Corticosteroid Drugs
clobetasol propionate
desonide
fluocinonide
hydrocortisone
mometasone
triamcinolone acetonide
Miscellaneous
Dermatologicals
ANALPRAM ADVANCED
CREAM KIT
ANALPRAM HC 1% CREAM,
2.5% LOTION
CARAC
ELIDEL
EURAX
PRAMOSONE, PRAMOSONE E
PROTOPIC
SOLARAZE
ZYCLARA
Topical Anti-Inflammatory
Drugs
VOLTAREN GEL
EAR-NOSE MEDICATIONS
Drugs Affecting The Ear
antipyrine/benzocaine
CIPRODEX
neomycin/polymyxin/
hydrocortisone
Drugs Affecting The Nose
ASTEPRO
azelastine
fluticasone
NASONEX
QNASL
triamcinolone acetonide
ENDOCRINE MEDICATIONS
Amylin Analogues
SYMLINPEN [INJ]
Androgen Drugs
ANDRODERM
ANDROGEL
AXIRON
testosterone cypionate [INJ]
Dipeptidyl Peptidase-IV
Inhibitors & Combos
JANUMET, JANUMET XR
JANUVIA
JUVISYNC
KOMBIGLYZE XR
ONGLYZA
Glucocorticoids
dexamethasone
methylprednisolone
prednisolone
prednisolone sodium
phosphate
prednisone
veripred
Glucose Elevating Drugs
GLUCAGEN [INJ]
GLUCAGON [INJ]
Growth Hormones
GENOTROPIN [INJ]
HUMATROPE [INJ]
NORDITROPIN [INJ]
Incretin Mimetics
BYDUREON [INJ]
BYETTA [INJ]
Insulins
HUMALOG [INJ]
HUMULIN [INJ]
LANTUS, LANTUS
SOLOSTAR [INJ]
LEVEMIR, LEVEMIR
FLEXPEN [INJ]
Insulin Sensitizers
pioglitazone
Oral Hypoglycemics
glimepiride
glipizide
glipizide ext-release
glyburide
glyburide/metformin
metformin
metformin ext-release
RIOMET
Sodium-Glucose Co-
Transporter 2 Inhibitors
INVOKANA
Thyroid Supplements
levothyroxine sodium
liothyronine
Other Endocrine Drugs
ACTONEL
alendronate sodium
ATELVIA
EVISTA
FORTEO [INJ]
ibandronate
methimazole
EYE MEDICATIONS
Antibacterial Drugs
AZASITE
BESIVANCE
ciprofloxacin
erythromycin
levofloxacin
MOXEZA
2014 Express Scripts Holding Company
All Rights Reserved
BASIC-T
PRMTA8WB-14 (09/04/13)
2014 The Ohio State University
Formulary Drug List by Therapeutic Class
The following is a list of commonly prescribed drugs. It represents an abbreviated
version of the drug list (formulary) that is the core of your prescription drug
benefit plan. This list does not guarantee coverage and is subject to change with
or without notice. Check your benefit materials for coverage information,
including the co-payments/co-insurances and any requirements associated with
your prescription drug benefit program. For specific questions about your
coverage, please call the phone number printed on your ID card.
PLEASE NOTE: Brand name drugs may move to non-formulary status if a
generic version becomes available during the year.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2014 THROUGH DECEMBER 31, 2014. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at our web site at http://hr.osu.edu/benefits/hb_prescription.aspx.
ofloxacin
polymyxin/trimethoprim
tobramycin
VIGAMOX
ZYMAXID
Antiglaucoma Drugs
ALPHAGAN P 0.1%
BETOPTIC S
COMBIGAN
dorzolamide/timolol
latanoprost
LUMIGAN
timolol maleate
TRAVATAN Z
travoprost
Corticosteroid Drugs
DUREZOL
LOTEMAX
prednisolone acetate
Other Eye Drugs
ALREX
BEPREVE
BROMDAY
ILEVRO
NEVANAC
PATADAY
PATANOL
PROLENSA
RESTASIS
TOBRADEX OINTMENT
TOBRADEX ST
tobramycin/dexamethasone
susp
ZYLET
GASTROINTESTINAL
MEDICATIONS
Antispasmodics/Drugs
Affecting GI Motility
dicyclomine hcl
metoclopramide hcl
H. Pylori Drugs
PYLERA
Proton Pump Inhibitors
lansoprazole delayed-release
NEXIUM
omeprazole delayed-release
pantoprazole delayed-
release
Other GI Drugs
AMITIZA
ASACOL HD
CANASA
CREON
DELZICOL
diphenoxylate/atropine
HALFLYTELY-BISACODYL
KRISTALOSE
LIALDA
LINZESS
MOVIPREP
PENTASA
RECTIV
RELISTOR [INJ]
SUCLEAR
sucralfate
SUPREP
UCERIS
ZENPEP (EXCEPT 5,000 U)
IMMUNOLOGICALS
Erythroid Stimulants
ARANESP [INJ]
PROCRIT [INJ]
Interferons
PEGASYS, PEGASYS
PROCLICK [INJ]
MUSCULOSKELETAL
MEDICATIONS
CNS Muscle Relaxants
baclofen
cyclobenzaprine
metaxalone
methocarbamol
tizanidine
Drugs to Prevent & Treat
Gout
allopurinol
COLCRYS
ULORIC
Injectable Drugs For
Arthritis
EUFLEXXA [INJ]
ORTHOVISC [INJ]
Non-Steroidal Anti-
Inflammatory Agents
CELEBREX
diclofenac sodium
delayed-release
etodolac
indomethacin
meloxicam
nabumetone
VIMOVO
NUTRITION & BLOOD
MODIFIERS
Antiplatelet Drugs
AGGRENOX
BRILINTA
clopidogrel
EFFIENT
Blood Detoxicants
FOSRENOL
RENVELA
Oral and Inj. Anticoagulants
ELIQUIS
enoxaparin [INJ]
FRAGMIN [INJ]
warfarin
XARELTO
Therapeutic Vitamins &
Minerals
cyanocobalamin [INJ]
eliphos
ergocalciferol
NASCOBAL
potassium chloride
ext-release
ZEMPLAR
Thrombin Inhibitors
PRADAXA
OBSTETRICAL &
GYNECOLOGICAL
MEDICATIONS
Contraceptives
BEYAZ
generic oral contraceptives
LO LOESTRIN FE
NATAZIA
NUVARING
SAFYRAL
Estrogen Drugs
CENESTIN
DIVIGEL
ENJUVIA
estradiol
EVAMIST
MINIVELLE
PREMARIN TABS
VAGIFEM
VIVELLE-DOT
Estrogen/Progestin
Combinations
COMBIPATCH
estradiol/norethindrone
acetate
PREMPHASE
PREMPRO
Ovulatory Stimulants
clomiphene citrate
GONAL-F [INJ]
Prenatal Vitamins
generic prenatal vitamins
Progestin Drugs
CRINONE
ENDOMETRIN
medroxyprogesterone
acetate
progesterone micronized
Specialized OB/GYN Drugs
CETROTIDE [INJ]
chorionic gonadotropin [INJ]
Vaginal Antiinfectives
metronidazole gel
terconazole
RESPIRATORY
MEDICATIONS
Antihistamines
arbinoxa
hydroxyzine hcl
hydroxyzine pamoate
promethazine
Antihistamine/Antitussives
hydrocodone/
chlorpheniramine
polistirex
promethazine/
dextromethorphan
Antitussive & Expectorants
benzonatate
hydrocodone/homatropine
Beta-2 Adrenergics
albuterol
ARCAPTA
FORADIL
levalbuterol
PERFOROMIST
PROAIR HFA
SEREVENT DISKUS
VENTOLIN HFA
Leukotriene Modifiers
montelukast
Other Drugs For Asthma
ASMANEX
budesonide neb susp
COMBIVENT RESPIMAT
DALIRESP
DULERA
EPIPEN, EPIPEN JR [INJ]
PULMICORT FLEXHALER
QVAR
SPIRIVA
SYMBICORT
TUDORZA
UROLOGICAL MEDICATIONS
Anticholinergic
Antispasmodics
DETROL LA
GELNIQUE
MYRBETRIQ
oxybutynin
oxybutynin ext-release
TOVIAZ
VESICARE
Drugs Used For BPH
finasteride
RAPAFLO
tamsulosin ext-release
DIABETIC SUPPLIES
Meters & Strips
ONETOUCH KITS/METERS;
BASIC, ULTRA 2,
ULTRAMINI, ULTRASMART,
VERIO IQ
ONETOUCH TEST STRIPS;
FASTTAKE, ONETOUCH,
SURESTEP, ULTRA, VERIO
BASIC-T
PRMTA8WB-14 (09/04/13)
2014 Express Scripts Holding Company
All Rights Reserved
Examples of Non-Formulary Medications with Selected Formulary Alternatives
The following is a list of selected non-formulary brand name medications with examples of
alternatives that are on the formulary. This list does not dictate nor control decisions regarding
appropriate care. As always, you and your health care provider make the final decision on which
medication(s) is/are right for you.
KEY
The symbol [INJ] next to a drug name indicates that the drug is available in injectable form only.
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 formulary products and allow generic substitutions when
medically appropriate.
Brand name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
Non-Formulary Medications Formulary Alternative(s)
ACCU-CHEK METERS/STRIPS OneTouch meters/strips
ADVAIR DISKUS/HFA Dulera, Symbicort
ALVESCO Asmanex, Pulmicort Flexhaler, QVAR
APIDRA Humalog
AUVI-Q Epipen, Epipen Jr
AVINZA morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER,
Opana ER, Oxycontin
BECONASE AQ flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl
BETASERON Avonex, Extavia, Rebif
BRAVELLE Gonal-f
BREEZE, CONTOUR OneTouch meters/strips
METERS/STRIPS
BREO ELLIPTA Dulera, Symbicort
CIMZIA Enbrel, Humira
EDARBI/EDARBYCLOR candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide,
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide,
Benicar/HCT
EXALGO morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER,
Opana ER, Oxycontin
FLOVENT DISKUS/HFA Asmanex, Pulmicort Flexhaler, QVAR
FOLLISTIM AQ Gonal-f
FORTESTA Androgel, Axiron
FREESTYLE, PRECISION OneTouch meters/strips
METERS/STRIPS
JENTADUETO Janumet, Janumet XR, Kombiglyze XR
KADIAN morphine sulfate ext-release, oxymorphone ext-release, Nucynta ER,
Opana ER, Oxycontin
KAZANO Janumet, Janumet XR, Kombiglyze XR
MAXAIR AUTOHALER Proair HFA, Ventolin HFA
MICARDIS/MICARDIS HCT candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide,
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide,
Benicar/HCT
NESINA Januvia, Onglyza
NOVOLIN Humulin
NOVOLOG Humalog
NUTROPIN/NUTROPIN AQ Genotropin, Humatrope, Norditropin
OMNARIS flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl
OMNITROPE Genotropin, Humatrope, Norditropin
PEGINTRON Pegasys
PROVENTIL HFA Proair HFA, Ventolin HFA
RHINOCORT AQUA flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl
SAIZEN Genotropin, Humatrope, Norditropin
SIMPONI Enbrel, Humira
STELARA Enbrel, Humira
TESTIM Androgel, Axiron
TEVETEN/TEVETEN HCT candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide,
losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide,
Benicar/HCT
TEV-TROPIN Genotropin, Humatrope, Norditropin
TRADJENTA Januvia, Onglyza
TRUETEST, TRUETRACK OneTouch meters/strips
METERS/STRIPS
VERAMYST flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl
VICTOZA Bydureon, Byetta
XELJANZ Enbrel, Humira
XOPENEX HFA Proair HFA, Ventolin HFA
ZETONNA flunisolide, fluticasone, triamcinolone acetonide, Nasonex, Qnasl
ZIOPTAN latanoprost, travoprost, Lumigan, Travatan Z