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Drug Exclusions April 1, 2020

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Drug Exclusions April 1, 2020 Drug Exclusions April 1, 2020 Why Doesn’t My Health Plan Cover Some Providers Drugs? To request a formulary exception for a drug noted on the list with a (+), call 877-440-0089. To request a From time to time, our pharmacy committee decides formulary exception for all other listed drugs, call the to no longer cover, or exclude, some drugs because precertification number on the member’s ID card. other safe, effective, less costly alternatives are available. The committee is composed of independent Members doctors and pharmacists who regularly review and To request a formulary exception for all drugs listed, compare prescription drugs to ensure the ones we call the Customer Service number on your ID card. cover include proven medications for treating the Note: Formulary exceptions can only be considered majority of medical conditions. with required documentation from the member’s Newly-launched products and new variations of health care provider. products already on the market are not automatically added to your health plan’s list of covered drugs, also What Happens If I Have A Prescription Filled known as a formulary. A product can be added to the For An Excluded Drug? formulary only if our pharmacy committee decides You will be able to get your drug, but you will pay the that it is clinically appropriate and cost-effective. full cost of it. What Should I Do If My Drug Is Excluded? What Drugs Are Excluded From Coverage? Talk to your doctor to see if a covered alternative drug The drugs on the following pages are excluded from is a good option for treating your condition. Note that coverage as of the date of this list. many excluded brand-name drugs have covered Your pharmacy benefit may not cover certain generic alternatives. categories of drugs, such as those used to treat weight Of course, you and your doctor make the final decision loss or sexual dysfunction. Please check your plan about the medications that are right for you. If your materials for details about coverage for a specific drug doctor believes no alternative drug will work for your category. medical condition, you or your doctor can request a formulary exception to have an excluded drug covered. Just follow these steps: BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. 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. BlueChoice Drug Exclusions List – Effective 4/1/20 1 Excluded Drug List Specialty drugs are noted with a (#). A Austedo (#) Cardizem CD/LA (brand) Daxbia esterified Abilify (brand) Auvi-Q Carnitor/SF Defitelio (#) estrogen/methyl- Abilify Mycite Avar (brand) Carospir Deflux testosterone Absorica/LD Aveed (brand) Celacyn Delstrigo Eucrisa Acanya Avenova Cequa Denavir Eurax lotion Aciphex Ayvakit (#) Ceracade Dermatop (brand) Evekeo/ODT (brand) Acnefree Azelex (brand) Cerave Desloratadine Evenity (#) Acticlate (brand & Azesco Cholecal DF Dexchlorpheniramine Evivo generic) Azor (brand) Chlorzoxarone 250 mg syrup Evomela (#+) Acuicyn Azelaic Acid- Cicatrace Pad Dexeryl Exondys 51 (#) Aczone 5% (brand) Niacinamide Cream Ciclopirox-Clobetasol Dexilant Ezallor Adakveo (#) Azeschew Shampoo Dexpak Ciclopirox-Clobetasol- Dextenza (#) F Adapalene-Benzoyl B Peroxide- Salicylic Acid Dexycu Fasenra (#+) Baclofen 5 mg Shampoo Diclegis (brand and Fenoglide (brand) Clindamycin Gel Balcoltra fenoprofen (generic) Adapalene-Benzoyl Ciclopirox-Salicylic Acid generic) Peroxide- Baqsimi Shampoo Diclofenac Sodium- Fenortho (brand) Baxdela Cimetidine-Lidocaine- Sodium Hyaluronate- Fetroja Niacinamide Gel Beau Rx Fexofenadine Adderall (brand) Salicylic Acid Cream Niacinamide Gel Adhansia XR Belbuca Cinqair (#+) Diclofono fexofenadine- Benicar/HCT (brand) Clarinex/Clarinex-D Diflorasone cream and pseudoephedrine Adlyxin Bensal HP Finasteride-Minoxidil Admelog Claritin/Claritin-D oint. Adzenys XR Benz Per-Clindamycin- Clenpiq Dimercaptopropane- Firdapse (#) Niacinamide- Clindagel Sulfonate First Atenolol Aemcolo Tretinoin Gel suspension Aerospan Clindamycin Phos- Diuril Afstyla (#) Benzaclin (brand) Niacinamide- Divigel (brand) First-Lansoprazole Benzamycin (brand) Tretinoin Cream Doptelet (#) (excluded only for Airduo Benzepro (brand) members 17 years Ajovy Clindamycin Phosphate- Doryx/MPC (brand) Aklief Benzocaine-Lidocaine- Niacinamide Lotion Dovato and older) Tetracaine Oint 1-4% Doxepin cream First-Omeprazole Alavert Benzonatate 150 mg (excluded only for Alcortin A Clindamycin Phosphate- Doxycycline DR 80mg Aldara (brand) Beovu (#) Niacinamide Gel Drizalma members 17 years Betamethasone Clindamycin-Benzoyl Duaklir and older) Alevicyn Antipruritic/ Dipropionate- Flolipid Plus Peroxide-Niacinamide Duexis Allegra/Allegra-D Minoxidil Gel Duobrii Fluconazole-Ibuprofen- Betapace/AF tablet Clindamycin-Niacinamid- Durolane (#+) Itraconazole- Allzital Bevacizumab prefilled Terbinafine Aloquin Spironolac-Tretinoin Dutoprol Alora (brand) syr. (#) Gel Duzallo Fluocinolone Bevyxxa Clobetasol Propionate- Dxevo Acetonide- Altoprev (brand) Biafine Niacinamide Cream Altreno Levocetirizine Dihyd Dyanavel XR (brand) Alvesco Bijuva Shampoo Dyrenium capsule Fluocinonide 0.1% Binosto (brand) Clobetasol Propionate- cream Alzair Bionect E Fluoroplex (brand) Ameluz Niacinamide Amrix (brand) Bocasal oral rinse Cream/Oint/Soln Econazole Nitrate- Fluticasone/salmeterol Bonjesta Colcrys (brand) Niacinamide Cream inhaler Amzeeq Bortezemib (#) Edecrin (brand) Folene Andexxa Consensi Androgel 1.62% (brand) Brineura (#) Conzip (brand) Edex Folika-V Briviact Cortaid max. strength EES granules Folite Android-10 (brand) Bromsite Effexor XR (brand) Folvite-FE Annovera Cotempla Antara (brand) Brukinsa (#) Crysvita (#+) Efudex (brand) Forfivo XL (brand) Bryhali Cuprimine Elestrin (brand) Fortamet (brand & Apadaz Bunavail (brand) Eletone generic) Aplenzin Cutaquig (#) Aptensio XR (brand) Bupap (brand) Cuvitru (#+) Emflaza (#) Fulphila (#+) Bupivacaine HCL Cyclobenzaprine ext rel Endari Fungoid-D Arakoda (#) Butalbital/APAP 50/300 Enhertu (#) Arestin Cyfolex G Arikayce (#) Byvalson Cymbalta (brand) Enstilar Cytomel (brand) Entty Spray Emulsion Gamifant (#) Armonair Respiclick C Envarsus XR (#) Gatifloxacin Arymo ER Cafergot tablet D dexamethasone Asacol HD (brand) Epaned (brand) Calcipotriene-Clobetasol D.H.E. (brand) Epiceram Gelclair Gel Asceniv (#) Propionate Daklinza (#) EpiPen/EpiPen Jr. Gelsyn (#+) Asparlas (#) Caldolor Genadur Atacand/HCT (brand) Dandelion Allergenic (brand) Cambia Extract EryPed susp. 200 & 400 Genvisc (#+) Ativan (brand) Candida Albicans Extract Dapsone-Niacinamide mg Giazo (brand) Atopiclair Caplyta Gloperba Atralin Gel Esomeprazole Carac (brand & generic) Dapsone-Niacinamide- Esperoct Glumetza (brand & Atrapro spray/gel/kit Carbinoxamine 6 mg Spironolactone Gel generic) Aurstat BlueChoice Drug Exclusions List – Effective 4/1/20 2 Glycopyrrolate 1.5mg J Luzu Niacinamide- Pennsaid 1.5% & 2% Gocovri Jatenzo Lyrica CR Triamcinolone solution GPL Pak Acetonide Cream Pepcid (brand) Jivi (#+) M Gralise (brand) Jornay PM Niacinamide-Tazarotene Pexeva (brand) Gvoke PFS Jublia Macrilen (#) Cream Phenol Macrodantin capsules Niacinamide-Tretinoin Pifeltro H Juluca Jynarque (#) Mavenclad (#) Cream/Gel Piqray (#+) Hemlibra (#) Mayzent (#) Niacinamide- Plaquenil (brand) Herzuma (#) K Mepsevii (#) Spironolactone- Plavix (brand) Horizant (brand) Kadian (brand) Metformin ER (only Tretinoin Gel Plenvu HPR Plus Kamdoy excluded when Nilandron Plexion/Cleanser HPR Plus MB Hydrogel Kanjinti (#+) prescribed as a Nitro-Dur (brand) (brand) Kit Kapspargo generic for brand Nitroglycerin lingual Polivy (#) Hyaluronate Sodium- Katerzia Fortamet or brand (brand) Portrazza (#) Niacinamide- Kelarx (silicone) Scar Glumetza) Nitrolingual Pred-Gati Tacrolimus Care Gel Methionine-Inos- Nitromis Prednisone Intensol Hyaluronate Sodium- Kerydin Choline-Levocarn Nityr (#) (brand) Niacinamide- Ketoconazole 2% foam Methylcobala Nivatopic Plus Pregenna Tretinoin Ketoconazole- Methylphenidate 72 Nivestym (#+) Prenara Hycofenix (brand) Hydrocortisone mg ER Nocdurna (#) Pretomanid Hydrisalic Cream Miacalcin injection/ Noctiva Prevacid Hydrocodone 2.5mg/ Ketamine HCL nasal spray Noritate Prevymis (#) guaifenesin 200mg Keveyis (#) Micort Nourianz Prilopentin hydrocortisone 1% in Kevzara (#+) Microvix LP Novacort Prilosec asorbase Khapzory (#) Midaz/ketamine troche/ Nubeqa (#+) Primlev Hydroquinone Kinerase ondansetron Nucala (#+) Pristiq (brand) Emulsion Klor-Con oral pack for Midazolam Nuplazid (#+) Probuphine Hydroquinone- solution Migranal (brand) Nurtec Procentra (brand) Hydrocortisone Kovaltry (#+) Millipred/DP Nutraderm Progesterone- Emulsion Krintafel Minastin 24FE (brand) Nutraplus Minoxidil Hydroquinone- Kymriah (#) Minitran (brand) Nutraseb Prolensa Hydrocortisone- Minivelle (brand) Nuvail Promiseb Tretinoin Emulsion L Minocin (brand) Nuvigil (brand) Protexa Hylatopic Plus Lactinol HX Minolira ER Nuwiq (#+) Protonix Hymovis (#+) Lactic Acid-Niacinamide Minoxidil-Progesterone- Nuzyra Proventil HFA Tretinoin Provigil (brand) I Cream O Lactulose oral packet Mircera (#) Prozac (brand) IBU 600-EZS 10gm Mitigare (brand) Ocaliva (#+) Pulmicort Respules Idelvion (#) Lanoxin 125 & 250 mcg Monodox (brand) Ocean for Kids (brand) Idhifa (#+) tablet Monodoxyne (brand) Odactra Pyridostigmine tablet Ilumya (#) Lansoprazole
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