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3Q2021 Precision Formulary Exclusion List

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3Q2021 Precision Formulary Exclusion List 3Q2021 Precision Formulary Exclusion List Therapeutic Category Excluded Medications Preferred Alternatives ALLERGIC REACTIONS Anaphylaxis Treatment Auvi-Q, Epipen Jr 2-Pak 0.15 mg Epipen, epinephrine ANALGESICS celecoxib, diflunisal, flurbiprofen, Cambia, Zipsor, Zorvolex ibuprofen, indomethacin, ketorolac, meloxicam, piroxicam, sulindac Non-Steroidal Anti-Inflammatory Agents (Oral) Relafen, Relafen DS nabumetone Qmiiz ODT meloxicam Non-Steroidal Anti-Inflammatory Pennsaid, Voltaren gel diclofenac solution, diclofenac gel (Topical) Flector, Licart diclofenac patch Non-Steroidal Anti-Inflammatory Ketorolac Nasal Spray, Sprix Nasal diclofenac, ibuprofen, meloxicam (Other) Spray Skeletal Muscle Relaxant Norgesic Forte, Orphengesic Forte orphenadrine tab, aspirin Combinations Ozobax baclofen Kadian ER, Nucynta ER, Zohydro ER, Arymo ER, Hysingla ER, hydromorphone HCl ER, morphine sulfate Oxycontin, Embeda, Exalgo ER, MS Oral Long-Acting ER, oxymorphone HCl ER, Xtampza ER Contin, oxycodone ER, oxycodone Opioid Analgesics powder Conzip, tramadol ER 100mg, tramadol ER tablets 200mg and 300mg capsules codeine sulfate, hydromorphone hcl, Oral Short-Acting Opioid Analgesics Nucynta, Oxaydo, Qdolo morphine sulfate, oxycodone hcl, oxymorphone hcl, tramadol Abstral, Fentora, Lazanda, Subsys, Transmucosal Fentanyl Analgesics fentanyl citrate lozenge fentanyl citrate buccal tab Apadaz, hydrocodone/acetaminophen, Opioid Combinations benzhydrocodone/acetaminophen oxycodone/acetaminophen ANTICONVULSANTS Oxtellar XR oxcarbazepine IR Seizure Disorders Lamictal ODT kit lamotrigine ODT, lamotrigine XR ANTIDEPRESSANTS Antidepressants bupropion 450mg XL, Forfivo XL bupropion XL magellanrx.com Therapeutic Category Excluded Medications Preferred Alternatives ANTIPSYCHOTICS aripiprazole, olanzapine, quetiapine, Schizophrenia Secuado, Saphris quetiapine ER, risperidone, asenapine ANTIBACTERIALS, ORAL Doryx, doxycycline hyclate DR Oral Antibiotics doxycycline, minocycline 80mg, Minolira ANTIFUNGALS, ORAL Oral Antifungals Tolsura itraconazole cap AUTONOMIC & CENTRAL NERVOUS SYSTEM Attention Deficit Disorder Adhansia XR Vyvanse, methylphenidate ER CARDIOVASCULAR atorvastatin, fluvastatin, lovastatin, Statins Zypitamag, Livalo pravastatin, rosuvastatin, simvastatin Inderal XL, Innopran XL propranolol ER Hypertension Kapspargo metoprolol ER Conjupri, Katerzia amlodipine Hypertension with Osteoarthritis Consensi amlodipine/celecoxib CONTRACEPTIVES Lo Loestrin junel FE, larin FE, microgestin FE, tarina FE Oral Camila,Incassia, Nora-Be, norethindrone, Slynd Norlyda, Norlyroc etonogestrel-ethinyl estradiol vaginal Vaginal Ring Annovera ring, Nuvaring Talk to your doctor about clinically Gel Phexxi appropriate options. Xulane, Zafemy, levonorgestrel/ethinyl Patch Twirla estradiol combined generic oral contraceptive CORTICOSTEROIDS Hemady dexamethasone Oral Anti-Inflammatory Agents Rayos DR prednisone ENDOCRINE Nocturia Noctiva desmopressin, Nocdurna Testosterone Replacement Aveed, Jatenzo, Natesto, Testopel testosterone, Androderm 2 | 2021 Magellan Rx Management, LLC. All rights reserved_MRX1069_0721 Therapeutic Category Excluded Medications Preferred Alternatives DERMATOLOGICAL AGENTS Acanya, Aczone 5%, Aktipak, Onexton, Epiduo Forte, adapalene, Benzaclin, Benzaclin Pump, adapalene/benzoyl peroxide, clindamycin Clindagel, clindamycin phosphate gel/lotion/solution, clindamycin/benzoyl 1% gel, Benzamycin, Duac, Epiduo, peroxide, erythromycin/benzoyl peroxide, Veltin, Ziana, Aklief, dapsone 7.5% tretinoin cream Topical Acne Treatment adapalene lotion, Differin lotion adapalene Avita tretinoin cream/gel Arazlo, Fabior, Tazorac tazarotene cream Topical Anesthetics Ztlido lidocaine patch Topical Antifungals Jublia terbinafine, Kerydin ALA Scalp lotion, Micort-HC cream hydrocortisone Topical Corticosteroids Apexicon E cream fluocinonide, betamethasone Capex shampoo Derma-Smoothe/FS, fluocinolone acetonide scalp oil Cordran tape flurandrenolide Pandel cream flurandrenolide, hydrocortisone valerate, triamcinolone acetonide Halobetasol foam(M), Lexette betamethasone, clobetasol, halobetasol cream/ointment Topical Corticosteroids Halog ointment betamethasone, mometasone, triamcinolone Impoyz cream clobetasol Psorcon cream, Verdeso foam betamethasone, fluocinolone Trianex hydrocortisone valerate, triamcinolone acetonide clobetasol proprionate, fluocinonide, Ultravate lotion halobetasol proprionate imiquimod cream pump 3.75% Topical Immune Response Modifier Zyclara, Zyclara Pump imiquimod 5% cream Duobrii Lotion clobetasol, fluocinonide, halobetasol, tazarotene, Enstilar Topical Plaque Psoriasis Calcipotriene Foam 0.005% (M), calcipotriene Sorilux metronidazole cream/gel/lotion, Finacea Rosacea Treatment Noritate, Metrogel foam, Soolantra 3 | 2021 Magellan Rx Management, LLC. All rights reserved_MRX1069_0721 Therapeutic Category Excluded Medications Preferred Alternatives DIABETES All other blood glucose meters and strips. Examples: Abbott (FreeStyle, Precision), Arkray Ascensia Diabetes Care (Contour/Contour Blood Glucose Meters & Strips (Glucocard), Bayer (Breeze), Nipro Next) (TRUEtest, TRUEtrack), Roche (Accu-Chek), Lifescan (One Touch) Continuous Glucose Monitoring FreeStyle Libre, FreeStyle Libre 2 Dexcom (CGM) alogliptin, alogliptin/metformin, Dipeptidyl Peptidase-4 (DPP4) alogliptin/pioglitazone, Kazano, Janumet, Janumet XR, Januvia, Inhibitors & Combinations Kombiglyze XR, Nesina, Onglyza, Jentadueto, Jentadueto XR, Tradjenta Oseni Invokamet, Invokamet XR, Sodium-glucose co-transporter Farxiga, Xigduo XR, Jardiance, Synjardy, Invokana, Steglatro, Segluromet, (SGLT2) Inhibitors & Combinations Synjardy XR, Glyxambi, Trijardy XR Steglujan, Qtern Bydureon, Bydureon Bcise, Byetta, Glucagon-Like Peptide-1 Agonists Adlyxin, Tanzeum Trulicity, Victoza, Ozempic, Rybelsus Insulins Novolin Humulin Admelog, Apidra, Fiasp, insulin Rapid-acting insulin Humalog, Lyumjev lispro, insulin aspart, Novolog Basaglar, Levemir, Tresiba, Basal insulin Lantus, Toujeo Semglee Glumetza, Fortamet, Riomet suspension, metformin HCl 24hr metformin ER (Glucophage generic), Biguanides ER osmotic release, metformin HCl metformin IR 24hr ER modified release GASTROINTESTINAL Anti-Diarrheal Agents Motofen diphenoxylate/atropine, loperamide granisetron solution/tablet, ondansetron Antiemetics Sancuso patch ODT Duexis, Vimovo, famotidine PLUS ibuprofen, omeprazole Anti-Inflammatory/Anti-Ulcer Agents naproxen/esomeprazole PLUS naproxen Pancreatic Enzymes Pancreaze, Pertzye, Viokace Creon, Zenpep Asacol HD, Delzicol, Dipentum, Inflammatory Bowel Disease Apriso, mesalamine Lialda, mesalamine DR 800 mg Chronic Idiopathic Constipation, Trulance, Amitiza, lubiprostone, Irritable bowel syndrome with Linzess Zelnorm constipation Opioid-Induced Constipation Movantik, Amitiza, Relistor Symproic 4 | 2021 Magellan Rx Management, LLC. All rights reserved_MRX1069_0721 Therapeutic Category Excluded Medications Preferred Alternatives omeppi, omeprazole with sodium bicarbonate (cap, powder pak), lansoprazole, omeprazole, pantoprazole, Proton Pump Inhibitors rabeprazole sprinkle cap, Aciphex Sprinkle caps, Dexilant esomeprazole mag DR capsules Golytely packets Gavilyte-C, Gavilyte-H, PEG 3350 Laxatives Moviprep, Plenvu, Osmoprep Clenpiq, Prepopik, Suprep IMMUNOMODULATORS Cimzia, Humira, Inflectra, Actemra, Autoimmune Agents3 Cosentyx, Olumiant, Ilumya, Orencia, Otezla, Avsola, Rinvoq ER, Remicade, Renflexis Simponi, Simponi Aria, Skyrizi, Stelara, Taltz, Tremfya, Xeljanz/XR MUSCULOSKELETAL Muscle Relaxants Amrix cyclobenzaprine ANTIMIGRAINES Ajovy Aimovig, Emgality CGRP Antagonists Reyvow Nurtec ODT, Ubrelvy Onzetra XSAIL, Zembrace sumatriptan injection, sumatriptan, Serotonin Receptor Agonists Symtouch, Imitrex, Maxalt/MLT, rizatriptan, eletriptan, zolmitriptan Relpax, Zomig, Treximet, Tosymra, OPHTHALMIC latanoprost ophthalmic solution, Vyzulta, Zioptan, Xalatan travoprost ophthalmic solution, Lumigan, Antiglaucoma Drugs Rhopressa, Rocklatan, Xelpros Timoptic Ocudose timolol ophthalmic solution Prolensa, diclofenac, ketorolac, Anti-Inflammatory Bromsite, Ilevro, Nevanac flurbiprofen azelastine ophthalmic solution, Antihistamines Bepreve, Lastacaft, Pazeo, Zerviate olopatadine ophthalmic solution Dry Eye Disease Cequa Restasis, Xiidra RESPIRATORY Anticholinergic/Long-Acting Beta Bevespi, Utibron, Duaklir Pressair Anoro Ellipta, Stiolto Respimat Agonist Combination Inhalers AirDuo Respiclick, Airduo Advair Diskus, Advair HFA, Breo Ellipta, Anti-Inflammatory/ Long-Acting Beta Digihaler, Dulera, Symbicort, fluticasone/salmeterol, Wixela Agonist Combination Inhalers budesonide/formoterol Inhub 5 | 2021 Magellan Rx Management, LLC. All rights reserved_MRX1069_0721 Therapeutic Category Excluded Medications Preferred Alternatives levalbuterol HFA, Proventil HFA, Xopenex HFA, Proair Digihaler, Short-Acting Beta-2 Adrenergic albuterol HFA (Perrigo, Teva, Par, Cipla, Proair HFA, Proair Respiclick, Inhalers Lupin, Sandoz) albuterol HFA (Prasco), Ventolin HFA Alvesco, Armonair Respiclick, Pulmonary Anti-Inflammatory Arnuity Ellipta, Flovent Diskus, Flovent Armonair Digihaler, Asmanex, Inhalers HFA, Pulmicort Flexhaler Asmanex HFA, QVAR Redihaler Chronic Obstructive Pulmonary Tudorza, Seebri, Incruse Ellipta Spiriva Disease (inhaled anticholinergics) UROLOGICAL Erectile Dysfunction Oral Agents Stendra sildenafil Interstitial Cystitis Elmiron amitriptyline, hydroxyzine OTHER Colcrys, Mitigare, Gloperba, Antigout Agents colchicine tablet colchicine capsule Clarinex Syrup desloratadine Antihistamine Carinex-D desloratadine with
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