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B2B Vigilant Drug Program Non-Essential Medication List

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B2B Vigilant Drug Program Non-Essential Medication List OptumRx Vigilant Drug Program Non-essential drug strategy Effective January 1, 2021 Thousands of medications are available today with even more entering the market — sometimes at a higher cost without additional value. OptumRx can help ensure that your pharmacy benefit dollars cover only the most clinically appropriate and affordable medications. Non-essential drug strategy* — Excludes select products that are available in the market but may not be approved by the U.S. Food and Drug Administration (FDA) or are deemed non-essential by the OptumRx Pharmacy & Therapeutics (P&T) Committee. These high-dollar products offer little clinical value versus other well-tested, FDA-approved agents. *Programs are also available for clients who prefer prior authorization rather than an exclusion strategy. Drug Name Drug Name 1ST MEDX-PATCH/ LIDOCAINE EXTERNAL adenosine (diagnostic) PATCH 4-0.0375-5-20 % ADRENALIN NASAL 7T GUMMY ES ADVANCED ALLERGY COLLECTION 7T LIDO ADVANCED BASE PLUS ACACIA SUBCUTANEOUS ADYPHREN ACCUCAINE ADYPHREN AMP ACESO AG ADYPHREN AMP II ACREMONIUM ADYPHREN II ACTICOAT 7 AGONEAZE ACTICOAT ABSORBENT AKOVAZ ACTICOAT ANTIMICROBIAL ALA-QUIN ACTICOAT EXTERNAL SHEET 16"X16" , ALBA-DERM 4"X48" , 4"X8" , 5"X5" , 8"X16" ALBUTEROL SULFATE INHALATION ACTICOAT FLEX 3 NEBULIZATION SOLUTION (5 MG/ML) 0.5% ACTICOAT FLEX 3 4"X4" alcohol injection ACTICOAT FLEX 7 ALCORTIN A ACTICOAT MOISTURE CONTROL ALDER EXTERNAL PAD 4"X4" , 4"X8" ALEVAMAX ACTICOAT SITE ALEVICYN ANTIPRURITIC ACTIVASE ALEVICYN ANTIPRURITIC SG EXTERNAL ACTIVE INJECTION BLM-1 GEL ACTIVE INJECTION BM ALEVICYN DERMAL SPRAY ACTIVE INJECTION D ALLEVYN AG NON-ADHESIVE EXTERNAL ACTIVE INJECTION DL PAD 8"X8" ACTIVE INJECTION DLM ALMOND (DIAGNOSTIC) ACTIVE INJECTION KET-L ALPAWASH ACTIVE INJECTION KETMARC-L ALTADERM ACTIVE INJECTION KIT L ALTAFLUOR ACTIVE INJECTION KL-3 ALTERNARIA ACTIVE INJECTION KM ALZAIR ALLERGY NASAL SPRAY ACTIVE INJECTION LM-2 AMELUZ ACTIVE INJECTION LM-DEP-1 AMERICAN BEECH ACTIVE INJECTION LM-DEP-2 AMERICAN COCKROACH ACTIVE INJECTION M-1 AMERICAN ELM ACTIVE-PAC/GABAPENTIN AMERICAN SYCAMORE ACTIVITE aminoamrms ACUICYN EXTERNAL SOLUTION aminobenzoate potassium oral packet ACUNOL aminoreliefrms ADAPALENE-BENZOYL PER-CLINDAMY AMMONIA N 13 ADAPALENE-BENZOYL PER-NIACINAM AMYTAL SODIUM 2 Drug Name Drug Name ANACAINE ATRAPRO CP ana-lex ATRAPRO HYDROGEL ANALPRAM HC EXTERNAL atropine sulfate injection solution 0.4 mg/ml, 1 ANALPRAM HC SINGLES EXTERNAL mg/ml, 8 mg/20ml ANASTIA atropine sulfate injection solution prefilled syringe 0.5 mg/5ml, 1 mg/10ml ANDEXXA ATROPINE SULFATE OPHTHALMIC ANIMI-3 SOLUTION 0.01 % ANIMI-3/VITAMIN D AUREOBASIDIUM ANJESO AUREOBASIDIUM PULLULANS ANODYNE LPT AUSTRALIAN PINE anucort-hc AUXIPRO VANISHING ANUSOL-HC RECTAL SUPPOSITORY AVAR CLEANSER APOTHESAR 2 AVAR EXTERNAL FOAM APOTHESAR PLUS AVAR EXTERNAL PAD APOTHESIL AVAR LS APPLE (DIAGNOSTIC) AVAR LS CLEANSER APRIZIO PAK AVAR-E EMOLLIENT APRIZIO PAK II AVAR-E GREEN AQUORAL MOUTH/THROAT SOLUTION AVAR-E LS ARESTIN AVENOVA argatroban in sodium chloride intravenous AVIDOXY DK solution 125-0.9 mg/125ml-%, 50-0.9 mg/50ml- % AVOCADO (DIAGNOSTIC) ARIDA AXIFOL ARIDOL AZALGIA ARIZONA CYPRESS AZEDRA DOSIMETRIC ARZOL SILVER NIT APPLICATORS AZEDRA THERAPEUTIC ASCOR AZELAIC ACID-NIACINAMIDE ASCORBIC ACID INTRAVENOUS AZESCHEW PRENATAL/POSTNATAL ASCORBIC ACID SOLUTION 500 MG/ML AZESCO INJECTION B-12 COMPLIANCE INJECTION ascorbic acid solution 500 mg/ml injection BACTERIOSTATIC WATER(PARABENS) ASPERGILLUS FUMIGATUS INJECTION BAFIERTAM ASPERGILLUS FUMIGATUS INTRADERMAL BAHIA SOLUTION 1:20 BAL-CARE DHA ASTERO BALD CYPRESS ASTRINGYN BANANA (DIAGNOSTIC) ATOPADERM BASADROX ATOPAVO BASE W301 ATOPICLAIR BAYBERRY (WAX MYRTLE) 3 Drug Name Drug Name B-COMPLEX INJECTION BIO GLO BEAU RX BIOFREQUENCY INSOLES BEEF (DIAGNOSTIC) BIONECT EXTERNAL CREAM belladonna alkaloids-opium BIONECT EXTERNAL GEL BENSAL HP bio-statin oral powder BENZ PER-CLIND-NIACIN-TRETIN BIOSTEP BENZAC AC WASH EXTERNAL LIQUID BIVALIRUDIN RTU BENZEFOAM BIVALIRUDIN-SODIUM CHLORIDE BENZEFOAMULTRA BLACK WALNUT POLLEN BENZEPRO CREAMY WASH BLACK WILLOW BENZEPRO EXTERNAL BOCASAL BENZEPRO EXTERNAL FOAM 5.2 %, 9.7 % BOTRYTIS benzepro external foam 5.3 % BOTRYTIS CINEREA BENZEPRO EXTERNAL LIQUID BOX ELDER BENZEPRO FOAMING CLOTHS bp 10-1 BENZEPRO SHORT CONTACT BP CLEANSING WASH BENZODOX bp foam benzoin compound bp wash external liquid 2.5 %, 7 % benzoin external tincture bpo BENZO-LIDOCAINE-TETRACAINE BRETYLIUM TOSYLATE INJECTION BENZOYL PEROX-HYDROCORTISONE BRIDION benzoyl peroxide external foam 9.8 % BRIMONIDINE-DORZOLAMIDE BENZOYL PEROXIDE EXTERNAL GEL 6.5 BROME %, 8 % BROMPHENIRAMINE MALEATE BENZOYL PEROXIDE FORTE- HC INTRAMUSCULAR BERMUDA GRASS BT INJECTION BESER EXTERNAL KIT BUPIVACAINE HCL INJECTION SOLUTION BETA 1 KIT 0.125 %, 312.5 MG/10ML BETALIDO BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0.125 % (50 ML), 125 BETALOAN SUIK MG/4ML, 250 MG/8ML, 312.5 MG/10ML, 625 BETAMETHASONE COMBO MG/20ML BETAMETHASONE DIPROP-MINOXIDIL BUPIVILOG BETAMETHASONE SOD PHOS & ACET CADIRAMD BETAMETHASONE SODIUM PHOSPHATE CAFFEINE-SODIUM BENZOATE INJECTION CALCIPOTRIENE-CLOBETASOL PROP BEVACIZUMAB calcium chloride BHI URI-CONTROL CALCIUM GLUCONATE SOLUTION 10 % BIIFENAC 1000 INTRAVENOUS BIIFENAC 500 calcium gluconate solution 10 % intravenous 4 Drug Name Drug Name CALCIUM GLUCONATE-NACL CERIANNA INTRAVENOUS SOLUTION 2-0.675 cerovel external lotion GM/100ML-% cervical specimen collection CALCIUM-FOLIC ACID PLUS D CETACAINE EXTERNAL AEROSOL CALIFORNIA PEPPER TREE CETACAINE EXTERNAL LIQUID CANDIDA ALBICANS EXTRACT CHEW-HESIVE CANTALOUPE (DIAGNOSTIC) CHICKEN MEAT (DIAGNOSTIC) CANTHARIDIN EXTERNAL CHOLECAL DF CAPHOSOL MOUTH/THROAT SOLUTION CHONDROITIN SULFATE OPHTHALMIC CAPSFENAC PAK CHRYSADERM DAY CAPSINAC CHRYSADERM NIGHT CARDIOPLEGIA DEL NIDO FORMULA CICASIL CARDIOPLEGIA IND PLASMA HIGH K CICATRACE PAD CARDIOPLEGIA IND PLASMA-TROMET ciclopirox treatment CARDIOPLEGIA INDUCTION HIGH K CICLOPIROX-CLOBETASOL CARDIOPLEGIA INDUCTION LOW DEX CICLOPIROX-CLOBETASOL-SAL ACID CARDIOPLEGIA INDUCTION NON-ENR CICLOPIROX-SALICYLIC ACID CARDIOPLEGIA MAIN LOW DEXTROSE CIFEREX CARDIOPLEGIA MAIN LOW TROMETHA CIFRAZOL CARDIOPLEGIA MAIN PLASMA-TROME CIMETIDINE-LIDO-SALICYLIC ACID CARDIOPLEGIA MAINTENANCE cisatracurium besylate (pf) intravenous CARDIOPLEGIA REPERFUSATE 4:1 solution 10 mg/5ml CARDIOVID PLUS cisatracurium besylate intravenous solution 20 CARRASYN HYDROGEL WOUND DRESS mg/10ml, 200 mg/20ml CASEIN (DIAGNOSTIC) CITRANATAL 90 DHA ORAL 90-1 & 300 MG CAT HAIR EXTRACT CITRANATAL ASSURE ORAL 35-1 & 300 MG CATHFLO ACTIVASE CITRANATAL B-CALM CATTLE EPITHELIUM CITRANATAL BLOOM CEDAR ELM CITRANATAL BLOOM DHA CEFTRI-IM CITRANATAL DHA CEFTRISOL PLUS CITRANATAL ESSENCE CEFUROXIME SODIUM-NACL CITRANATAL HARMONY ORAL CAPSULE CELA BASE 27-1-260 MG CELACYN CITRANATAL MEDLEY CELLPAD CITRANATAL RX CEM-UREA CLADOSPORIUM CLADOSPORIOIDES CENTANY AT CLADOSPORIUM SPHAEROSPERMUM CERACADE clariscan CERAMAX CLIN SINGLE USE CLINDACIN ETZ EXTERNAL KIT 5 Drug Name Drug Name CLINDACIN PAC DAPSONE-NIACINAMIDE-SPIRONOLAC CLINDAMY-BENZOYL PER-NIACINAM DAVITE CLINDAMYCIN PHOS-NIACINAMIDE DEBACTEROL CLINDAMYCIN-NIACIN-TRETINOIN DEFITELIO CLIND-NIACIN-SPIRONOLAC-TRETIN dehydrated alcohol injection CLINIMIX N9G20E DELUO CLOBETASOL PROP-LEVOCETIRIZINE DERMACINRX ANALGESIC COMBOPAK CLOBETASOL PROP-NIACINAMIDE DERMACINRX AZENASE PAK CLODAN EXTERNAL KIT DERMACINRX CINLONE-I CPI CLOPIDOGREL & ASPIRIN DERMACINRX CLORHEXACIN COATAMAX PATCH DERMACINRX DUOPATCH PHARMAPAK COCAINE HCL NASAL DERMACINRX EMPRICAINE COCKLEBUR DERMACINRX LEXITRAL PHARMAPAK COCOA BEAN (DIAGNOSTIC) DERMACINRX NEUROTRAL PHARMAPAK COLCIGEL DERMACINRX PHN COLLATYL DERMACINRX PRIZOPAK CONTRAST ALLERGY PREMED PACK DERMACINRX PUREFOLIX CONVENIENCE PAK DERMACINRX SURGICAL COMBOPAK COPASIL EXTERNAL DERMACINRX SURGICAL PHARMAPAK CORN POLLEN DERMACINRX THERAZOLE PAK CORTANE-B EXTERNAL DERMACINRX TICANASE PAK COVARYX DERMACINRX TOPICAL BASE COVARYX HS DERMACINRX ZRM CO-VERATROL DERMASORB HC CRAB (DIAGNOSTIC) DERMASORB TA CREAM BASE DERMASORB XM CREAM BASE NIOSOMES DERMAZENE CREAM CONCENTRATE DERMAZYL CREAM-HEAVY BASE NIOSOMES DEXAMETHASONE ACE & SOD PHOS C-TOPICAL DEXAMETHASONE SOD PHOS-BUPIV CURVULARIA DEXAMETHASONE-MOXIFLOXACIN CUSHING SYNDROME DIAGNOSTIC DEXAMETH-MOXIFLOX-KETOROLAC CUTIS PLUS DEXERYL cyclobenzaprine hcl oral tablet 10 mg DEXIFOL CYCLOSPORINE IN KLARITY DEXLIDO CYSTADANE DEXLIDO-M cytra k crystals dexmedetomidine hcl in nacl intravenous DANDELION solution 200 mcg/50ml, 400 mcg/100ml DAPSONE-NIACINAMIDE DEXOPIN 6 Drug Name Drug Name DEXTENZA DUET DHA 400 DFS DR/MS/MENTH/CAP PAK DUET DHA BALANCED ORAL 25-1 & 267 MG DFS/MS/MENTH/CAP PAK DURACHOL DIAB EXTERNAL GEL DURYSTA DIAB F.D.G. FREEZE-DRIED DUST MITE MIXED ALLERGEN EXT DICLO GEL DYNABAC 5.0 DICLO GEL WITH XRYLIX SHEETS DYURAL-40 TRANSDERMAL DYURAL-80 diclofenac sodium transdermal gel 3 % DYURAL-L DICLOFENAC-NA HYALURON-NIACIN DYURAL-LM diclofex dc EASTERN COTTONWOOD DICLOFONO ECONASIL diclopak ECONAZOLE NITRATE-NIACINAMIDE DICLOPR ECZEMOL diclosaicin EEMT DICLOSTREAM EEMT HS DICLOTREX effervescent pot chloride DICLOVIX EGG WHITE (DIAGNOSTIC) DICLOVIX M EHA DICLOZOR ELCYS DILTIAZEM HCL-DEXTROSE INTRAVENOUS ELETONE SOLUTION 125-5 MG/125ML-% ELETONE TWINPACK DIMENTHO ELLZIA PAK DIMERCAPTOPROPANE-SULFONATE EMERPHED DITHOL EMOLIVAN DIVISTA EMOLLIENT BASE DMSA EMPRICAINE-II DMT SUIK EMULSION SB DOG EPITHELIUM ENBRACE HR DOG FENNEL ENGLISH PLANTAIN DONNATAL ENGYSTOL INJECTION DOTAREM ENLYTE DOTATOC GA 68 ENTERO VU ORAL SUSPENSION 24 % DOUBLEDEX ENTTY SPRAY EMULSION DRECHSLERA ENZADYNE DRITHO-CREME
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