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Adventhealth Prescription Benefit Plan Non-Essential Medication List

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Adventhealth Prescription Benefit Plan Non-Essential Medication List AdventHealth Prescription Benefit Plan Non-Essential Medication List Excluded Drug Preferred Alternative ABSORICA generic isotretinoin capsules ABSTRAL fentanyl citrate lozenge ACUICYN OTC OCuSOFT lid scrub, ocular antibiotics, OTC artificial tears ADAPALENE SOLUTION Rx generic adapalene cream or lotion, Rx generic/OTC adapalene gel, EpiDuo, generic topical tretinoin ALEVICYN/SPRAY GEL OTC emollients or creams, OTC generic hydrocortisone, OTC wound care products ALLZITAL generic butalbital/acetaminophen (50mg-325mg tablet) ALZAIR Chloraseptic Allergen Block AMRIX cyclobenzaprine (5mg or 10mg) 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 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 AUGMENTIN generic amoxicillin/clavulanate suspension (125MG/5ML 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 BEAU RX Kelocote, Recedo BENZACLIN generic clindamycin/benzoyl peroxide BENZEPRO generic or OTC topical benzoyl peroxide BENZONATATE (Solubiomix) generic benzonatate BESER (fluticasone, emollient no 65) Fluticasone 0.05% lotion/cream, OTC emollient BIAFINE OTC hyaluronate products, OTC wound dressings, barrier creams BINOSTO alendronate, ibandronate BIONECT OTC hyaluronate products BOCASAL OTC saliva mouthwash, powder, or spray/pump BONJESTA OTC doxylamine, OTC pyridoxine BPCO OTC wound care products, barrier creams and ointments Page | 1 Medications on this list are excluded from the AdventHealth prescription benefit due to the availability of less expensive prescription and over the counter alternatives. This list applies to those covered on the Traditional (PPO) and High Deductible Health Plan (HDHP) and unless specified by strength, includes all available strengths on the product. AdventHealth Prescription Benefit Plan Non-Essential Medication List Excluded Drug Preferred Alternative BRYHALI Generic halobetasol ointment or cream, clobetasol propionate; betamethasone augmented 0.05%; fluocinonide BUTALBITAL-ACETAMINOPHEN generic butalbital/acetaminophen (50mg-325mg tablet) (50MG-300MG CAPSULE) CAROSPIR generic spironolactone tablets CELACYN OTC Mederma, OTC Scarguard MD, OTC ScarAway 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) CONZIP generic tramadol extended-release capsules or tablets COREMINO generic immediate-release minocycline capsules or tablets, doxycycline DENAVIR Generic oral acyclovir, famciclovir, and valacyclovir DERMULCERA OTC wound care products, barrier creams and ointments DEXERYL OTC emollients or creams, OTC generic hydrocortisone DEXPAK dexamethasone tablets (1.5 mg) DICLOFENAC SUBMICRONIZED generic oral NSAIDs, generic oral diclofenac DIFLORASONE DIACETATE Generic high to super-high potency topical steroid (e.g., CREAM/OINTMENT fluocinonide, betamethasone dipropionate) DONNATAL generic Lomotil tablets DUEXIS famotidine & ibuprofen DULOXETINE HCL 40MG duloxetine 20mg, 30mg, 60mg DURLAZA RX/OTC aspirin, clopidogrel DUTOPROL generic metoprolol, hydrochlorothiazide DXEVO Generic dexamethasone tablets EDLUAR eszopiclone, zaleplon, zolpidem ELETONE OTC emollients or creams, OTC generic hydrocortisone ENTTY OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids EPICERAM OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids EPICYN OTC benzoyl peroxide cleansers ERTACZO generic clotrimazole, econazole, ketoconazole, terbinafine EURAX generic topical permethrin, oral ivermectin Page | 2 Medications on this list are excluded from the AdventHealth prescription benefit due to the availability of less expensive prescription and over the counter alternatives. This list applies to those covered on the Traditional (PPO) and High Deductible Health Plan (HDHP) and unless specified by strength, includes all available strengths on the product. AdventHealth Prescription Benefit Plan Non-Essential Medication List Excluded Drug Preferred Alternative EVZIO Narcan EXTINA 2% ketoconazole shampoo or cream FABIOR Generic topical adapalene, tretinoin, tazarotene creams/gels FENOFIBRATE 43MG. 130MG generic fenofibrate, micronized/nanocrystallized FENOPROFEN CALCIUM generic oral NSAIDs FENTORA fentanyl citrate lozenge FEXMID (brand and generic) cyclobenzaprine (5mg or 10mg) FLUOVIX (fluocinonide/silicone scar Fluocinonide 0.1% cream, OTC Scargard sheet) FORFIVO XL bupropion extended release GEL-MATRIX SILICONE PAD OTC Scargel, OTC silicone gel sheet (CICATRACE, SILIVEX, SCARCINPAD, SIL-K, KELOTOP, SILTREX) GENADUR OTC nail strengthener GLUMETZA generic Glucophage XR GLYCATE generic glycopyrrolate (1mg tablets) GOCOVRI generic amantadine IR (100mg tablets) GONITRO generic nitroglycerin sublingual tablets, generic nitroglycerin translingual spray GRALISE gabapentin immediate-release HORIZANT gabapentin immediate-release HPR/PLUS/MB/HYDROGEL generic topical clobetasol or hydrocortisone, OTC emollient products (CeraVe, etc.) HYCLODEX Di-Dak Sol (sodium hypochlorite 0.0125%), Dakin’s solution (sodium hypochlorite 0.125%, 0.25%, and 0.50%), Hysept (sodium hypochlorite 0.5%), and H-Chlor (0.062/0.125%) HYCOFENIX OTC 1% hydrocortisone HYDROCODONE-ACETAMINOPHEN hydrocodone-acetaminophen 10mg-300mg tablets, (10MG-325MG ORAL SOLUTION) 10mg-325mg tablets, 7.5-325mg oral solution HYLATOPIC PLUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids, OTC wound care products IMPOYZ Generic high potency topical steroid (e.g., fluocinonide 0.05%, betamethasone dipropionate 0.05%) INDERAL XL Inderal LA capsules, propranolol tablets INNOPRAN XL Inderal LA capsules, propranolol tablets INTERMEZZO eszopiclone, zaleplon, zolpidem ISOTRETINOIN generic isotretinoin capsules JUBLIA generic terbinafine, fluconazole, itraconazole, ciclopirox Page | 3 Medications on this list are excluded from the AdventHealth prescription benefit due to the availability of less expensive prescription and over the counter alternatives. This list applies to those covered on the Traditional (PPO) and High Deductible Health Plan (HDHP) and unless specified by strength, includes all available strengths on the product. AdventHealth Prescription Benefit Plan Non-Essential Medication List Excluded Drug Preferred Alternative KAMDOY Topical lidocaine KELARX OTC Mederma, OTC Scarguard MD KERAGELT OTC wound care products KHEDEZLA (brand and generic) desvenlafaxine succinate extended release, desvenlafaxine extended release (Ranbaxy) KRISTALOSE/LACTULOSE PACKETS generic lactulose solution AJODA fentanyl citrate lozenge LEVICYN/SG OTC emollients or creams, OTC generic hydrocortisone, OTC wound care products LEVORPHANOL 3 MG Generic morphine IR, oxycodone IR LEXETTE generic halobetasol ointment or cream; generic clobetasol; generic betamethasone; generic fluocinonide LIDOCAINE HCL/ALOE/COLLAGEN lidocaine, OTC aloe, OTC emollients LIDOCAINE/TETRACAINE generic lidocaine 5% topical, lidocaine-prilocaine topical cream LIDOCAINE/PRILOCAINE 2.5%/2.5% generic lidocaine 5% topical, lidocaine-prilocaine topical cream (KIT) LIDOTREX lidocaine, OTC vitamin E, OTC aloe, OTC emollients LORZONE generic chlorzoxazone (500 mg tablets) LOYON topical dimethicone LURADROX OTC hyaluronate products LUXAMEND OTC hyaluronate products, OTC wound dressings, barrier creams LYRICA CR immediate-release gabapentin, immediate-release Lyrica MICROCYN, MICROCYN HYDROGEL OTC wound care products MINOCYCLINE HCL ER generic immediate-release minocycline capsules or tablets, doxycycline MINOCYCLINE HCL MICROSPHERES generic immediate-release minocycline capsules or tablets, doxycycline MINOLIRA ER generic immediate-release minocycline capsules or tablets, doxycycline NALFON generic oral NSAIDs NAPRELAN naproxen NAPROXEN/ESOMEPRAZOLE MAG naproxen & esomeprazole magnesium, lansoprazole, omeprazole, or pantoprazole NATESTO generic topical testosterone, IM testosterone NEOCERA OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids Page | 4 Medications on this list are excluded from the AdventHealth prescription benefit due to the availability of less expensive prescription and over the counter alternatives. This list applies to those covered on the Traditional (PPO) and High Deductible Health Plan (HDHP) and unless specified by strength, includes all available strengths on the product. AdventHealth Prescription Benefit Plan Non-Essential Medication List Excluded Drug Preferred Alternative NEOSALUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids NEUTRASAL OTC saliva mouthwash, powder, or spray/pump
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