Excluded Drug List

The following drugs are excluded from coverage as they are not approved by the FDA

ACTIVE-PREP KIT I (- COMPOUND KIT) ­

ACTIVE-PREP KIT II (-- CREAM COMPOUND KIT) ­

ACTIVE-PREP KIT III (KETOPROFEN--GABAPENTIN CREAM COMPOUND KIT) ­

ACTIVE-PREP KIT IV (-GABAPENTIN-- CREAM COMPOUND KIT) ­

ACTIVE-PREP KIT V (ITRACONAZOLE- SODIUM CREAM CMPD KIT) ­

ADAZIN CREAM (BENZO--LIDO- 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 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 ( 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 ( & 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 (-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 CREAM 2% COMPOUND KIT) ­

ENOVARX-BACLOFEN (BACLOFEN CREAM 1% COMPOUND KIT) ­

ENOVARX-CYCLOBENZAPRINE (CYCLOBENZAPRINE TD CREAM 20MG/GR COMPOUND KIT) ­

ENOVARX- (IBUPROFEN CREAM 10% COMPOUNDING KIT) ­

ENOVARX-LIDOCAINE (LIDOCAINE CREAM 10% COMPOUND KIT) ­

ENOVARX- (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 ( TABS) ­

CAPITAL W/ 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 ( TABS) ­

FENOFIBRATE 40MG, 120MG TABLETS ­

FENOGLIDE TABS (FENOFIBRATE TABS) ­

FIORICET/CODEINE CAPS (-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 (-CLIDINIUM CAPS) ­

LOCOID/LIPOCREAM (HYDROCORTISONE BUTYRATE CREAM) ­

LOPROX (CICLOPIROX SHAMPOO) ­

LOTRONEX TABS (ALOSETRON TABS) ­

METOZOLV ODT (METOCLOPRAMIDE ODT) ­

MINOCIN CAPS (MINOCYCLINE HCL CAP) ­

Page 7 of 9

Excluded Drug List

MYSOLINE TABS ( 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 (-APAP) ­

PRADAXA CAPS (DABIGATRAN CAPS) ­

PSORCON (DIFLORASONE DIACETATE CREAM) ­

QUILLICHEW ER CHEW TABS (METHYLPHENIDATE ER CHEW TAB) ­

RAYOS TABS (PREDNISONE DELAYED RELEASE TABS) ­

REVESTA CAPS (FOLIC ACID- CAP) ­

RETIN-A MICRO/PUMP (TRETINOIN MICROSPHERE) ­

SECONAL CAPS () ­

SITAVIG TABS (ACYCLOVIR BUCCAL TAB) ­

TIVORBEX (INDOMETHACIN CAPSULES) ­

TRIANEX (TRIAMCINOLONE ACETONIDE OINT) ­

VANATOL LQ (BUTALBITAL-ACETAMINOPHEN-CAFFEINE SOLN) ­

VALCYTE TABS (VALGANCICLOVIR HCL TAB) ­

VANOS (FLUOCINONIDE CREAM) ­

XOLEGEL (KETOCONAZOLE GEL 2%) ­

VUSION OINT (MICONAZOLE-ZINC OXIDE-WHITE PETROLATUM) ­

ZIPSOR (DICLOFENAC POTASSIUM CAPSULES) ­

ZORVOLEX (DICLOFENAC CAPSULES) ­

Page 8 of 9

Excluded Drug List

ZUPLENZ FILM (ONDANSETRON FILM)

Page 9 of 9 ­