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Excluded Drug List, Effective May 1,2021

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Excluded Drug List, Effective May 1,2021 Drug Exclusions May 1, 2021 Why Doesn’t My Health Plan Cover Some Providers Drugs? To request a formulary exception for a drug noted on the list with a (+), call 877-440-0089. To request a From time to time, our pharmacy committee decides formulary exception for all other listed drugs, call the to no longer cover, or exclude, some drugs because precertification number on the member’s ID card. other safe, effective, less costly alternatives are available. The committee is composed of independent Members doctors and pharmacists who regularly review and To request a formulary exception for all drugs listed, compare prescription drugs to ensure the ones we call the Customer Service number on your ID card. cover include proven medications for treating the Note: Formulary exceptions can only be considered majority of medical conditions. with required documentation from the member’s Newly-launched products and new variations of health care provider. products already on the market are not automatically added to your health plan’s list of covered drugs, also What Happens If I Have A Prescription Filled known as a formulary. A product can be added to the For An Excluded Drug? formulary only if our pharmacy committee decides You will be able to get your drug, but you will pay the that it is clinically appropriate and cost-effective. full cost of it. What Should I Do If My Drug Is Excluded? What Drugs Are Excluded From Coverage? Talk to your doctor to see if a covered alternative drug The drugs on the following pages are excluded from is a good option for treating your condition. Note that coverage as of the date of this list. many excluded brand-name drugs have covered Your pharmacy benefit may not cover certain generic alternatives. categories of drugs, such as those used to treat weight Of course, you and your doctor make the final decision loss or sexual dysfunction. Please check your plan about the medications that are right for you. If your materials for details about coverage for a specific drug doctor believes no alternative drug will work for your category. medical condition, you or your doctor can request a formulary exception to have an excluded drug covered. Just follow these steps: Check your benefit information to verify coverage or view your personal benefit information on our website. This list may contain trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with your health plan. This list may change or expand from time to time without prior notice. Drug Exclusions List – Effective 5/1/21 1 Excluded Drug List Specialty drugs are noted with a (#). A Android-10 (brand) Benzocaine-Lidocaine- Carteolol Ophthalmic Cosela (#) Abecma (#) Antara (brand) Tetracaine Oint Carticel Cotempla Abilify (brand) Apadaz Benzhydrocodone/ Cataflam Crysvita (#) Abilify Mycite Aplenzin Acetaminophen Celacyn Cuprimine (#) Absorica/LD Apligraf (#) Benzonatate 150 mg Celexa Cutaquig (#) Acanya Aptensio XR (brand) Beovu (#) Cequa Cuvitru (#) Aciphex Arakoda Betamethasone Ceracade Cyclobenzaprine ext rel Acnefree Arazlo Dipropionate- Cerave Cyfolex Acthrel (#) Arestin Minoxidil Cholecal DF Cymbalta (brand) Acticlate (brand & gen.) Arikayce (#) Betapace/AF tablet Chorionic Cystadane (#) Acuicyn Armonair Digihaler Bevacizumab prefilled Gonadotropin (#) Cystadrops (#) Acyclovir 5% cream Armonair Respiclick syr. (#) Chlorzoxazone 250 mg, Cytomel (brand) Artesunate Bevyxxa 375 mg & 750 mg Aczone 5% (brand) D Adagen (#) Arymo ER Biafine Cicatrace Pad Adakveo (#) Asacol HD (brand) Bijuva Ciclopirox-Clobetasol D.H.E. (brand) Adapalene-Benzoyl Asceniv (#) Binosto (brand) Shampoo Daklinza (#) Peroxide- Asmanex Bionect Ciclopirox-Clobetasol- Dandelion Allergenic Ext. Clindamycin Gel Asparlas (#) Bocasal oral rinse Salicylic Acid Shampoo Danyelza (#) Adapalene-Benzoyl Aspergillus Fumigatus Bonjesta Ciclopirox-Salicylic Acid Dapsone-Niacinamide Gel Peroxide- Aspirin/Omeprazole Bortezemib (#) Shampoo Dapsone-Niacinamide- Niacinamide Gel Atacand/HCT (brand) Botox Cosmetic (#) Ciprofloxacin/Fluocino- Spironolactone Gel Adderall (brand) Ativan (brand) Bravelle (#) lone Otic Daxbia Adhansia XR Atopiclair Breyanzi (#) Cimetidine-Lidocaine- Dayvigo Adlyxin Atralin Breztri Aerosphere Salicylic Acid Cream Defitelio (#) Admelog Atrapro spray/gel/kit Brineura (#) Cinqair (#) Deflux Adzenys XR Aurstat Briviact Clarinex/Clarinex-D Delstrigo Aemcolo Austedo (#) Bromsite Claritin/Claritin-D Denavir Aerospan Auvi-Q Bronchitol Clenpiq Dermatop (brand) Afstyla (#) Avar (brand) Brukinsa (#) Clindagel Desloratadine Airduo Aveed (brand) (#) Bryhali Clindamycin Phos- Desowen Ajovy Avenova Budesonide/Formoterol Niacinamide- Dexchlorpheniramine syr. Aklief Avsola (#) Bunavail (brand) Tretinoin Cream Dexeryl Ala Scalp Azelex (brand) Bupap (brand) Clindamycin Phosphate- Dexilant Alavert Azesco Bupivacaine HCL Niacinamide Lotion Dexpak Alcortin A Azor (brand) Butalbital/APAP 50/300 1-4% Dextenza (#) Aldara (brand) Azelaic Acid-Niacinamide Bynfezia Pen (#) Clindamycin Phosphate- Dexycu Alevicyn Antipruritic/Plus Cream Byvalson Niacinamide Gel Diclegis (brand and gen.) Azeschew Clindamycin-Benzoyl Diclofenac caps Allegra/Allegra-D C Peroxide-Niacinamide Diclofenac Sodium- Allzital B Aloquin Cabenuva Gel Sodium Hyaluronate- Alora (brand) Baclofen 5 mg Caduet Clindamycin-Niacinamid- Niacinamide Gel Altoprev (brand) Balcoltra Cafergot tablet Spironolac-Tretinoin Diclofono Altreno Bafiertam (#) Calcipotriene- Gel Differin gel Alvesco Barhemsys Betamethasone Clobetasol Propionate- Diflorasone cream & Alzair Baxdela Calcipotriene-Clobetasol Levocetirizine Dihyd oint. Amcinonide 0.1% cream Beau Rx Propionate Shampoo Dihydroergotamine & ointment Belbuca Caldolor Clobetasol Propionate- spray Ameluz Benicar/HCT (brand) Cambia Niacinamide Dimercaptopropane- Amondys 45 (#) Bensal HP Candida Albicans Extract Cream/Oint/Soln Sulfonate Amphetamine ER Susp Benz Per-Clindamycin- Caplyta Colcrys (brand) Diuril Amrix (brand) Niacinamide- Carac (brand & generic) Conjupri Divigel (brand) Amzeeq Tretinoin Gel Carbinoxamine 6 mg Consensi Doptelet (#) Andexxa (#) Benzaclin (brand) Cardizem CD/LA (brand) Conzip (brand) Doryx/MPC (brand) Androgel 1.62% (brand) Benzamycin (brand) Carnitor/SF Cordran Doxepin cream/tabs Benzepro (brand) Carospir Cortaid max. strength Doxycycline DR 80mg Drug Exclusions List – Effective 5/1/21 2 Doxycycline Finasteride-Minoxidil Herzuma (#) Intuniv (brand) Lanoxin 125 & 250 mcg Monohydrate cap 75 Firdapse (#) Horizant (brand) Inveltys tablet mg First Atenolol susp. HPR Plus/MB Hydrogel Iodoquinol- Lansoprazole Drizalma First-Lansoprazole Kit Hydrocortisone- Lazanda Duaklir (excluded only for Hyaluronate Sodium- Ketoconazole Cream Ledipasvir/Sofosbuvir (#) Duexis members 17 years Niacinamide- Ionil liquid Levicyn dermal spray Duobrii and older) Tacrolimus Ipamorelin Acetate (#) Levitra Dutoprol First-Omeprazole Hyaluronate Sodium- Isturisa (#) Levorphanol Duzallo (excluded only for Niacinamide- Ivermectin- Levulan Kerastik Dxevo members 17 years Tretinoin Metronidazole- (brand) Dyanavel XR (brand) and older) Hycofenix (brand) Niacinamide Gel Lexapro (brand) Dyrenium capsule Flolipid Hydrisalic Lexette J Fluconazole-Ibuprofen- Hydrocodone 2.5 mg/ Lialda (brand) E Itraconazole- guaifenesin 200 mg Jatenzo Librax (brand) Econazole Nitrate- Terbinafine hydrocortisone 1% in Jelmyto (#) Libtayo (#) Niacinamide Cream Fluocinolone asorbase Jivi (#) Licart Edecrin (brand) Acetonide- Hydroquinone Jornay PM Lidocaine-Tetracaine Edex Niacinamide Cream Emulsion Jublia Cream EES granules Fluorouracil cream 0.5% Hydroquinone- Juluca Lidocaine cream 4.12% Effexor XR (brand) Fluoroplex (brand) Hydrocortisone K Lidoderm (brand) Efudex (brand) Fluticasone/salmeterol Emulsion Lidotrex (lidocaine) Elestrin (brand) inhaler Hydroquinone- Kadian (brand) 2% gel Elepsia XR Folene Hydrocortisone- Kamdoy Lipofen (brand) Eletone Folika-V Tretinoin Emulsion Kanjinti (#) Locoid (brand) Emflaza (#) Folite Hylatopic Plus Kapspargo Lodrane D Endari Folvite-FE Hymovis (#) Katerzia Lokelma Enstilar Forfivo XL (brand) Hyperhep B (#) Kedrab (#) Lonhala Entty Spray Emulsion Fortamet (brand & gen.) Hyperrab (#) Kelarx (silicone) Scar Loprox (brand) Envarsus XR (#) Fosamax + D Hyperrab S/D (#) Care Gel Loteprednol ophth gel Epaned (brand) Fotivda (#) Keramatrix Loyon I Epiceram Fulphila (#) Kerydin Lucemyra Epicoccum Nigrum Fungoid-D IBU 600-EZS Ketoconazole 2% foam Lumoxiti (#) EpiPen/Jr. (brand) Idelvion (#) Ketoconazole- Lunesta (brand) G EryPed 200 & 400 mg Idhifa (#) Hydrocortisone Lupkynis (#) Esomeprazole Gamifant (#) Ilumya (#) Cream Luradrox gel Esperoct (#) Gatifloxacin Iluvien (#) Ketoprofen ER Lutathera (#) esterified estrogen/ dexamethasone imiquimod cream 3.75% Ketamine HCL Luxturna (#) methyl-testosterone Gelclair Gel Imiquimod- Ketodan Luzu Eucrisa Gemtesa Levocetirizine Dihcl- Ketorolac spray Lyrica/CR Eurax lotion Genadur Niacinamide Gel Keveyis (#) Lyumjev Evekeo/ODT (brand) Genvisc (#) Imiquimod- Khapzory (#) Evenity (#) Giazo (brand) Levocetirizine Dihcl- Kinerase M Evivo Gimoti Tretinoin Gel Klisyri Macrilen (#) Evkeeza (#) Gloperba Imitrex (brand) Klor-Con oral pack for Macrodantin capsules Evomela (#) Glumetza (brand & Imlygic (#) solution Margenza (#) Exondys 51 (#) generic) Imogam (#) Kovaltry (#) Mavenclad (#) Ezallor Glycopyrrolate 1.5mg Impoyz Krintafel Mayzent (#) Gocovri Imvexxy Kristalose pak Mepsevii (#) F GPL Pak Inbrija (#) Krystexxa (#) Metformin ER (only Fasenra (#) Gralise (brand) Inderal LA/XL Kymriah (#) excluded when Fenofibrate 130 mg Grastek
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