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High-Cost Drug Exclusions

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High-Cost Drug Exclusions PHARMACY SERVICES High-Cost Drug Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary. Please visit your health plan’s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service at the number listed on the back of your member ID card. Drug Alternatives Absorica Claravis, Myorisan, and Zenatane Acanya benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin AcipHex Sprinkles omeprazole, pantoprazole, and lansoprazole doxycycline immediate release (IR), minocycline IR, erythromycin, and Acticlate sulfamethoxazole-trimethoprim Aczone benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin adapalene 0.1% cream over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel adapalene 0.1% gel over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel adapalene 0.1% lotion over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel Altoprev atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin Amrix cyclobenzaprine tablet Antara gemfibrozil and fenofibrate ApexiCon E desoximetasone 0.05% cream and triamcinolone 0.5% cream fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Beconase AQ Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. Belsomra diphenhydramine, doxepin, and trazodone Binosto alendronate 70 mg fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as budesonide AQ Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. High-Cost Drug Exclusions Drug Alternatives Byvalson Bystolic plus valsartan Cambia packets diclofenac tablet Carac fluorouracil 0.5% external cream Centany mupirocin 2% external ointment Clindagel benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin clindamycin/ tretinoin benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin clocortolone pivalate cream mometasone 0.1% cream and triamcinolone 0.1% cream clocortolone pivalate pump mometasone 0.1% cream and triamcinolone 0.1% cream Cloderm cream mometasone 0.1% cream and triamcinolone 0.1% cream Cloderm pump mometasone 0.1% cream and triamcinolone 0.1% cream Clorpres chlorthalidone plus clonidine hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and Cordran 0.05% ointment fluocinolone 0.025% ointment hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and Cordran tape fluocinolone 0.025% ointment Cuprimine Depen Titratabs (penicillamine) Daxbia cephalexin 250 mg or cephalexin 500 mg Dexilant omeprazole, pantoprazole, and lansoprazole Differin 0.1% cream over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel Differin 0.1% gel over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel Differin 0.1% lotion over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel diflorasone diacetate cream desoximetasone 0.05% cream and triamcinolone 0.5% cream diflorasone diacetate ointment desoximetasone 0.25% ointment and fluocinonide 0.05% ointment Effective 1/1/18 High-Cost Drug Exclusions Drug Alternatives doxycycline immediate release (IR), minocycline IR, erythromycin, and Doryx sulfamethoxazole-trimethoprim Duexis ibuprofen plus famotidine Durlaza aspirin 81 mg Dutoprol metoprolol plus HCTZ fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Dymista Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. Edarbi irbesartan, losartan, valsartan, and olmesartan Edarbyclor valsartan/ HCTZ, irbesartan/ HCTZ, and losartan/ HCTZ Edluar zolpidem and zaleplon Emflaza prednisone, prednisolone, and methylprednisolone omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) esomeprazole magnesium medications, such as Nexium 24 HR. omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) esomeprazole strontium medications, such as Nexium 24 HR. Fabior benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin Flector diclofenac topical gel and diclofenac topical solution fluocinonide 0.1% cream halobetasol 0.05% cream and clobetasol 0.05% cream flurandrenolide 0.05% hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and ointment fluocinolone 0.025% ointment Fortamet metformin and metformin ER (non-osmotic, non-modified release) Glumetza metformin and metformin ER (non-osmotic, non-modified release) Gonitro nitroglycerin SL (sublingual) tablet Gralise gabapentin Halog cream desoximetasone 0.25% cream and betamethasone AF 0.05% cream fluocinonide 0.05% ointment, desoximetasone 0.25% ointment, and Halog ointment betamethasone dipropionate 0.05% ointment Effective 1/1/18 High-Cost Drug Exclusions Drug Alternatives Horizant gabapentin Inderal XL propranolol HCL ER InnoPran XL propranolol HCL ER Intermezzo zolpidem and zaleplon Istalol timolol eye drops Lescol XL atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin Livalo atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin Locort 11 day generic dexamethasone tablets Locort 7 day generic dexamethasone tablets Lovaza prescription or over-the-counter (OTC) omega-3 fatty acids metformin ER modified release metformin and metformin ER (non-osmotic, non-modified release) metformin ER osmotic release metformin and metformin ER (non-osmotic, non-modified release) doxycycline immediate release (IR), minocycline IR, erythromycin, and Minolira sulfamethoxazole-trimethoprim fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as mometasone nasal Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. doxycycline immediate release (IR), minocycline IR, erythromycin, and Morgidox sulfamethoxazole-trimethoprim Nalfon fenoprofen Naprelan naproxen ER (extended release) tablet fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Nasonex Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. Neuac benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) Nexium medications, such as Nexium 24 HR. Effective 1/1/18 High-Cost Drug Exclusions Drug Alternatives Noctiva oxybutynin, desmopressin nasal spray, and desmopressin tablets omeprazole- sodium omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) bicarbonate medications, such as Zegerid OTC. omeprazole- sodium omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) bicarbonate packet medications, such as Zegerid OTC. fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Omnaris Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. Onexton benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin hydrocortisone butyrate 0.1% cream, fluocinolone 0.025% cream, and Pandel cream betamethasone valerate 0.1% cream Pennsaid diclofenac topical gel and solution Prestalia perindopril plus amlodipine omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) Prevacid SoluTab medications, such as Prevacid 24 HR. Prilosec packet omeprazole, pantoprazole, and lansoprazole Protonix packet omeprazole, pantoprazole, and lansoprazole Psorcon cream desoximetasone 0.05% cream and triamcinolone 0.5% cream fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Qnasl Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. Rayos prednisone, prednisolone, and methylprednisolone fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Rhinocort AQ Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. Rozerem over-the-counter (OTC) melatonin doxycycline immediate release (IR), minocycline IR, erythromycin, and Solodyn sulfamethoxazole-trimethoprim Sprix diclofenac tablet, etodolac, meloxicam, and nabumetone doxycycline immediate release (IR), minocycline IR, erythromycin, and Targadox sulfamethoxazole-trimethoprim Tazorac Gel benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin Effective 1/1/18 High-Cost Drug Exclusions Drug Alternatives Tekturna irbesartan, losartan, valsartan, and olmesartan Tekturna HCT valsartan/ HCTZ, irbesartan/ HCTZ, and losartan/ HCTZ hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and Texacort fluocinolone 0.025% ointment Timoptic Ocudose timolol eye drops Tivorbex indomethacin tablet Topicort spray desoximetasone 0.05% gel and fluocinonide 0.05% solution Tretin-X generic tretinoin Trianex ointment triamcinolone 0.025% ointment and triamcinolone 0.1% ointment Triglide gemfibrozil and fenofibrate Vanos cream halobetasol 0.05% cream and clobetasol 0.05% cream Vascepa prescription or over-the-counter (OTC) omega-3 fatty acids Veltin benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Veramyst Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. doxycycline immediate
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