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)
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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)
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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)
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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)
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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)
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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 (DABIGATRAN CAPS)
PSORCON (DIFLORASONE DIACETATE CREAM)
QUILLICHEW ER CHEW TABS (METHYLPHENIDATE ER CHEW TAB)
RAYOS TABS (PREDNISONE DELAYED RELEASE TABS)
REVESTA CAPS (FOLIC ACID-CHOLECALCIFEROL CAP)
RETIN-A MICRO/PUMP (TRETINOIN MICROSPHERE)
SECONAL CAPS (SECOBARBITAL)
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)
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Excluded Drug List
ZUPLENZ FILM (ONDANSETRON FILM)
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