Excluded Drug List, Effective October 1, 2021

Check your benefit information to verify coverage or view your personal benefit information on our website. This list may contain trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with your health plan. This list may change or expand from time to time without prior notice.

Drug Exclusions List – Effective 10/1/21 1

Drug Exclusions October 1, 2021

Why Doesn’t My Health Plan Cover Some Drugs? From time to time, our pharmacy committee decides to no longer cover, or exclude, some drugs because other safe, effective, less costly alternatives are available. The committee is composed of independent doctors and pharmacists who regularly review and compare prescription drugs to ensure the ones we cover include proven medications for treating the majority of medical conditions.

Newly-launched products and new variations of products already on the market are not automatically added to your health plan’s list of covered drugs, also known as a formulary. A product can be added to the formulary only if our pharmacy committee decides that it is clinically appropriate and cost-effective.

What Should I Do If My Drug Is Excluded? Talk to your doctor to see if a covered alternative drug is a good option for treating your condition. Note that many excluded brand-name drugs have covered generic alternatives.

Of course, you and your doctor make the final decision about the medications that are right for you. If your doctor believes no alternative drug will work for your medical condition, you or your doctor can request a formulary exception to have an excluded drug covered. Just follow these steps:

Providers To request a formulary exception for a drug noted on the list with a (+), call 877-440-0089. To request a formulary exception for all other listed drugs, call the precertification number on the member’s ID card.

Members To request a formulary exception for all drugs listed, call the Customer Service number on your ID card.

Note: Formulary exceptions can only be considered with required documentation from the member’s health care provider.

What Happens If I Have A Prescription Filled For An Excluded Drug? You will be able to get your drug, but you will pay the full cost of it.

What Drugs Are Excluded From Coverage? The drugs on the following pages are excluded from coverage as of the date of this list.

Your pharmacy benefit may not cover certain categories of drugs, such as those used to treat weight loss or sexual dysfunction. Please check your plan materials for details about coverage for a specific drug category.


Excluded Drug List

Specialty drugs are noted with a (#).

A

Abecma (#) Abilify (brand) Abilify Mycite Absorica/LD Acanya Accolate Accupril Aciphex Acnefree Acthrel (#) Acticlate (brand & gen.) Actiq Acuicyn Acyclovir 5% cream Aczone Adagen (#) Adakveo (#) Adapalene-Benzoyl

Peroxide-Clindamycin gel

Adapalene-Benzoyl Peroxide-Niacinamide gel

Adcirca Adderall (brand) Adderall XR Adhansia XR Adlyxin Admelog Aduhelm Adzenys XR Aemcolo Aerospan Afstyla (#) Airduo Ajovy Aklief Ala Scalp Ala Scalp Lotion 2% Alavert Alcortin A Aldactone Aldara (brand) Alevicyn Antipruritic/Plus Allegra/Allegra-D Allzital Aloprim Aloquin Alora (brand) Altace Altoprev (brand) Altreno Alvesco Alzair

Azelex (brand) Azeschew Azesco Azilect

Azor (brand) Azstarys

B

Baclofen 5 mg Bafiertam (#) Balcoltra Banzel Barhemsys Baxdela Beau Rx

Ambien/CR Amcinonide 0.1% cream

& ointment Ameluz Amerge Ammonul Amondys 45 (#) Amphetamine ER susp Amrix (brand) Amzeeq Andexxa (#) Androgel 1.62% (brand) Android-10 (brand) Antara (brand) Antivert Apadaz Aplenzin Apligraf (#) Aptensio XR (brand) Arakoda Arazlo Arestin Aricept Arikayce (#) Armonair Digihaler Armonair Respiclick Artesunate Arthrotec Arymo ER Asacol HD (brand) Asceniv (#) Asmanex Asparlas (#) Aspergillus Fumigatus Aspirin/Omeprazole Atacand/HCT (brand) Ativan (brand) Atopiclair Atralin Atrapro spray/gel/kit Atripla Aurstat Austedo (#) Auvi-Q Avapro Avar (brand) Aveed (brand) (#) Avenova Azelaic Acid-

Niacinamid cream

Belbuca Benicar/HCT (brand) Bensal HP Benz Per-Clindamycin-

Niacinamide-Tretinoin gel

Benzaclin (brand) Benzamycin (brand) Benzepro (brand) Benzhydrocodone/

Acetaminophen Benzocaine-Lidocaine-

Tetracaine oint Benzonatate 150 mg Beovu (#) Betamethasone

Dipropionate-Minoxidil

Betapace/AF tablet Bevacizumab prefilled

syr. (#) Bevyxxa Biafine Bijuva Binosto (brand) Bionect Bocasal oral rinse Bonjesta Bortezemib (#) Botox Cosmetic (#) Bravelle (#) Brexafemme Breyanzi (#) Breztri/Aerosphere Brineura (#) Briviact Bromsite Brukinsa (#) Bryhali Budesonide/Formoterol Bunavail (brand) Bupap (brand) Buphenyl Bupivacaine HCL

Butalbital/APAP 50/300 Butrans Bynfezia Pen (#) Byvalson

C

Caduet Cafergot tablet Calcipotriene-

Betamethasone Calcipotriene-Clobetasol

Propionate Calcitonin inj. Caldolor Cambia Canasa Sup 1000 mg Candida Albicans Extract Caplyta Carac (brand & generic) Carbatrol Carbinoxamine 6 mg Cardizem CD/LA (brand) Carnitor/SF Carospir Carteolol Ophthalmic Carticel Cataflam Celacyn Celebrex Celexa Cequa Ceracade Cerave Chlorzoxazone 250 mg,

375 mg & 750 mg Cholecal DF Cicatrace Pad Ciclopirox-Clobetasol

shampoo Ciclopirox-Clobetasol-

Salicylic Acid shampoo Ciclopirox-Salicylic Acid

shampoo Cimetidine-Lidocaine-

Salicylic Acid cream Cinqair (#) Ciprodex Ciprofloxacin/Fluocino-

lone Otic Clarinex/Clarinex-D Claritin/Claritin-D Clenpiq Clindagel

Clindamycin Phos-Niacinamide-Tretinoin cream

Clindamycin Phosphate-Niacinamide gel

Clindamycin Phosphate-Niacinamide lotion 1-4%

Clindamycin-Benzoyl Peroxide-Niacinamide gel

Clindamycin-Niacinamid-Spironolac-Tretinoin gel

Clobetasol Propionate-Levocetirizine Dihyd shampoo

Clobetasol Propionate-Niacinamide cream/ oint/soln

Clozaril Colcrys (brand) Colesevelam Pak 3.75 Colestid Comtan Concerta Conjupri Consensi Conzip (brand) Cordran Cordran 80x3 Tape

4mcg/Cm Corgard Cortaid max. strength Cosela (#) Cotempla Cozaar Crestor Crysvita (#) Cuprimine (#) Cutaquig (#) Cuvitru (#) Cyclobenzapr tab 7.5mg Cyclobenzaprine ext rel Cyfolex Cymbalta (brand) Cystadane (#) Cytomel (brand)

D

D.H.E. (brand) Daklinza (#) Dandelion Allergenic Ext. Dapsone gel Dapsone-Niacinamide

gel


Dapsone-Niacinamide-Spironolactone gel

Daxbia Daypro Dayvigo Decara K Defitelio (#) Deflux Delstrigo Denavir Depacon Depakene Depakote/ER Dermatop (brand) Dermotic Oil Desloratadine Desonate gel 0.05% Desowen Desoxyn Detrol/LA Dexchlorpheniramine syr. Dexedrine Dexeryl Dexilant Dexpak Dextenza (#) Dexycu Diastat Acudial/Pediatric Diclegis (brand and gen.) Diclofenac caps Diclofenac Dis 1.3% Diclofenac Sodium-

Sodium Hyaluronate-Niacinamide gel

Diclofono Differin gel Diflorasone cream &

oint. Dihydroergotamine spr Dilantin/Infatabs Dilantin-125 Dilaudid Dimercaptopropane-

Sulfonate Diovan/HCT Ditropan XL Diuril Divigel (brand) Dolophine Doryx/MPC (brand) Doxepin cream/tabs Doxycycline DR 80mg Doxycycline

Monohydrate cap 75 mg

Drizalma Duaklir

Duexis Duobrii Duragesic Dutoprol Duzallo Dxevo Dyanavel XR (brand) Dyazide Dyrenium capsule

E

Econazole Nitrate-Niacinamide cream

Edecrin (brand) Edex EES granules Effexor XR (brand) Efudex (brand) Elepsia XR Elestrin (brand) Eletone Emflaza (#) Empaveli (#) Emtriva Enablex Enstilar Entty Spray Emulsion Envarsus XR (#) Epaned (brand) Epiceram Epicoccum Nigrum EpiPen/Jr. (brand) EryPed 200 & 400 mg Esomeprazole Esperoct (#) esterified estrogen/

methyl-testosterone Eucrisa Eurax lotion Evekeo/ODT (brand) Evenity (#) Evivo Evkeeza (#) Evomela (#) Exelon Exforge/HCT Exondys 51 (#) Ezallor

F

Fasenra (#) Fazaclo Fenofibrate 130 mg Fenoglide (brand) fenoprofen (generic) Fenortho (brand) Ferric Maltol Fetroja Fexmid tab 7.5 mg

Fexofenadine fexofenadine-

pseudoephedrine Fibricor tab 105 mg &

35 mg Finasteride-Minoxidil Fioricet/Codeine Firdapse (#) First Atenolol susp. First-Lansoprazole

(excluded only for members 17 years and older)

First-Omeprazole (excluded only for members 17 years and older)

Flector Dis 1.3% Flolipid Flomax Cap 0.4 mg Fluconazole-Ibuprofen-

Itraconazole-Terbinafine

Fluocinolone Acetonide-Niacinamide cream

Fluoroplex (brand) Fluorouracil cream 0.5% Fluticasone/salmeterol

inhaler Focalin/XR Folene Folika-V Folite Folvite-FE Forfivo XL (brand) Fortamet (brand & gen.) Fosamax + D Fosrenol Fotivda (#) Fulphila (#) Fungoid-D

G

Gabitril Gamifant (#) Gatifloxacin

dexamethasone Gelclair Gel Gemtesa Genadur Genvisc (#) Geodon Giazo (brand) Gimoti Gloperba Glumetza (brand &

generic) Glycopyrrolate 1.5mg

Gocovri GPL Pak Gralise (brand) Grastek Gvoke PFS

H

Halcinonide cream 0.1% Halcion Halog/Halog Sol 0.1% Hectorol Hemady Hemlibra (#) Herzuma (#) Horizant (brand) HPR Plus/MB Hydrogel

kit Hyaluronate Sodium-

Niacinamide-Tacrolimus

Hyaluronate Sodium-Niacinamide-Tretinoin

Hycofenix (brand) Hydrisalic Hydrocodone 2.5 mg/

guaifenesin 200 mg hydrocortisone 1% in

asorbase Hydroquinone

Emulsion Hydroquinone-

Hydrocortisone Emulsion

Hydroquinone-Hydrocortisone-Tretinoin Emulsion

Hylatopic Plus Hymovis (#) Hyperhep B (#) Hyperrab (#) Hyperrab S/D (#) Hyzaar

I

IBU 600-EZS Ibudone Ibuprofen/famotidine Idelvion (#) Idhifa (#) Ilumya (#) Iluvien (#) imiquimod cream 3.75% Imiquimod-

Levocetirizine Dihcl-Niacinamide gel

Imiquimod-Levocetirizine Dihcl-Tretinoin gel

Imitrex (brand) Imlygic (#) Imogam (#) Impoyz Imvexxy Inbrija (#) Inderal LA/XL Indocin caps./supp./

susp. Indomethacin Infugem (#) Ingrezza (#) Innopran XL Intermezzo Intrarosa Intuniv (brand) Invega Inveltys Iodoquinol-

Hydrocortisone-Ketoconazole cream

Ionil liquid Ipamorelin Acetate (#) Isosorbide 40mg Isturisa (#) Ivermectin-

Metronidazole-Niacinamide gel

J

Jadenu Jatenzo Jelmyto (#) Jivi (#) Jornay PM Jublia Juluca

K

Kadian (brand) Kamdoy Kapspargo Kapvay Katerzia Kedrab (#) Kelarx (silicone) Scar

Care gel Keppra/XR Keramatrix Kerendia Kerydin Ketamine HCL Ketoconazole 2% foam Ketoconazole-

Hydrocortisone cream

Ketodan Ketoprofen ER Ketorolac spray


Keveyis (#) Khapzory (#) Kinerase Klisyri Klonopin Klor-Con oral pack for

solution Kloxxado Kovaltry (#) Krintafel Kristalose pak Krystexxa (#) Kuvan Kymriah (#)

L

Lactic Acid-Niacinamide cream

Lactinol HX Lactulose oral packet

10gm Lamictal Lamictal Chw Lamictal ODT tab Lamictal Starter Lamictal XR Lampit Lanoxin 125 & 250 mcg

tablet Lansoprazole Lasix Lazanda Ledipasvir/Sofosbuvir (#) Letairis Levicyn dermal spray Levitra Levorphanol Levulan Kerastik

(brand) Lexapro (brand) Lexette Lialda (brand) Librax (brand) Libtayo (#) Licart Lidocaine cream 4.12% Lidocaine HCL Soln 9

Mg/Ml Lidocaine-Tetracaine

cream Lidoderm (brand) Lidotrex (lidocaine)

2% gel Lipitor Lipofen (brand) Locoid (brand) Lodrane D Lokelma Lonhala

Lopressor Loprox (brand) Lorzone tab Loteprednol ophth gel Lotrel Lovaza Loyon Lucemyra Lumoxiti (#) Lunesta (brand) Luradrox gel Lutathera (#) Luxturna (#) Luzu Lyrica/CR Lyumjev

M

Macrilen (#) Macrodantin capsules Margenza (#) Mavenclad (#) Maxalt/MLT Mayzent (#) Mepsevii (#) Mestinon tabs (brand) Metformin ER (only

excluded when prescribed as a generic for brand Fortamet or brand Glumetza)

Methadose Methionine-Inos-

Choline-Levocarn Methoxsalen

(Photopheresis) Methylcobala Methylin Methylphenidate 72 mg

ER Methyltestos cap 10mg Miacalcin injection/

nasal spray Micardis/HCT Micort Microvix LP Midaz/ketamine troche/

ondansetron Midazolam Migranal (brand) Millipred/DP Minastrin 24 FE (brand) Minitran (brand) Minivelle (brand) Minocin (brand) Minocycline ER caps Minolira ER

Minoxidil-Progesterone-Tretinoin

Mirapex/ER Mircera (#) Mitigare (brand) Mitomycin (#) Mobic Mondoxyne (brand) Monodox (brand) Monoferric Morgidox (brand) Morphabond ER Moxatag (brand) MS Contin Mugard Mulpleta (#) Mupirocincream Mydayis Mylotarg (#)

N

Nabi-HB (#) Nalfon (brand) Namenda Titration Pak Namenda/ER Nandrolone decanoate Naprosyn susp. 125 mg/

5 mL (brand) Naprosyn tab 500mg Naproxen sodium ER

(generic Naprelan) naproxen/

esomeprazole Nascobal Nasonex (brand) Nayzilam Neocera Neosalus/CP Neurontin

Neutrasal Nexium Nextstellis Niacin (generic) tab 500

mg Niacinamide-

Spironolactone Gel Niacinamide-

Spironolactone-Tretinoin gel

Niacinamide-Spironolactone-Tretinoin gel

Niacinamide-Sulfacetamide Sodium

Niacinamide-Tacrolimus oint.

Niacinamide-Tazarotene cream

Niacinamide-Tretinoin cream/gel

Niacinamide-Triamcinolone Acetonide cream

Niacor Nilandron (#) Nilutamide (#) Nitro-Dur (brand) Nitroglycerin lingual

(brand) Nitrolingual Nitromist Nityr (#) Nivatopic Plus Nocdurna Noctiva Norco Noritate Norvasc Nourianz Novacort Novolin Relion Nucala (#) Nulibry (#) Nuplazid (#) Nurtec ODT Nutraderm Nutraplus Nutraseb Nuvail Nuvigil (brand) Nuwiq (#) Nuzyra Nyvepria (#)

O

Ocaliva (#) Ocean for Kids Odactra Ogivri (#) Olumiant (#) omeprazole (OTC only) omeprazole/sodium

bicarbonate Onexton Onfi tab and susp. Onpattro (#) Ontruzant (#) Onzetra Opana/ER Oracea (both brand &

generic doxycycline (Rosacea) delayed release capsules are excluded)

Orafate (#) Oravig Orfadin

Orgovyx (#) Orph Cit/Asp tab

Caffeine Ortikos Osmolex ER Otiprio Otovel Ovace Plus/Wash (brand) Oxbryta (#) Oxervate (#) Oxtellar XR (brand) Oxycodone/

acetaminophen sol. Ozobax

P

Palforzia (#) Palynziq (#) Panhematin (#) Panzyga (#) Parlodel Parsabiv (#) Pennsaid 1.5% & 2% sol. Pepaxto (#) Pepcid (brand) Percocet Pexeva (brand) Phenobarbital/

Belladonna Alkaloids Phenol Phenytek Pifeltro Piqray (#) Plaquenil (brand) Plavix (brand) Plenvu Plexion/Cleanser (brand) Pliaglis cream Polivy (#) Ponvory (#) Portrazza (#) Praluent Pravachol Pred-Gati Prednisone Intensol

(brand) Pregabalin ER Pregenna Prenara Prenatal 19 Pretomanid Prevacid Prevymis (#) Prilopentin Prilosec Primlev Prinivil Pristiq (brand) Probuphine

Procardia XL Procentra (brand) Progesterone-Minoxidil Prolate Prolensa Prometrium cap Promiseb Protexa Prothelial(#) Protonix Provenge Proventil HFA Provigil (brand) Prozac (brand) Pulmicort Respules

(brand) Pyridostigmine tablet

30 mg Pyridoxal-5 Phosphate Pyrimethamine-

Leucovorin


Q

Qbrexza pad Qelbree Qmiiz ODT Qtern Quartette (brand) Qudexy XR (brand) Questran/Light Quillichew ER (brand) Quillivant XR (brand) Qutenza (#) Quzyttir

R

Rabeprazole Ragwitek Ranexa Rayaldee Rayos (brand) Razadyne/ER Rebinyn (#) Reblozyl Recarbrio Recedo Red Algae Regen-Cov Relafen DS Relexxii Relistor injection/

tablets Relpax Remedient Remodulin (#) Renagel Renvela Requip XL Restoril

Resveratrol Retacrit (#) Retin-A/Micro (brand) Retisert (#) Revatio Revcovi (#) Revesta Rexaphenac (brand) Reyvow Rhofade cream Rhopressa Riluzole (#) Riomet ER Risperdal tab Ritalin/LA Rocaltrol Rocklatan Romidepsin (#) Roszet Roxicodone Roxybond Rozerem Ruzurgi (#) Rylaze (#) Rynoderm

S

S2 Sabril Salex (brand) Salicylic Acid-Sulfaceta-

mide Sodium Salisol Salivamax Samsca Saphris Scarcin gel Scarsilk gel/pad Scenesse (#) Sebuderm Secuado Segluromet selenium sulfide

shampoo 2.25% Semglee Sensipar tab Sernivo Seroquel/XR (brand) Sevenfact (#) Seysara Siklos (#) Silenor (brand) Siliq (#) Sil-K Pad Simvastatin Sinemet/CR Singulair (brand)

Sitavig Sitzmarks Sodium Hyaluronate-

Hydroquinone Emulsion

Sofosbuvir/Velpatasvir (#) Sogroya (*) Solaravix Solaraze (brand) Solesta (#) Soliqua Solodyn Solosec Sovaldi (#) Spinraza (#) Spravato (#) Sprix (brand) Stalevo Staxyn Steglatro Steglujan Stendra Strattera (brand) Striant (brand) Suboxone Sumadan wash (brand) Sumaxin (brand) Sunosi Sutab Symdeko (#) Symfi Symjepi Sympazan Symproic Symtuza Synderderm Syndros Synera (brand) Syprine (#)

T

Taclonex Tacrolimus cream Takhzyro (#) Talicia Targadox (brand) Targretin (#) Tarka Tasigna (#) Taytulla cap 1 mg/20 mc Tegretol/XR Tegsedi (#) Tenormin Tepezza (#) Tepotinib HCL (#) Teriparatide (#) Testopel (brand) Tetravex gel Tetrix

Thiola EC (#) Thrombate III (#) Thyquidity (#) Tiazac (brand) Tibsovo (#) Ticalast Tiglutik (#) Timolol gel Tirosint capsule/sol. Tivorbex (brand) Tobi solution (brand) (#) Tolak (brand) Tolsura Topamax/spr cap Topicort Spray Toprol XL Tosymra Tracleer Tramadol HCL ER Treprostinil (#) Treximet (brand) Trezix (brand) Trianex oint. 0.05%

(brand) Tribenzor Tridesilon (brand) Triglide (brand) Trijardy XR Trileptal Trimo-San gel Trinaz Triptodur (#) Trivisc (#) Trogarzo (#) Trokendi XR Tronvite Trop-Phenyl Trulance Truvada 200/300 Turalio (#) Tussicaps (brand) Tuxarin ER Twirla Tylenol/Codeine Tymlos (#)

U

Ubrelvy Udenyca (#) Uloric Ultracet Ultram Ultravate lotion Uroxatral tablet Ursodiol Utibron Neohaler

V

Vabomere

Valcyte Valium (brand) Valtoco Valtrex (brand) Vanatol LQ (brand) Vanos (brand) Vanoxide-HC lotion Varizig Varubi Vaseretic (brand) Vasotec (brand) Veltassa (#) Veltin Vemlidy (#) Ventavis (#) Ventolin HFA Verdeso foam 0.05%

(brand) Veregen ointment Verquvo Vesicare Vexasyn gel Vibramycin (brand) Viekira Pak/XR (#) Viltepso (#) Vimovo Viread Visbiome Visco-3 (#) Vitafol FE Vitafol strips Vitasure Vitrase Vivlodex Vizimpro (#) Voltaren gel (brand) Vonvendi (#) Vosol HC VP-Vite Rx VSL#3 Vtol LQ Vumerity (#) Vyepti Vyleesi Vyndamax (#) Vyndaqel (#) Vyondys 53 (#) Vytorin (brand) Vyxeos (#) Vyzulta

W

Wakix Welchol Wellbutrin SR/XL (brand) Winlevi Wixela Inhub Wynzora


X

Xadago Xanax/XR (brand) Xaquil XR Xatmep (#) Xeloda Xelpros Xembify (#) Xenazine (brand) (#) Xenleta Xepi Xerese Xhance Ximino Xofluza Xopenex HFA Xpovio Pak (#)

Xtampza ER Xultophy Xuriden (#) Xvite Xyosted Xywav

Y

Ybuphen Yescarta (#) Yonsa (#) Yosprala Yupelri Yutiq (#)

Z

Zalvit Zarontin

Zavara Zegalogue Zegerid (brand & generic) Zelac Zembrace Zemplar Zenzedi (brand) Zepatier (#) Zeposia (#) Zerviate Zestoretic Zestril Zetia (brand) Ziana (brand) Zilretta (#) Zilxi Zinc Sulfate Zinplava

Zipsor (brand) Zocor Zofran/ODT (brand) Zohydro ER cap Zolgensma (#) Zoloft (brand) Zolpimist Zomig Zonalon Zonegran 25 & 100 mg

caps Zorvolex (brand) Zovirax Zuplenz (brand) Zurampic Zyclara Zyflo CR (brand) Zyloprim

Zypitamag Zyprexa/Zydis Zyrtec/Zyrtec-D Zytiga Tab

Generic Drugs Excluded from Certain Manufacturers

These generic drugs are excluded from coverage only when produced by certain manufacturers but can be available from alternate sources. Consult your pharmacist for more information.

acetic acid/alum acetate

albuterol sulfate anusol-hc atropine sulfate bacitracin/neomycin/

polymyxin bacitracin/polymyxin b brimonidine tartrate carteolol hcl

castellani paint cormax scalp

application cromolyn sodium cyclopentolate hcl dorzolamide hcl/

timolol m

flunisolide

flurbiprofen sodium

latanaprost

levobunolol hcl neomycin/polymyxin/

dexamethasone neomycin/polymyxin/

gramicidin opium pedi-boro soak pads pedi-dry phenylephrine hcl podofilox

polymycin b sulfate/ trimethoprim

proparacaine hcl salactic film sal-plant sulfacetamide sodium sulfacetamide sodium/

prednisolone sulfacetamide sodium/

sulfur

tetracaine hcl timolol maleate

ophthalmic tobramycin/

dexamethasone tropazone tropicamide ureacin


Excluded Compound Bases, Bulk Powders & Compound Kits

This list contains many ingredients that are not covered under your prescription benefit coverage when included in certain bases and bulk powders used in compounded drugs, as well as compound kits. Please note that this list is not comprehensive; other compound ingredients are also excluded.

0-9

2-Deoxy-D-Glucose 5-Fluorouracil 5-Methyltetra-

Hydrofolate 5-Methyltetra-

Hydrofolic A 7-Keto DHEA

A

Acacia Acetone Acetyl Hexapeptide-8 Acidophilus

Lactobacillus Albendazole Almond oil, sweet Alprostadil Amitriptyline HCL Amphotericin B Apple flavor Arbem H-Cosmetic Ascorbic Acid Aspirin Auxipro Plasticized Avicel Ph 105

Microcrysta Azithromycin

B

Baclofen Bacteriostatic Water Banana creme flavor Base C Polyethyl-Ene

Glyco Base cream with

Liposome Base gelatin Gummy

Troche Base X Base-Pcca Mbk (Fatty

Acid) Beclomethasone

Dipropiona Benzocaine Benzoin compound

tincture Benzyl alcohol Betahistine HCL/

Dihydrochlori Betamethasone Sodiu

Phos Bethanechol Chloride

m

BHRT base Biotin Bitter drug powder Boric Acid Bromfenac Sodium Budesonide Bupropion HCL

C

Cannabidiol Capsublend-P Capsule Clear Veggie Lo

(All) Capsule Coni-Snap (All) Carboxymethylcellu-

lose So Carnitine (L) Celecoxib Cellulose Microcrystallin Cellulose/Cmc Na

Microcry Cetaphil moisturizing

cream Cetyl Myristoleate Cherry syrup Chloramphenicol Cholesterol Chorionic Gonadotropin Chrysaderm Day Cimetidine Ciprofloxacin HCL Citric Acid Anhydrous Clindamycin HCL/

Monohydra Clindamycin Phosphate Clobetasol Propionate/

Micronized Clotrimazole Coal Tar Cocaine HCL Cocoa butter Coenzyme Q10 Copasil Corn oil Curcumin Cyanocobalamin Cyclobenzaprine HCL

D

Dehydroepiandroster-one

Dermabase

Dexamethasone/ Acetate Anh/Sodium Phos

Diazepam Dichloralphen-Azone Diclofenac Sodium Diltiazem HCL Dimercapto-1-

Propanesulfo Dimercaptosucc-Inic

Acid Dimethyl Sulfoxide Doxepin HCL Doxycycline Hyclate Drcaps size 1 clear

E

Edetate Disodium Dihydrat

EGCG Emollient cream/base Empty capsule, all sizes

& colors Emu oil Erythromycin

Ethylsuccina Estradiol/Micronized/

Valerate Estriol/Micronized Ethoxy Diglycol Ethyl Alcohol Ethyl Oleate

F

Fagron Capfill Pro/ Dispersapro/ Supreme cream

Fattibase Fattyblend Ferulic Acid First-Baclofen 5 First-Dukes mouthwashFirst-Lansoprazole First-Metronida-Zole 50First-Mouthwash Blm First-Omeprazole First-Progester-One Vgs

10/ 20/50 First-Testosterone/Mc First-Vancomycin 25/50Flavor blend Flavor Plus Flavor Sweet-SF

Fluconazole Fluocinonide Fluorouracil Flurbiprofen F-Melt Freedom Derma-N Freedom Poloxitol

G

Gabapentin Gentamicin Sulfate Glutamine Glutathione-L Glycerin Glycolic Acid Glycopyrrolate Grape flavor Guaifenesin Gum base gelatin

H

Hormone cream base Botani

Hrt base (All) Hrt Natural/Supreme

cream base Hyaluronic Acid Sodium SHydrocodone Bitartrate Hydrocortisone/

Acetate/ Micronized Hydrogel Hydromorphone HCL Hydroquinone Hydroxyethyl Cellulose

45 Hydroxyprogester-One

Capro Hydroxypropyl

Cellulose 1/ Methylcellu

Hydroxyurea Hypromellose

Methocel K1

a

I

Ibuprofen Imiquimod Isometheptene Mucate Itraconazole Ivermectin

J

N/A

K

Ketamine HCL Ketoconazole Ketoprofen/Micronized/

Ultra Micronized Ketotifen Hydrogen

Fumara Kinetin

L

Lactic Acid Lactose/Anhydrous Lactose Monohydrate/

spray Lanolin Anhydrous Lansoprazole L-Arginine Leucovorin Calcium Leuprolide Acetate Levofloxacin

Hemihydrate L-Glutamine Lidocaine/HCL Liothyronine Sodium Lipmax Lipopen/Absorption

Enhanc Lipopen Ultra/base L-Methylfolate Calcium Lollibase Lollipop base Lorazepam Loxoral base Lozibase S L-Thyroxine Sodium Lugols

M

Magnesium Glycinate Mannitol Marshmallow flavor Mediderm Medi-Rdt base Medium Chain

Triglyceride Melatonin Mercaptopurine

Monohydrat Metformin HCL Methocel E4m Premium Methscopolamine

Bromide Methylcellulose


Methylcobalamin Methyltestosterone Metoprolol Tartrate Metronidazole/

Benzoate Miconazole/Nitrate Midazolam Mineral oil light Mometasone Furoate Morphine Sulfate Mucolox Mupirocin

N

Nabumetone Naltrexone HCL/

Anhydrous Natapres Niacinamide Nifedipine Nourivan Antiox cream

base Nystatin/Foreign

O

Ointment base emulsifying

Olive oil Omeprazole Ondansetron HCL

Dihydrate Ora-Blend/SF Oral mix flavored susp. Oral suspension Ora-Plus Ora-Sweet/SF Oxycodone HCL Oxytocin

P

Palmitoyl Pentapeptide-3

Papaverine HCL

Paraffin PCCA Anhydrous

Lipoderm B PCCA cosmetic HRT base PCCA custom Lipo-Max PCCA DMAE complex PCCA emollient cream

base PCCA Emulsifix-205 base PCCA fixed oil base PCCA gelatin base PCCA Lecithin Isopropyl

P PCCA Lipoderm base/

HMW PCCA Loxasperse base PCCA Natacream PCCA plasticized base PCCA Pluronic F127

base PCCA Polyglycol Troche PCCA Pracasil Tm-Plus

base PCCA rapid-dissolve

tablets PCCA Sorbitol lollipop

base PCCA Spira-wash base PCCA Sweet-SF PCCA syrup vehicle PCCA T3 Sodium Dilution PCCA T4 Sodium

Dilution PCCA vanishing cream/

light/ lotion PCCA Vanpen base PCCA Xylifos base PCCA -Plus Penderm Pentravan/Plus Peppermint oil Phentermine

Hydrochloride

Phentolamine Mesylate Phytobase Plo Gel – Mediflo pre-

mix Pluronic F127 Polox Polyethylene

Glycol/blend/ 300/400/1450/3350

Polypeg suppository base

Povidone-Iodine Praziquantel Pregnenolone/

micronized Prilocaine HCL Progesterone/Microniz

ed/Ultra Micronized Progesterone wettable Promethazine HCL Propylene Glycol Prostaglandin E1 Purified water Pyrantel Pamoate Pyridoxal-5-Phosphate

Mon

Q

Quinacrine HCL Quinine Sulfate

Dihydrate

R

Ranitidine HCL Resveratrol 98%

S

Salicylic Acid Salt durable cream Salt Stable Lo/Ls

Advanced Sermorelin Acetate Sesame oil

Sildenafil Citrate Silica gel Simethicone Simple syrup Sirolimus Sodium Bicarbonate Sodium Chloride/

Bacterios Sodium Hyaluronate Sodium Metabisulfite Solu-K gel Sorbitol Spg Supposi-Base Spironolactone Sterile water for

injection Stevia extract Steviol Glycosides Succimer DMSA Sucralfate Sulfacetamide Sodium Sulfadiazine Sulfamethoxazole Sulfapyridine Supposibase F Suspendit Synapsin Syrspend SF/Alka

T

Tamoxifen Citrate Tea tree oil Terbinafine HCL Testosterone/

Cypionate Testosterone

micronized/S/Y Testosterone non-

micronized Testosterone

Propionate Tetracaine/HCL Tetracycline HCL

Thymol Thyroid Porcine Tobramycin/Sulfate Tofacitinib Citrate Topiramate Tramadol HCL Transdermal pain base Tretinoin Triamcinolone

Acetonide Troche base Tutti Frutti flavor

U

Ubiquinol Ursodiol

V

Vancomycin HCL Verapamil HCL Versabase/foam Versapro Versatile cream base

W

Watermelon flavor Wax paraffin beads White Petrolatum Wiley Basic Elements

BHRT Witepsol H15/Base F

X

Xylitol

Y

Yellow Petrolatum

Z

N/A


Topical Product Exclusions

Product Type Excluded Product Category and Examples Covered Alternatives

Topical Pain Formulations

Camphomex (CAMPHOR-HISTAMINE-MENTHOL-LIQUID

SPRAY) Lidocaine HCL cream/lotion 3% Lidocin (LIDOCAINE HCL GEL) Lidorx (LIDOCAINE HCL GEL) Lidovex (lidocaine cream) Livixil Pak (lidocaine-prilocaine kit) Medi-Derm/L-RX (LIDOCAINE-CAPSAICIN-MENTHOL-

METHYL SALICYLATE CREAM) Medi-Derm-RX (CAPSAICIN-MENTHOL-METHYL SALICYLATE

CREAM) Mentholix (LIDOCAINE-MENTHOL LIQUID SPRAY) Silmanix Pain Relieving (CAPSAICIN-MENTHOL-

HISTAMINE CREAM) Tetramex (TETRACAINE-MENTHOL-CAMPHOR LIQUID SPRAY)

• OTC Capsaicin patches, cream, gel

• Lidoderm or generic Lidocaine 5% patches

• Lidocaine 5% ointment

• Lidocaine 2% gel

• Voltaren 1% gel

• Generic Diclofenac 1.5% solution

Topical Pain Patches

Anodynerx (CAPSAICIN-LIDOCAINE-MENTHOL) Atendia (LIDOCAINE-MENTHOL) Captracin (CAPSAICIN-MENTHOL) Levatio patch (CAPSAICIN-MENTHOL) Lidenza (LIDOCAINE-MENTHOL) Medi-patch (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL

SALICYLATE) Menthocin/Lidocaine (LIDOCAINE-CAPSAICIN-MENTHOL-

METHYL SALICYLATE) Qroxin (CAPSAICIN-MENTHOL) Reciphexamin (LIDOCAINE-MENTHOL) Relyyks (LIDOCAINE-MENTHOL) Relyyt (CAPSAICIN-MENTHOL) Renovo (CAPSAICIN-MENTHOL) Sinelee (CAPSAICIN-MENTHOL) Solaice (CAPSAICIN-MENTHOL) Synvexia (LIDOCAINE-MENTHOL) Velma Pain Relief (METHYL SALICYLATE-LIDOCAINE-

MENTHOL)

• OTC Capsaicin patches


Ear Pain Formulations & Combinations

Antipyrine/Benzocaine Otic (Generic) Cortane B-Otic (PRAMOXINE-HC-CHLOROXYLENOL OTIC

SOLUTION) Otic Care (ANTIPYRINE-BENZOCAINE-POLYCOSANOL OTIC

SOLUTION) Oticin drops (CHLOROXYLENOL-PRAMOXINE) Oto-End 10 solution (CHLOROXYLENOL-PRAMOXINE-

HYDROCORTISONE) Otozin drops (BENZOCAINE-ANTIPYRINE-ZINC ACETATE) Pinnacaine 20% Drops (BENZOCAINE)

• Dexamethasone otic

• Pediotic

• Neomycin/polymyxin/hydrocortisone otic

• Acetic acid/hydrocortisone

• Ciprodex

• Cipro otic

• Cortisporin

Scar Products Renuu (ALLANTOIN-LIDOCAINE-PETROLATUM) Scar patch (ALLANTOIN-LIDOCAINE-PETROLATUM)




• Miscellaneous emollients (petrolatum, lanolin,glycerin, mineral oil, aloe vera, dimethicone)


Product Type Excluded Product Category and Examples Covered Alternatives

Convenience Multi-Product Kits

Active-Medicated specimen (URINE SPECIMEN

COLLECTION KIT) Active-PAC/Gabapentin (GABAPENTIN CAPS, LENZAGEL

[LIDOCAINE-MENTHOL]) Advanced DNA Medicated CO (DNA COLLECTION

PRODUCT KIT) Analpram Advanced (HC-PRAMOXINE CREAM, DIET

MANAGE PROD TAB, CLEAN WIPE KIT) Bupivilog kit (TRIAMCINOLONE INJECTION, BUPIVACAINE

HCL INJECTION KIT) DermacinRX Inflammatral Pak (DICLOFENAC DELAYED-

RELEASE TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) DermacinRX Kit Silapak (TRIAMCINOLONE ACET CREAM,

DIMETHICONE CREAM, SILICONE TAPE) DermacinRX Lexitral (DICLOFENAC SOLUTION, CAPSAICIN

CREAM) DermacinRX surgical (CHLORHEXIDINE GLUCONATE 4%

SOLUTION) DermacinRX Ticanase Pak (FLUTICASONE NASAL

SUSPENSION, SODIUM CHLORIDE SPRAY) Derma SilkRX Anodynexa Pak (DICLOFENAC DELAYED-

RELEASE TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) Derma SilkRX Diclopak (DICLOFENAC DELAYED-RELEASE

TABLETS, CAPSAICIN CREAM) Derma SilkRX SDS Pak (TRIAMCINOLONE CREAM,

DIMETHICONE, SILICONE TAPE) DermaWerx Surgical Plus P (CHLORHEXIDINE SOL 4%-

MUPIROCIN, DIMETHICONE, TAPE KIT) DNA collection kit (LIDOCAINE ORAL SOLUTION, GLYCERIN

SWAB, BUCCAL SWAB) Genadur kit (DERMATOLOGICAL PRODUCTS MISC

TOPICAL/ORAL – KIT) Inflammacin (DICLOFENAC SODIUM, CAPSAICIN CREAM

THERA PACK) Morgidox (DOXYCYCLINE HYCLATE CAPSULES WITH

CLEANSER KIT) SanadermRX Skin Repair (TRIAMCINOLONE ACET

CREAM, DIMETHICONE CREAM, SILICONE TAPE) Silazone PharmaPak (TRIAMCINOLONE ACET CREAM,

SILICONE SHEET PACK)

• OTC Capsaicin patches, cream, gel




• Lidocaine 2% or 4% solution

• Voltaren 1% gel

• Generic Diclofenac 1.5% solution

• Generic topical steroids – alclomethasone,betamethasone, clobetasol, desonide,fluocinoline, fluocinonide, fluticasone,halobetasol, mometasone, triamcinolone

• Chlorhexidine gluconate solution

Rvs 3/13/2017 1 19199-‐3-‐2017

Rvs 3/13/2017 2 19199-‐3-‐2017

Excluded Drug List, Effective October 1, 2021

Documents

Transcript of Excluded Drug List, Effective October 1, 2021