Medimpact Drug Exclusions

MedImpact Drug Exclusions

4-1-2019

Rebate-Driven Exclusions Excluded Drug Preferred Alternative ADLYXIN Trulicity, Bydureon, Bydureon BCise, Byetta ADMELOG Humalog ADMELOG SOLOSTAR Humalog ADZENYS ER Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine, Vyvanse ADZENYS XR-ODT Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine, Vyvanse AEROSPAN Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler AIRDUO RESPICLICK Advair Diskus/HFA, Breo Ellipta, Dulera, Symbicort (brand and authorized generic) AJOVY Aimovig, Emgality ALVESCO Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler APIDRA Humalog APIDRA SOLOSTAR Humalog APTENSIO XR methylphenidate, dexmethylphenidate, Concerta, Quillichew ER, Quillivant XR ARMONAIR RESPICLICK Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler BASAGLAR KWIKPEN U-100 Lantus, Toujeo, Tresiba, Levemir BECONASE AQ OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl BELBUCA Butrans BELVIQ/XR Contrave BEPREVE azelastine, olopatadine CEQUA Restasis, Xiidra COTEMPLA XR-ODT methylphenidate, dexmethylphenidate, Concerta, Quillichew ER, Quillivant XR DELZICOL Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine DIPENTUM Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine EMADINE azelastine, olopatadine ESTROGEL Divigel EXTAVIA Aubagio, Avonex, glatiramer, Gilenya, Glatopa, Plegridy, Rebif GENOTROPIN Norditropin HUMATROPE Norditropin INVOKANA Jardiance, Farxiga INVOKAMET Synjardy, Synjardy XR, Xigduo XR INVOKAMET XR Synjardy, Synjardy XR, Xigduo XR KAZANO Janumet, Janumet XR, Jentadueto, Jentadueto XR KEVZARA Actemra, Enbrel, Humira, Xeljanz

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative KOMBIGLYZE XR Janumet, Janumet XR, Jentadueto, Jentadueto XR LASTACAFT azelastine, olopatadine LEVALBUTEROL TARTRATE ProAir HFA, ProAir RespiClick, Ventolin HFA MYDAYIS Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine,Vyvanse

NESINA Januvia, Tradjenta (brand and authorized generic) NOVOLIN Humulin NOVOLOG Humalog NUTROPIN Norditropin NUTROPIN AQ Norditropin OLUMIANT Actemra, Enbrel, Humira, Xeljanz OMNARIS OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl OMNITROPE Norditropin ONGLYZA Januvia, Tradjenta OSENI Januvia, Tradjenta, pioglitazone (brand and authorized generic) OZEMPIC Trulicity, Bydureon, Bydureon BCise, Byetta PANCREAZE Creon, Zenpep PAZEO azelastine, olopatadine PERTZYE Creon, Zenpep PRADAXA Eliquis, Xarelto PROVENTIL HFA ProAir HFA, ProAir RespiClick, Ventolin HFA QSYMIA Contrave QTERN Glyxambi SAIZEN Norditropin SAXENDA Contrave SEEBRI NEOHALER Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta SEGLUROMET Synjardy, Synjardy XR, Xigduo XR SIMPONI (50 mg) Actemra, Cosentyx, Enbrel, Humira, Stelara, Xeljanz STEGLATRO Jardiance, Farxiga STEGLUJAN Glyxambi SYMPROIC Linzess, Movantik TALTZ Cosentyx, Enbrel, Humira, Otezla, Stelara TECHNIVIE Epclusa, Harvoni, Mavyret, Vosevi TRULANCE Linzess TUDORZA PRESSAIR Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta UTIBRON NEOHALER Anoro Ellipta, Stiolto Respimat, Bevespi Aerosphere

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative VIEKIRA PAK Epclusa, Harvoni, Mavyret, Vosevi VIEKIRA XR Epclusa, Harvoni, Mavyret, Vosevi XOPENEX HFA ProAir HFA, ProAir Respiclick, Ventolin HFA ZEPATIER Epclusa, Harvoni, Mavyret, Vosevi ZETONNA OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl ZOMACTON Norditropin

Non-Essential Drugs 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 APLENZIN bupropion extended release, bupropion AQUORAL OTC saliva mouthwash, powder, or spray/pump ASPIRIN/OMEPRAZOLE OTC aspirin, 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) 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 BIAFINE OTC hyaluronate products, OTC wound dressings, barrier creams BINOSTO alendronate, ibandronate

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative 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 BRYHALI Generic halobetasol ointment or cream, clobetasol propionate lotion; generic betamethasone; generic 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 DERMULCERA OTC wound care products, barrier creams and ointments DESVENLAFAXINE ER desvenlafaxine succinate ER, desvenlafaxine ER (Ranbaxy) DEXERYL OTC emollients or creams, OTC generic hydrocortisone DEXPAK dexamethasone tablets (1.5 mg) DICLOFENAC SODIUM topical diclofenac DICLOFENAC SUBMICRONIZED generic oral NSAIDs, generic oral diclofenac DIFENOXIN HCL/ATROPINE SULFATE generic Lomotil tablets DUEXIS famotidine & ibuprofen DULOXETINE HCL generic duloxetine DURLAZA RX/OTC aspirin, clopidogrel DUTOPROL generic metoprolol, hydrochlorothiazide 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

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative EVZIO Narcan EXTINA 2% ketoconazole shampoo or cream FENOFIBRATE generic fenofibrate, micronized/nanocrystallized FENOPROFEN CALCIUM generic oral NSAIDs FENTORA fentanyl citrate lozenge FEXMID (brand and generic) cyclobenzaprine (5mg or 10mg) FORFIVO XL bupropion extended release 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 betamethasone dipropionate, clobetasol propionate, fluocinonide, triamcinolone acetonide INDOCIN diclofenac oral and capsicum INDERAL XL Inderal LA capsules, propranolol tablets INNOPRAN XL Inderal LA capsules, propranolol tablets INTERMEZZO eszopiclone, zaleplon, zolpidem ISOTRETINOIN generic isotretinoin capsules 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) LACTULOSE PACKETS (generic) generic lactulose solution LAZANDA fentanyl citrate lozenge LEVICYN/SG OTC emollients or creams, OTC generic hydrocortisone, OTC

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative wound care products 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 METFORMIN HCL ER generic metformin IR, generic Glucophage XR (metformin ER) MICROCYN 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 SODIUM ER 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 NEOSALUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids NEUTRASAL OTC saliva mouthwash, powder, or spray/pump NIVATOPIC PLUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids, OTC wound care products NORITATE 0.75% metronidazole cream or lotion NORTRIPTYLINE 20 MG/10ML UNIT- Generic nortriptyline capsules and oral solution (10mg/5mL) DOSE CUPS NUVAIL OTC nail strengthener

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative ONSOLIS fentanyl citrate lozenge ONZETRA XSAIL sumatriptan OSMOLEX ER generic amantadine IR (100mg tablets) PENNSAID diclofenac PEXEVA paroxetine PLIXDA Rx generic adapalene cream or lotion, Rx generic/OTC adapalene gel, EpiDuo, generic topical tretinoin PRESTALIA amlodipine and benazepril PROMISE B OTC topical antifungal products, OTC topical steroids, OTC ketoconazole/dandruff shampoos PRUTECT OTC hyaluronate products, OTC wound dressings, barrier creams RADIAPLEX RX OTC hyaluronate products, OTC aloe, OTC emollient products, OTC wound care products RAMELTEON eszopiclone, zaleplon, zolpidem RAYOS prednisone IR REGENECARE lidocaine, OTC vitamin E, OTC aloe, OTC emollients RESTIZAN OTC Mederma, OTC Scarguard MD, OTC ScarAway ROZEREM eszopiclone, zaleplon, zolpidem RYCLORA (brand and generic) OTC diphenhydramine, OTC chlorpheniramine RYVENT (brand and generic) generic carbinoxamine (4 mg tablets) SALIVAMAX OTC saliva mouthwash, powder, or spray/pump SCARCARE OTC Mederma, OTC Scarguard MD, OTC Bio Oil SCARCIN OTC Mederma, OTC Scarguard MD, OTC ScarAway SEBUDERM OTC topical antifungal products, OTC topical steroids, OTC ketoconazole/dandruff shampoos SEYSARA generic immediate-release minocycline capsules or tablets, doxycycline SILIPAC OTC Mederma, OTC Scarguard MD, OTC Bio Oil SOLODYN generic immediate-release minocycline capsules or tablets, doxycycline SONAFINE OTC hyaluronate products, OTC wound dressings, barrier creams SP SCAR MANAGEMENT OTC Mederma, OTC Scarguard MD, OTC ScarAway SPRIX ibuprofen, naproxen SUBSYS fentanyl citrate lozenge SULFACLEANSE generic sulfur/sodium sulfacetamide topical products SUVICORT lidocaine, OTC aloe, OTC emollients SYNERDERM palm oil TAPERDEX dexamethasone tablets (1.5 mg) TETRIX OTC wound care products, barrier creams and ointments

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative TIROSINT generic levothyroxine tablets TIVORBEX indomethacin TREXIMET sumatriptan, naproxen TREZIX (brand and generic) acetaminophen/codeine TRIANEX generic triamcinolone acetonide 0.03%-0.1% ointment ULTRAVATE Generic halobetasol ointment or cream, clobetasol propionate lotion; generic betamethasone; generic fluocinonide VANATOL LQ butalbital/acetaminophen/caffeine (50mg-325mg-40mg) tablets/capsules VANATOL S butalbital/acetaminophen/caffeine (50mg-325mg-40mg) tablets/capsules VELTIN (brand and generic) generic clindamycin topical, generic tretinoin topical VENELEX OTC wound care products, barrier creams and ointments VERDESO generic desonide 0.05% cream, lotion, or ointment VIMOVO naproxen & esomeprazole VIVLODEX meloxicam XERESE oral acyclovir, famciclovir, valacyclovir XEROFORM PETROLATUM DRESSING OTC wound care products XHANCE OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl XIMINO generic immediate-release minocycline capsules or tablets, doxycycline XOLEGEL 2% ketoconazole shampoo or cream YOSPRALA Rx/OTC aspirin, RX/OTC omeprazole ZECUITY sumatriptan ZEMA-PAK dexamethasone tablets (1.5 mg) ZEMBRACE SYMTOUCH sumatriptan ZIANA (brand and generic) generic clindamycin topical, generic tretinoin topical ZILEUTON ER montelukast , zafirlukast ZIPSOR diclofenac ZOLPIMIST eszopiclone, zaleplon, zolpidem ZONACORT dexamethasone tablets (1.5 mg) ZONALON topical corticosteroid ZORVOLEX diclofenac ZTLIDO immediate-release gabapentin, immediate-release Lyrica, generic lidocaine 5% topical patches, OTC lidocaine cream, generic Rx lidocaine cream, solution, or ointment ZUPLENZ ondansetron ODT ZYCLARA imiquimod 5% cream ZYFLO montelukast , zafirlukast ZYFLO CR montelukast , zafirlukast

MedImpact Drug Exclusions

4-1-2019

High-Cost, Non-Essential Products Excluded Drug Preferred Alternative ACCUCAINE lidocaine topical ACTIVE-PAC generic gabapentin IR and lidocaine/menthol topical ADAZIN OTC lidocaine, benzocaine, methyl salicylate, capsaicin creams ALCORTIN A hydrocortisone-iodoquinol cream, ciclopirox cream, clotrimazole cream ALLEVESS PATCH topical capsaicin and menthol ALOQUIN hydrocortisone-iodoquinol cream ATOPICLAIR OTC hyaluronate products AVIDOXY DK generic doxycycline, OTC salicylic acid BENSAL HP topical hydrocortisone, OTC emollients, salicylic acid BENZODOX 30 generic doxycycline, OTC benzoyl peroxide BENZEPRO generic OTC or Rx topical benzoyl peroxide products CAPHOSOL OTC saliva mouthwash, powder, or spray/pump CAPXIB celecoxib, capsaicin/menthol CLINDAMYCIN PHOS/SKIN CLNSR 19 Acanya (clindamycin 1.2%/benzoyl peroxide 2.5%); Benzaclin generic (clindamycin 1%/benzoyl peroxide 5%); erythromycin 3%, benzoyl peroxide 5% CLINDAMYCIN/BENZOYL/EMOL CMB94 Acanya (clindamycin 1.2%/benzoyl peroxide 2.5%); Benzaclin generic (clindamycin 1%/benzoyl peroxide 5%; erythromycin 3%, benzoyl peroxide 5% CYCLOBENZAPRINEPAX generic cyclobenzaprine 10 mg tablets CYCLOTENS cyclobenzaprine 10 mg tablets DERMACINRX CINLONE-I CPI triamcinolone 40mg injectable; lidocaine/prilocaine DERMACINRX LEXITRAL topical diclofenac, topical capsaicin cream DERMACINRX PHN PAK topical generic lidocaine DERMACINRX PRIZOPAK topical lidocaine, prilocaine DERMACINRX PUREFOLIX folic acid and vitamin D DERMACINRX SILAPAK triamcinolone, dimethicone DERMACINRX SILAZONE triamcinolone, dimethicone DERMACINRX SURGICAL PHARMAPAK mupirocin and chlorhexidine DERMACINRX THERAZOLE PAK clotrimazole/betamethasone cream or lotion DERMACINRX ZRM PAK lidocaine/dimethicone cream DERMAPAK PLUS topical tretinoin DERMASORB HC hydrocortisone cream DERMASORB TA triamcinolone cream DERMASORB XM urea cream DICLO GEL-XRYLIX SHEET topical diclofenac DICLOFENAC SODIUM/MENTHOL topical diclofenac, OTC menthol/methyl salicylate DICLOPAK topical diclofenac

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative DICLOPR topical diclofenac, OTC menthol/methyl salicylate DICLOZOR topical diclofenac DMT SUIK injectable dexamethasone DOLOTRANZ lidocaine/prilocaine cream, lidocaine topical gel DS PREP PAK topical diclofenac DURACHOL OTC vitamin D3, folic acid DYZBAC folic acid, vitamin B12, OTC multivitamin ESOMEP-EZS Generic or OTC omeprazole, lansoprazole, OTC Pill Glide spray EZ FLU KIT Seasonal influenza virus vaccine FLEXIPAK diclofenac tablets, capsaicin cream HYDROCORTISONE betamethasone dipropionate, clobetasol propionate, fluocinonide, triamcinolone acetonide INFLAMMACIN diclofenac solution; methyl salicylate/menthol/camphor patch INFLAMMA-K diclofenac solution; methyl salicylate/menthol/camphor patch IV INFUSION CPI lidocaine/prilocaine cream KERALAC urea cream KERALYT OTC topical salicyclic acid gel or cream KRISTALOSE generic lactulose syrup LENZAPATCH topical lidocaine and menthol LIDO-K generic lidocaine 5% ointment LIDOCAINE/PRILO/M.SALICY/MENTH topical lidocaine/prilocaine cream, lidocaine gel, methyl salicylate/menthol LIDOPAC topical lidocaine LIDOPATCH topical lidocaine and menthol LIDORX OTC lidocaine 4% gel LIDORXKIT topical lidocaine LIDOTRAL topical lidocaine LIDOTRANS 5 PAK topical lidocaine LIDOVEX topical lidocaine LIDOXIB celecoxib and topical lidocaine/menthol LIDOZION generic lidocaine 5% ointment LOPROX KIT OTC clotrimazole 1%, terbinafine 1%, and tolnaftate 1% MEBOLEX multivitamin, folic acid, cholecalciferol, resveratrol MEDROX topical capsaicin and menthol MENTHO-CAINE lidocaine/menthol spray OTC, lidocaine cream OTC METFORMIN/BLOOD SUGAR generic metformin and formulary glucose test strips DIAGNOST METHAVER folic acid, multivitamin METOPIC urea cream MIGRANOW sumatriptan, camphor/menthol gel

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative MORGIDOX generic doxycycline MULTIVIT #34/FA/NADH/UBIQUINON folic acid, vitamin B12, OTC multivitamin NAPROPAK COOL naproxen NAPROXENPAX naproxen NOVACORT hydrocortisone/pramoxine creams NOXIFOL-D3 OTC vitamin D3, folic acid NOXIPAK fluocinolone/urea/silicone NUDROXIPAK Rx generic celecoxib capsules, OTC topical capsaicin/methyl salicylate NUDROXIPAD DSDR-50/75 Rx generic diclofenac delayed-release tablets, OTC topical capsaicin/methyl salicylate NUDROXIPAK E-400 Rx generic etodolac tablets, OTC topical capsaicin/methyl salicylate NUDROXIPAK I-800 OTC/Rx generic Ibuprofen tablets, OTC topical capsaicin/methyl salicylate NUDROXIPAK N-500 OTC/Rx generic nabumetone, OTC topical capsaicin/methyl salicylate NYATA topical nystatin PEDIPAK ciclopirox PHENOBARB/HYOSCY/ATROPINE/SCOP dicyclomine, hyoscyamine PRUCLAIR OTC hyaluronate products REVESTA OTC vitamin D3, folic acid ROSADAN metronidazole cream ROXIFOL-D OTC vitamin D3, folic acid RYNODERM urea cream SALEX KIT OTC salicylic acid cream, OTC hydrating cleanser or lotion SMARTRX GABAKIT gabapentin, topical lidocaine/menthol SMARTRX GABA-V KIT gabapentin, topical lidocaine/menthol SOLUPAK topical lidocaine SULFACETAMIDE/SULFUR/CLEANSR23 sulfacetamide and sulfur lotion TICALAST azelastine, fluticasone TICANASE OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl TICASPRAY OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl TRIXYLITRAL topical diclofenac, OTC kinesiology therapy tape, OTC lidocaine cream, generic Rx lidocaine solution, cream, or ointment ULTRAVATE X halobetasol cream UREA urea cream URE-K urea cream

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative UREVAZ urea cream VENIPUNCTURE CPI topical lidocaine VEREGEN imiquimod cream, podofilox solution VOPAC MDS generic diclofenac gel WHYTEDERM SURGIPAK ciclopirox WHYTEDERM TRILASIL PAK triamcinolone, dimethicone WOUND DEBRIDEMENT-LIDOCAINE topical lidocaine solution WPR PLUS OTC lidocaine cream, generic Rx lidocaine cream, solution, or ointment, OTC methyl salicylate/menthol cream XILAPAK topical fluocinolone solution XRYLIDERM topical lidocaine patches XRYLIX topical diclofenac