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Excluded Drug List Excluded Drug List The following drugs are excluded from coverage as they are not approved by the FDA ACTIVE-PREP KIT I (FLURBIPROFEN-CYCLOBENZAPRINE CREAM COMPOUND KIT) ­ ACTIVE-PREP KIT II (KETOPROFEN-BACLOFEN-GABAPENTIN CREAM COMPOUND KIT) ­ ACTIVE-PREP KIT III (KETOPROFEN-LIDOCAINE-GABAPENTIN CREAM COMPOUND KIT) ­ ACTIVE-PREP KIT IV (TRAMADOL-GABAPENTIN-MENTHOL-CAMPHOR CREAM COMPOUND KIT) ­ ACTIVE-PREP KIT V (ITRACONAZOLE-PHENYTOIN SODIUM CREAM CMPD KIT) ­ ADAZIN CREAM (BENZO-CAPSAICIN-LIDO-METHYL SALICYLATE CRE) ­ AFLEXERYL-LC PAD (LIDOCAINE-MENTHOL PATCH) ­ AFLEXERYL-MC PAD (CAPSAICIN-MENTHOL TOPICAL PATCH) ­ AIF #2 DRUG PREPERATION KIT (FLURBIPROFEN-GABAPENT-CYCLOBEN-LIDO-DEXAMETH CREAM COMPOUND KIT) ­ AGONEAZE (LIDOCAINE-PRILOCAINE KIT) ­ ALCORTIN A (IODOQUINOL-HYDROCORTISONE-ALOE POLYSACCHARIDE GEL) ­ ALEGENIX MIS (CAPSAICIN-MENTHOL DISK) ­ ALIVIO PAD (CAPSAICIN-MENTHOL PATCH) ­ ALODOX CONVENIENCE KIT (DOXYCYCLINE HYCLATE TAB 20 MG W/ EYELID CLEANSERS KIT) ­ ANACAINE OINT (BENZOCAINE OINT) ­ ANODYNZ MIS (CAPSAICIN-MENTHOL DISK) ­ APPFORMIN/D (METFORMIN & DIETARY MANAGEMENT CAP PACK) ­ AQUORAL (ARTIFICIAL SALIVA - AERO SOLN) ­ ATENDIA PAD (LIDOCAINE-MENTHOL PATCH) ­ ATOPICLAIR CRE (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ Page 1 of 9 Updated JANUARY 2017 Excluded Drug List AURSTAT GEL/CRE (DERMATOLOGICAL PRODUCTS MISC) ­ AVALIN-RX PAD (LIDOCAINE-MENTHOL PATCH) ­ AVENOVA SPRAY (EYELID CLEANSER-LIQUID) ­ BENSAL HP (SALICYLIC ACID & BENZOIC ACID OINT) ­ CAMPHOMEX SPRAY (CAMPHOR-HISTAMINE-MENTHOL LIQD SPRAY) ­ CAPSIDERM PAD (CAPSAICIN-MENTHOL PATCH) ­ CAPTRACIN (CAPSAICIN-MENTHOL PATCH) ­ CETACAINE AER (BUTAMBEN-TETRACAINE-BENZOCAINE AEROSOL SPRAY) ­ CHEMSIL K-12 PST (PASTE BASE) ­ CHEMSIL K-51 (GEL BASE) ­ CHEW-HESIVE OIN (GELATIN) ­ CICLOPIROX TOPICAL SOLN KIT (CICLOPIROX SOLUTION 8% & VITAMIN E 5% TOPICAL) ­ CIDALEAZE CRE (LIDOCAINE CREAM) ­ CURE-ALL CRE (DERMATOLOGICAL PRODUCTS MISC) ­ DERMACINRX CINLONE PAK (TRIAMCINOLONE INJ-LIDOCAINE/PRILOCAINE CREAM) ­ DERMACINRX INFLAMAATRAL PAK (DICLOFENAC-RANITIDINE-CAPSAICIN CR THPK) ­ DERMACINRX LEXITRAL THERAPY PAK (DICLOFENAC SOLN-CAPSAICIN CREAM) ­ DERMACINRX SILAPAK (TRIAMCINOLONE CREAM-DIMETHICONE CREAM-SILICONE TAPE) ­ DERMACINRX SILAZONE PAK (TRIAMCINOLONE CREAM-SILICONE SHEET) ­ DERMACINRX SURGICAL COMBO PAK (CHLORHEXADINE-DIMETHICONE-SILICONE TAPE-HOMEOPATHIC KIT) ­ DERMA SILKRX ANODYNEXA PAK (DICLOFENAC-RANITIDINE-CAPSAICIN CR TRPK) ­ DERMACINRX ZRM (LIDOCAINE PATCH-EMOLLIENT CREAM) ­ DIPENTOCAINE CRE (DICLOFENAC-GABAPENTIN-LIDOCAINE CREAM COMPOUND KIT) ­ DS PREP PAK (DICLOFENAC GEL 1% & BENZALK CL WIPE THERAPY PACK) ­ DSG PAK (DICLOFENAC GEL 1% & OCCLUSIVE DRESSING THERAPY PACK) ­ DYNAMIC/PLUS PAK (LIDOCAINE 2%, LEMON GLYCERIN SWABS, BUCCAL SWAB STICK, & LATEX GLOVES) ­ Page 2 of 9 Excluded Drug List ELENZAPATCH DIS (LIDOCAINE-MENTHOL PATCH) ­ ELETONE CRE (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ ENDOXCIN PAD (LIDOCAINE-MENTHOL PATCH) ­ ENOVARX-AMITRIPTYLINE (AMITRIPTYLINE CREAM 2% COMPOUND KIT) ­ ENOVARX-BACLOFEN (BACLOFEN CREAM 1% COMPOUND KIT) ­ ENOVARX-CYCLOBENZAPRINE (CYCLOBENZAPRINE TD CREAM 20MG/GR COMPOUND KIT) ­ ENOVARX-IBUPROFEN (IBUPROFEN CREAM 10% COMPOUNDING KIT) ­ ENOVARX-LIDOCAINE (LIDOCAINE CREAM 10% COMPOUND KIT) ­ ENOVARX-NAPROXEN (NAPROXEN CREAM 10% COMPOUND KIT) ­ EQUIPTO-AMITRIPTYLINE (AMITRIPTYLINE CREAM 2% COMPOUND KIT) ­ EQUIPTO-BACLOFEN (BACLOFEN CREA 2% COMPOUND KIT) ­ EQUIPTO-NAPROXEN (NAPROXEN CREAM 10% COMPOUND KIT) ­ FLEXIN PAD (CAPSAICIN-MENTHOL PATCH) ­ FLEXIZOL COMBIPAK (DICLOFEN DR TAB 75MG-RANITIDINE TAB 150MG-LIDO CR) ­ GAPEAM BUDIBAC (GABAPENTIN-PENTOXYFYLLINE-AMANTADINE-BUPIVACAINE-DICLOFENAC-BACLOFEN- CYCLOBENZAPRINE COMPOUND KIT) ­ GELCLAIR (POVIDONE-SODIUM HYALURONATE-GLYCYRRHETINIC ACID GEL) ­ GENADUR (DERMATOLOGICAL PRODUCTS MISC) ­ HALAC (HALOBETASOL PROP OINT 0.05% & AMMONIUM LACTATE LOT 12% KIT) ­ HEAL AID CRE PLUS (DERMATOLOGICAL PRODUCTS MISC) ­ HPR PLUS CRE (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ HYLATOPIC CRE PLUS (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ INFLA-EAZE (DICLOFENAC 1% GEL W/ GLOVES AND WIPES) ­ IMFLAMMA-K KIT (DICLOFENAC TD SOLN 1.5% & CAMPH-MEN-METHYL SAL PATCH KIT) ­ INOVA/KIT (BENZOYL PEROXIDE PAD 4% & VITAMIN E TOPICAL 5% KIT/BENZOYL PEROX PAD 4% & SALICYLIC AC PAD 1% & VIT ­ E 5% KIT ) ­ K2K PAIN RELIEVING PATCH (LIDOCAINE-MENTHOL PATCH) ­ Page 3 of 9 Excluded Drug List LENZAPATCH DIS (LIDOCAINE-MENTHOL PATCH) ­ LEVATIO PAD (CAPSAICIN-MENTHOL PATCH) ­ LIDENZA PAD (LIDOCAINE-MENTHOL PATCH) ­ LIDODEXTRAPI PAD (LIDOCAINE-MENTHOL PATCH) ­ LIDOPIN CRE (LIDOCAINE CREAM 3%) ­ LIDOVIN CRE (LIDOCAINE CREAM) ­ LIDOZOL CRE (LIDOCAINE CREAM) ­ LIMENCIN PATCH (LIDOCAINE-MENTHOL PATCH) ­ LIVIXIL PAK (LIDOCAINE-PRILOCAINE CREAM KIT WITH OCCLUSIVE DRESSING) ­ LORENZA PAD (LIDOCAINE-MENTHOL PATCH) ­ LP LITE KIT (LIDOCAINE-PRILOCAINE CREAM KIT) ­ LUXAMEND CRE (WOUND DRESSING CREAM) ­ MAC PATCH (CAPSAICIN-MENTHOL TOPICAL PATCH) ­ MEDI-PATCH PAD RX (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SAL PATCH) ­ MEDROX PAD (CAPSAICIN-MENTHOL TOPICAL PATCH) ­ MEDROX OINT (CAPSAICIN-MENTHOL-METHYL SALICYLATE OINT) ­ MENTHOCIN PAD (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SAL PATCH) ­ MENTHOLIX (LIDOCAINE-MENTHOL LIQUID SPRAY) ­ MEGRIX (CAPSAICIN-MENTHOL DISK) ­ MIGRYL MIS (CAPSAICIN-MENTHOL DISK) ­ NAZIREX CRE (LEVOCETIRIZINE-LORATADINE CREAM COMPOUND KIT) ­ NEUTRASAL (ARTIFICIAL SALIVA – PACKET) ­ NEUVAXIN PAD (CAPSAICIN-MENTHOL PATCH) ­ NEOSALUS CRE (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ NIVATOPIC CRE (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ PAIN RELIEF PAD PATCH (CAPSAICIN-MENTHOL TOPICAL PATCH) ­ Page 4 of 9 Excluded Drug List PALLERIX MIS (CAPSAICIN-MENTHOL DISK) ­ PROLIDA (LIDOCAINE-MENTHOL PATCH) ­ PROVENZA (LIDOCAINE-MENTHOL PATCH) ­ PRUCLAIR CRE (DERMATOLOGICAL PRODUCTS MISC – CREAM) ­ PRUMYX CRE (DERMATOLOGICAL PRODUCTS MISC) ­ PUROXCIN PAD (LIDOCAINE-MENTHOL PATCH) ­ QROXIN PAD (CAPSAICIN-MENTHOL PATCH) ­ RECEDO GEL (SCAR TREATMENT PRODUCTS – GEL) ­ RECIPHEXAMINE DIS (LIDOCAINE-MENTHOL PATCH) ­ RELADOR PAK (LIDOCAINE-PRILOCAINE CREAM KIT WITH OCCLUSIVE DRESSING) ­ RELEEVIA PAD (CAPSAICIN-MENTHOL PATCH) ­ RELYYKS (LIDOCAINE-MENTHOL PATCH) ­ RELYYT DIS (CAPSAICIN-MENTHOL PATCH) ­ REMAXAZON PAD (LIDOCAINE-CAPSAICIN-CHONDROITIN-GLUCOS PATCH) ­ RENOVO PAD (CAPSAICIN-MENTHOL PATCH) ­ RENUU PAD (ALLANTOIN-LIDOCAINE-PETROLATUM PATCH) ­ REXAPHENAC CRE (DICLOFENAC CREAM 1%) ­ RRB PAK (BETAMETHASONE 0.05% & ROSS RU SD WOUND CARE HYDROGEL) ­ SALEX CREAM KIT (SALICYLIC ACID CREAM 6% & CLEANSER LIQD KIT) ­ SALICYCLIC AC KIT (SALICYLIC ACID CREAM 6% & CLEANSER LIQD KIT) ­ SCAR PATCH PAD (ALLANTOIN-LIDOCAINE-PETROLATUM PATCH) ­ SILMANIX CRE (CAPSAICIN-MENTHOL-HISTAMINE CREAM) ­ SILVERA PAIN RELIEF PATCH (CAPSAICIN-LIDOCAINE-MENTHOL PATCH) ­ SINELEE PAD (CAPSAICIN-MENTHOL PATCH) ­ SOLAICE PAD (CAPSAICIN-MENTHOL PATCH) ­ SOLMARA PAD (LIDOCAINE-MENTHOL PATCH) ­ Page 5 of 9 Excluded Drug List SPECIMEN COLLECTION KIT (FUROSEMIDE 20MG & URINE COLLECTION KIT) ­ SUMAXIN CP KIT (SULFACETAMIDE SOD-SULFUR PAD 10-4% & SKIN CLEANSER KIT) ­ SYNVEXIA PAD/CRE (LIDOCAINE-MENTHOL PATCH/CREAM) ­ TEROCIN PATCH (LIDOCAINE-MENTHOL PATCH) ­ TETRAMEX SPR (TETRACAINE-MENTHOL-CAMPHOR LIQD SPRAY) ­ TETRIX CRE (DERMATOLOGICAL PRODUCTS MISC) ­ TRETIN-X CRE KIT (TRETINOIN CREAM 0.1% W/ CLEANSER & MOISTURIZER KIT) ­ TROPAZONE CREAM/LOTION (WOUND DRESSINGS – CREAM/LOTION) ­ VELMA PAD (METHYL SALICYLATE-LIDOCAINE-MENTHOL PATCH) ­ VELTRIX CRE (LIDOCAINE-MENTHOL CREAM) ­ VENIA PATCH (LIDOCAINE-MENTHOL PATCH) ­ VEXA PAD (ALLANTOIN-LIDOCAINE-PETROLATUM PATCH) ­ VYTONE (IODOQUINOL-HYDROCORTISONE IN ALOE) ­ XYPHEX MIS (CAPSAICIN-MENTHOL DISK) ­ YODORA CRE (DERMATOLOGICAL PRODUCTS MISC) ­ ZACARE KIT (BENZOYL PEROXIDE LOTION & HYALURONATE SODIUM GEL KIT) ­ ZERUVIA PAD (LIDOCAINE-MENTHOL PATCH) ­ The following drugs are excluded as there are formulary alternatives ABSORICA CAPS (ISOTRETINOIN) AEROSPAN INH (FLUNISOLIDE HFA INHAL) ALA-SCALP (HYDROCORTISONE LOTION 2%) ALOGLIPTAN TABS ALOGLIPTAN/METFORMIN TABS ALOGLIPTAN/PIOGLITAZONE TABS ALTOPREV TABS (LOVASTATIN SR TABS) Page 6 of 9 Excluded Drug List ALVESCO INH (CICLESONIDE INHAL AEROSOL) ­ AMRIX CAP (CYCLOBENZAPRINE HCL CAP SR) ­ APLENZIN TABS (BUPROPION SR) ­ ATIVAN TABS (LORAZEPAM TABS) ­ CAPITAL W/ CODEINE SUSP (ACETAMINOPHEN W/CODEINE SUSPENSION) ­ CARAC (FLUOROURACIL CREAM) ­ CLINDACIN KIT PAC 1% (CLINDAMYCIN PHOS SWAB 1% & CLEANSER KIT) ­ CLINDAGEL (CLINDAMYCIN PHOSPHATE GEL 1%) ­ DUEXIS TABS (IBUPROFEN-FAMOTIDINE TABS) ­ DYANAVEL XR SUSPENSION (AMPHETAMINE ER ORAL SUSPENSION) ­ FELBATOL TABS (FELBAMATE TABS) ­ FENOFIBRATE 40MG, 120MG TABLETS ­ FENOGLIDE TABS (FENOFIBRATE TABS) ­ FIORICET/CODEINE CAPS (BUTALBITAL-APAP-CAFF-CODEINE CAPS) ­ GAVILYTE-H KIT (BISACODYL TAB & PEG 3350-KCL-SOD BICARB-NACL FOR SOLN) ­ HALOG CRM/OINT (HALCINONIDE) ­ INCRUSE ELLIPTA INH (UMECLIDINIUM BR AERO) ­ INDOCIN SUPP (INDOMETHACIN SUPP) ­ KAZANO TAB (ALOGLIPTIN-METFORMIN TAB) ­ KOMBIGLYZE XR TAB (SAXAGLIPTIN-METFORMIN TAB) ­ LIBRAX CAPS (CHLORDIAZEPOXIDE-CLIDINIUM CAPS) ­ LOCOID/LIPOCREAM (HYDROCORTISONE BUTYRATE CREAM) ­ LOPROX SHAMPOO (CICLOPIROX SHAMPOO) ­ LOTRONEX TABS (ALOSETRON TABS) ­ METOZOLV ODT (METOCLOPRAMIDE ODT) ­ MINOCIN CAPS (MINOCYCLINE HCL CAP) ­ Page 7 of 9 Excluded Drug List MYSOLINE TABS (PRIMIDONE TAB) ­ NAPROXEN CR/ER TABLETS (GENERIC NAPRELAN TABS) ­ NUVESSA GEL (METRONIDAZOLE VAGINAL GEL) ­ NORITATE CRE 1% (METRONIDAZOLE CREAM 1%) ­ OLUX/E (CLOBETASOL PROPIONATE) ­ ONGLYZA TABS (SAXAGLIPTAN TAB) ­ OSENI TAB (ALOGLIPTIN-PIOGLITAZONE TAB) ­ PARNATE TABS (TRANYLCYPROMINE TABS) ­ PERCOCET TABS (OXYCODONE-APAP) ­ PRADAXA CAPS
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