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Medimpact Drug Exclusions October 1, 2020

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Medimpact Drug Exclusions October 1, 2020 MedImpact Drug Exclusions October 1, 2020 Formulary Exclusions Excluded Drug Preferred Alternative ADHANSIA XR Methylphenidate ER, dexmethylphenidate XR, Concerta, Mydayis ADLYXIN Ozempic, Rybelsus, Trulicity, Victoza, Byetta, Bydureon, Bydureon Bcise ADMELOG Humalog ADMELOG SOLOSTAR Humalog Kwikpen ADZENYS ER Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine, Vyvanse ADZENYS XR-ODT Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine, Vyvanse AEROSPAN Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler AIRDUO RESPICLICK Advair Diskus/HFA, Breo Ellipta, Symbicort (brand and authorized generic) AJOVY Aimovig, Emgality 120mg ALVESCO Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler APIDRA Humalog APIDRA SOLOSTAR Humalog Kwikpen APTENSIO XR Methylphenidate ER, dexmethylphenidate XR, Concerta, Mydayis ARMONAIR RESPICLICK Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler ARMONAIR DIGIHALER Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler BAFIERTAM Gilenya, Mavenclad, Mayzent, Tecfidera, Avonex, Betaseron, Copaxone, Glatiramer, Glatopa, Plegridy, Rebif, Vumerity, Aubagio BASAGLAR KWIKPEN U-100 Lantus, Toujeo, Tresiba, Levemir BECONASE AQ OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl BELBUCA Butrans BELVIQ/XR Contrave BEPREVE azelastine, olopatadine BEVESPI AEROSPHERE Anoro Ellipta, Stiolto Respimat BREZTRI AEROSPHERE Trelegy Ellipta CEQUA Restasis, Xiidra COTEMPLA XR-ODT Methylphenidate ER, dexmethylphenidate XR, Concerta, Mydayis DAYVIGO Zolpidem, zaleplon, eszopiclone, Belsomra DELZICOL (brand and generic) Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine DEXCOM, DEXCOM G4, DEXCOM G5, Dexcom G6 DEXCOM G5-G4 SENSOR DIPENTUM Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine DUAKLIR PRESSAIR Anoro Ellipta, Stiolto Respimat DULERA Advair Diskus/HFA, Breo Ellipta, Symbicort MedImpact.com 1 Copyright © 2020 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions October 1, 2020 Excluded Drug Preferred Alternative EMADINE azelastine, olopatadine ESTROGEL Divigel EVERSENSE SMART TRANSMITTER Dexcom G6 EXTAVIA Aubagio, Avonex, Betaseron, Copaxone, glatiramer, Gilenya, Glatopa, Mavenclad, Mayzent, Plegridy, Rebif, Tecfidera, Vumerity FREESTYLE LIBRE 10 DAY READER Dexcom G6 FREESTYLE LIBRE 10 DAY SENSOR FREESTYLE LIBRE 14 DAY READER FREESTYLE LIBRE 14 DAY SENSOR GENOTROPIN Norditropin GUARDIAN CONNECT TRANSMITTER Dexcom G6 GUARDIAN SENSOR 3 HUMATROPE Norditropin INVOKANA Jardiance, Farxiga INVOKAMET Synjardy, Synjardy XR, Xigduo XR INVOKAMET XR Synjardy, Synjardy XR, Xigduo XR JORNAY PM Methylphenidate ER, dexmethylphenidate XR, Concerta, Mydayis KAZANO Janumet, Janumet XR KEVZARA Enbrel, Humira, Rinvoq, Xeljanz, Xeljanz XR KOMBIGLYZE XR Janumet, Janumet XR LASTACAFT azelastine, olopatadine LYUMJEV, LYUMJEV KWIKPEN U-100, Humalog, Humalog Kwikpen LYUMJEV KWIKPEN U-200 MOTEGRITY Linzess NATESTO Testosterone Cypionate, Testosterone Enanthate, Testosterone transdermal, AStriant NESINA Januvia (brand and authorized generic) NOVOLIN N, NOVOLIN N FLEXPEN Humulin N, Humulin N Kwikpen NOVOLIN R, NOVOLIN R FLEXPEN Humulin R, Humulin R KwikPen NOVOLIN 70/30, NOVOLIN 70-30 Humulin 70/30, Humulin 70/30 Kwikpen FLEXPEN NOVOLOG, NOVOLOG KWIKPEN Humalog Kwikpen NOVOLOG MIX 70/30, NOVOLOG MIX Humalog Mix 75-25, Humalog Mix 75-25 Kwikpen 70/30 KWIKPEN NUTROPIN Norditropin NUTROPIN AQ Norditropin OLUMIANT Enbrel, Humira, Rinvoq, Xeljanz, Xeljanz XR OMNARIS OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl OMNITROPE Norditropin MedImpact.com 2 Copyright © 2020 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions October 1, 2020 Excluded Drug Preferred Alternative ONGLYZA Januvia OSENI Januvia, pioglitazone (brand and authorized generic) PANCREAZE Creon, Zenpep PAZEO azelastine, olopatadine PERTZYE Creon, Zenpep PRADAXA Eliquis, Xarelto QSYMIA Contrave QTERN Individual components: Jardiance, Synjardy/XR, Farxiga, Xigduo XR, Januvia, Janumet, Janumet XR RASUVO Otrexup SAIZEN Norditropin SAVAYSA Eliquis, Xarelto SAXENDA Contrave SEEBRI NEOHALER Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta SEGLUROMET Synjardy, Synjardy XR, Xigduo XR SEMGLEE Lantus, Levemir, Tresiba, Toujeo Solostar SIMPONI (50 mg) Cosentyx, Enbrel, Humira, Otezla, Rinvoq, Stelara, Tremfya, Xeljanz, Xeljanz XR STEGLATRO Jardiance, Farxiga STEGLUJAN Individual components: Jardiance, Synjardy/XR, Farxiga, Xigduo XR, Januvia, Janumet, Janumet XR SYMPROIC Linzess, Movantik TALTZ Cosentyx, Enbrel, Humira, Otezla, Skyrizi, Stelara, Tremfya, Xeljanz, Xeljanz XR TERIPARATIDE Forteo, Tymlos (Bonsity authorized generic) TRIJARDY XR Individual components: Farxiga, Xigduo XR, Jardiance, Synjardy, Synjardy XR, Janumet, Janumet XR, Januvia, metformin TRULANCE Linzess TUDORZA PRESSAIR Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta UTIBRON NEOHALER Anoro Ellipta, Stiolto Respimat VERAMYST Fluticasone RX/OTC, Flonase OTC, Mometasone VIEKIRA PAK Epclusa, Harvoni, Mavyret, Vosevi VIEKIRA XR Epclusa, Harvoni, Mavyret, Vosevi WIXELA INHUB Advair Diskus/HFA, Breo Ellipta, Symbicort YUPELRI Lonhala Magnair ZELNORM Linzess ZEPATIER Epclusa, Harvoni, Mavyret, Vosevi ZETONNA OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl ZOMACTON Norditropin MedImpact.com 3 Copyright © 2020 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions October 1, 2020 Non-Essential Drugs Excluded Drug Preferred Alternative ABSORICA, ABSORICA LD generic isotretinoin capsules ABSTRAL fentanyl citrate lozenge ACUICYN OTC OCuSOFT lid scrub, ocular antibiotics, OTC artificial tears ACTICOAT, ACTICOAT 7, OTC and other silver products ACTICOAT FLEX 3, ACTICOAT FLEX 7, ACTICOAT SURGICAL ADAPALENE SOLUTION Rx generic adapalene cream or lotion, Rx generic/OTC adapalene gel, EpiDuo, generic topical tretinoin AERONEB GO Aerochamber ALEVICYN/SPRAY GEL OTC emollients or creams, OTC generic hydrocortisone, OTC wound care products ALLEVYN, ALLEVYN ADHESIVE, OTC and other foam bandage products ALLEVYN HEEL ALLEVYN AG, ALLEVYN AG OTC and other foam bandage and silver products ADHESIVE, ALLEVYN AG GENTLE ALLZITAL generic butalbital/acetaminophen (50mg-325mg tablet) ALZAIR Chloraseptic Allergen Block AMRIX cyclobenzaprine (5mg or 10mg) AMZEEQ Oral doxy/minocycline, topical antibiotics for acne (e.g. dapsone, clindamycin) ANTARA fenofibrate, micronized/nanocrystallized APEXICON E Generic high potency topical steroid (e.g., fluocinonide 0.05%, betamethasone dipropionate 0.05%) APLENZIN bupropion extended release, bupropion AQUORAL OTC saliva mouthwash, powder, or spray/pump ARAZLO Other tazarotene, tretinoin, or adapalene products ASPIRIN/OMEPRAZOLE OTC aspirin, OTC omeprazole ASTERO topical lidocaine ATOPADERM OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids, OTC wound care products ATOPICLAIR OTC hyaluronate products AUGMENTIN generic amoxicillin/clavulanate suspension (125 mg/5 mL suspension) AUVI-Q Epi-Pen, generic epinephrine autoinjector, Symjepi AVENOVA OTC OCuSOFT lid scrub, ocular antibiotics, OTC artificial tears AVO CREAM OTC hyaluronate products, OTC wound dressings, barrier creams AZADROX OTC wound care preparations +/- urea and/or silver BALSAM PERU-CASTOR OIL OTC wound care products, barrier creams and ointments BEAU RX Kelocote, Recedo BENZACLIN generic clindamycin/benzoyl peroxide MedImpact.com 4 Copyright © 2020 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions October 1, 2020 Excluded Drug Preferred Alternative BENZEPRO generic or OTC topical benzoyl peroxide BENZONATATE (Solubiomix) generic benzonatate BIAFINE OTC hyaluronate products, OTC wound dressings, barrier creams BINOSTO alendronate, ibandronate BIONECT OTC hyaluronate products BIOSTEP OTC collagen dressings BIOSTEP AG OTC collagen dressings and silver products BOCASAL OTC saliva mouthwash, powder, or spray/pump BONJESTA OTC doxylamine, OTC pyridoxine BPCO OTC wound care products, barrier creams and ointments BRYHALI Generic halobetasol ointment or cream, clobetasol propionate; generic betamethasone augmented 0.05%; generic fluocinonide BUTALBITAL-ACETAMINOPHEN generic butalbital/acetaminophen (50 mg-325 mg tablet) (50 mg-300 mg capsules) BUTALBITAL-ACETAMINOPHEN Other butalbital products, such as generic (25 mg-325 mg tablets) butalbital/acetaminophen (50 mg-325 mg tablet). CAMBIA Diclofenac oral tablets, other generic NSAIDs CAROSPIR generic spironolactone tablets CELACYN OTC Mederma, OTC Scarguard MD, OTC ScarAway CELACYN POST PROCEDURE OTC moisturizing creams/cleansers CERACADE OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids CERAMAX OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion CHLORZOXAZONE 375 mg, 750 mg generic chlorozoxazone (500 mg tablets) CIRCUDERM OTC wound care products, barrier creams and ointments CONSENSI Generic amlodipine and celecoxib (individually) CONZIP generic tramadol extended-release capsules or tablets COREMINO generic immediate-release minocycline capsules or tablets, doxycycline DAXBIA Cephalexin DELUO OTC antiseptic cleansers DENAVIR Generic oral acyclovir, famciclovir, and valacyclovir DERMULCERA OTC wound care products, barrier creams and ointments DESVENLAFAXINE ER desvenlafaxine succinate ER, desvenlafaxine ER (Ranbaxy) DEXABLISS Regular (not in
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