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APWU CDH Option Formulary Exclusions 01012020

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APWU CDH Option Formulary Exclusions 01012020 APWU Health Plan: Consumer Driven Option January 2020 Preferred Drug List Exclusions The medications covered on this list are not covered by the CDH plan. In most cases, if you fill a prescription for one of these drugs, you will pay the full price of the medication. Take action to avoid paying full price. If you are currently utilizing one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the preferred alternatives. Compare drug prices at www.myuhc.com® or the UnitedHealthcareTM Mobile App. Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Acne Absorica Brand isotretinoin [Amnesteem, Claravis, Myorisan, Zenatane (branded generics for Accutane)] clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin (generic Cleocin-T) plus Acanya Brand & Generic OTC benzoyl peroxide benzoyl peroxide 5%/erythromycin 3% gel (generic Benzamycin), erythromycin gel (generic Aktipak Brand Erygel) Altreno Brand OTC Differin gel, tretinoin cream (generic Retin-A) Avar Brand sulfacetamide sodium/sulfur 10-5% Avar LS Brand sulfacetamide sodium/sulfur 10-5% Avita 0.025% Generic Only OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Benzac, Desquam, Panoxyl, Brevoxyl Brand & Generic OTC benzoyl peroxide clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Benzaclin jar Brand & Generic T) plus OTC benzoyl peroxide clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Benzaclin pump Brand & Generic T) plus OTC benzoyl peroxide Clindacin Kit/Pac Brand clindamycin 1% gel, solution (generic Cleocin T) Clindagel Brand & Generic clindamycin 1% gel, solution (generic Cleocin T) Differin 0.1% cream, gel, lotion Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Differin 0.3% gel Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Doryx Brand & Generic Monodox) clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Duac Brand T) plus OTC benzoyl peroxide Epiduo Brand OTC Differin 0.1% gel plus OTC benzoyl peroxide Epiduo Forte Brand OTC Differin 0.1% gel plus OTC benzoyl peroxide Fabior Brand OTC Differin 0.1% gel, tretinoin cream (generic Retin-A), Tazorac minocycline tablet (generic Dynacin) Generic Only minocycline immediate-release capsules (generic Minocin) Minolira Brand minocycline immediate-release capsules (generic Minocin) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg or 100 mg (generic Morgidox Kit Brand Monodox) clindamycin 1.2%/benzoyl peroxide 5% gel (generic Duac), clindamycin solution (generic Cleocin- Neuac 1.2%-5% Kit Brand T) plus OTC benzoyl peroxide clindamycin topical solution (generic Cleocin T) + OTC benzoyl peroxide or clindamycin/benzoyl Onexton Brand peroxide (generic Duac) 1.2%-5% Plexion Brand sulfacetamide sodium/sulfur 10-5% Retin-A cream Brand OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Retin-A gel Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) Retin-A Micro Brand & Generic OTC Differin 0.1% gel, tretinoin cream (generic Retin-A) doxycycline hyclate (generic Vibramycin), doxycycline monohydrate 50 mg and 100 mg (generic Seysara Brand Monodox), minocycline immediate-release capsules (generic Minocin) Solodyn4 Brand & Generic minocycline immediate-release capsules (generic Minocin) Sumadan Brand & Generic sulfacetamide soldium/sulfur 10-5% Page 1 Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 Acne (Continued) Sumadan Kit Brand & Generic sodium sulfacetamide/sulfur 10-5% Sumadan XLT Kit Brand sulfacetamide sodium/sulfur 10-5% Sumaxin CP Brand sodium sulfacetamide/sulfur 10-5% Sumaxin TS Brand & Generic sodium sulfacetamide/sulfur 10-5% Targadox Brand doxycycline hyclate (generic Vibramycin), doxycycline monohydrate (generic Monodox) tazarotene 0.1% cream (generic Tazorac) Generic Only OTC Differin, tretinoin cream (generic Retin-A), Tazorac 0.1% cream clindamycin solution (generic Cleocin-T) plus tretinoin cream (generic Retin-A) or OTC Differin Veltin Brand 0.1% Ximino Brand minocycline immediate-release capsules (generic Minocin) clindamycin solution (generic Cleocin-T) plus tretinoin cream (generic Retin-A) or OTC Differin Ziana Brand & Generic 0.1% ADHD Adderall Brand amphetamine/dextroamphetamine immediate-release (generic Adderall) methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Adzenys Brand Concerta, Vyvanse amphetamine/dextroamphetamine extended-release (generic Generic Only Adderall XR methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Aptensio XR Brand Concerta, Vyvanse methylphenidate extended-release (generic Metadate CD, Ritalin LA), Adderall XR, Concerta, Cotempla XR-ODT Brand Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Daytrana Brand Concerta, Vyvanse Dexedrine (Brand Only) Brand dextroamphetamine extended-release (generic Dexedrine), Adderall XR methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Dyanavel XR Brand Concerta, Vyvanse amphetamine/dextroamphetamine immediate-release (generic Adderall), dextroamphetamine Evekeo Brand & Generic immediate-release (generic Dexedrine) methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Focalin XR Brand Concerta, Vyvanse Intuniv Brand guanfacine extended-release (generic Intuniv) guanfacine extended-release (generic Intuniv) Kapvay Brand & Generic methylphenidate extended-release tablet (generic Concerta) Generic Only Concerta methylphenidate extended-release (generic Metadate CD, Ritalin LA), Adderall XR, Concerta, Mydayis Brand Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Quillichew ER Brand Concerta, Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Quillivant XR Brand Concerta, Vyvanse methylphenidate extended-release capsules (generic Metadate CD, Ritalin LA), Adderall XR, Ritalin LA Brand Concerta, Vyvanse Strattera Brand atomoxetine (generic Strattera) Zenzedi Brand amphetamine/dextroamphetamine (generic Adderall), dextroamphetamine (generic Dexedrine) Allergic Reactions Auvi-Q Brand epinephrine auto-injector (generic EpiPen/EpiPen Jr.), Symjepi EpiPen/Epipen Jr Brand epinephrine auto-injector (generic EpiPen/EpiPen Jr.), Symjepi Allergies Allegra Brand & Generic OTC Allegra Astepro Brand & Generic azelastine (g0.1% nasal spray ) (generic Astelin) (g ) Beconase AQ Brand Rhinocort Benadryl Brand & Generic OTC Benadryl () p (gp)p Bepreve Brand ophthalmic solution (generic Patanol), Lastacaft Clarinex Brand & Generic levocetirizine (g(generic Xyzal), y ) OTC - pAllegra, pClaritin, Xyzal (g, Zyrtec ) g Clarinex-D Brand & Generic Claritin D, Zyrtec D fluticasone (generic Flonase), azelastine 0.1% (generic Astelin), OTC - Flonase, Nasacort, Dymista Brand Rhinocort OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Elestat Brand & Generic ophthalmic solution (generic Patanol), Lastacaft Page 2 Therapeutic Use Medication Name Brand and/or Generic Alternatives 2 3 OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Allergies (Continued) Emadine Brand ophthalmic solution (generic Patanol), Lastacaft Histex Brand & Generic n/a Karbinal ER Brand carbinoxamine tablets (generic Palgic) flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Nasacort AQ Brand & Generic Rhinocort flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Nasonex Brand & Generic Rhinocort flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Omnaris Brand Rhinocort OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Optivar Brand ophthalmic solution (generic Patanol), Lastacaft OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Pataday Brand & Generic ophthalmic solution (generic Patanol), Lastacaft OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine 0.1% Patanol Brand ophthalmic solution (generic Patanol), Lastacaft OTC ketotifen (Zaditor), azelastine ophthalmic solution (generic Optivar), olopatadine ophthalmic Pazeo Brand solution (generic Patanol), Lastacaft flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Qnasl Brand Rhinocort flunisolide (generic Nasarel), fluticasone (generic Flonase), Zetonna, OTC - Flonase, Nasacort, Rhinocort Aqua Brand & Generic Rhinocort Ryclora Brand & Generic OTC chlorpheniramine (generic Chlor-Trimeton) RyVent Brand carbinoxamine tablets (generic Palgic) Singulair Chewable Tablet Brand montelukast chewable tablet (generic Singulair) Singulair Tablet Brand montelukast tablet (generic Singulair) Zyrtec oral solution Brand & Generic OTC Children’s Zyrtec Allergy Syrup Zyrtec Tablet Brand & Generic OTC Zyrtec Alzheimer's Disease Aricept 23mg Brand & Generic donepezil 10 mg (generic Aricept) Exelon Patch Brand rivastigmine transdermal patch (generic Exelon), rivastigmine capsules (generic Exelon) Namenda XR Brand & Generic memantine immediate-release (generic Namenda) Namzaric
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