MedImpact Drug Exclusions 4-1-20 Formulary Exclusions Excluded Drug Preferred Alternative ADHANSIA XR Methylphenidate ER, dexmethylphenidate XR, Concerta, Quillichew ER, Quillivant XR ADLYXIN Ozempic, Rybelsus, Trulicity, Victoza, Byetta, Bydureon, Bydureon Bcise ADMELOG Insulin lispro ADMELOG SOLOSTAR Insulin lispro 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, Symbicort (brand and authorized generic) AJOVY Aimovig, Emgality 120mg ALVESCO Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler APIDRA Insulin lispro APIDRA SOLOSTAR Insulin lispro APTENSIO XR Methylphenidate ER, dexmethylphenidate XR, 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 ER, dexmethylphenidate XR, Concerta, Quillichew ER, Quillivant XR DELZICOL (brand and generic) Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine DIPENTUM Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine DUAKLIR PRESSAIR Anoro Ellipta, Bevespi Aerosphere, Siolto Respimat DULERA Advair Diskus/HFA, Breo Ellipta, Symbicort EMADINE azelastine, olopatadine ESTROGEL Divigel EXTAVIA Aubagio, Avonex, Betaseron, glatiramer, Gilenya, Glatopa, Mavenclad, Mayzent, Plegridy, Rebif, Tecfidera, Vumerity GENOTROPIN Norditropin MedImpact Healthcare Systems, Inc. Page 1 pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions 4-1-20 Excluded Drug Preferred Alternative HUMATROPE Norditropin INVOKANA Jardiance, Farxiga INVOKAMET Synjardy, Synjardy XR, Xigduo XR INVOKAMET XR Synjardy, Synjardy XR, Xigduo XR JORNAY PM Methylphenidate ER, dexmethylphenidate XR, Concerta, Quillichew ER, Quillivant XR KAZANO Janumet, Janumet XR KEVZARA Enbrel, Humira, Rinvoq, Xeljanz, Xeljanz XR KOMBIGLYZE XR Janumet, Janumet XR LASTACAFT azelastine, olopatadine LEVALBUTEROL TARTRATE ProAir HFA, ProAir RespiClick, Ventolin HFA MOTEGRITY Linzess MYDAYIS Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine,Vyvanse NESINA Januvia (brand and authorized generic) NOVOLIN Humulin NOVOLIN R FLEXPEN Humulin KwikPen NOVOLOG Humalog NUTROPIN Norditropin NUTROPIN AQ Norditropin OLUMIANT Enbrel, Humira, Xeljanz, Xeljanz XR OMNARIS OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl OMNITROPE Norditropin ONGLYZA Januvia OSENI Januvia, pioglitazone (brand and authorized generic) PANCREAZE Creon, Zenpep PAZEO azelastine, olopatadine PERTZYE Creon, Zenpep PRADAXA Eliquis, Xarelto PROVENTIL HFA ProAir HFA, ProAir RespiClick, Ventolin HFA (brand and authorized generic) QSYMIA Contrave QTERN Glyxambi RASUVO Otrexup SAIZEN Norditropin SAVAYSA Eliquis, Xarelto SAXENDA Contrave MedImpact Healthcare Systems, Inc. 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MedImpact Drug Exclusions 4-1-20 Excluded Drug Preferred Alternative SEEBRI NEOHALER Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta SEGLUROMET Synjardy, Synjardy XR, Xigduo XR SIMPONI (50 mg) Cosentyx, Enbrel, Humira, Stelara, Xeljanz, Xeljanz XR STEGLATRO Jardiance, Farxiga STEGLUJAN Glyxambi SYMPROIC Linzess, Movantik TALTZ Cosentyx, Enbrel, Humira, Otezla, Skyrizi, Stelara, Tremfya TECHNIVIE Epclusa, Harvoni, Mavyret, Vosevi TRULANCE Linzess TUDORZA PRESSAIR Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta UTIBRON NEOHALER Anoro Ellipta, Stiolto Respimat, Bevespi Aerosphere VIEKIRA PAK Epclusa, Harvoni, Mavyret, Vosevi VIEKIRA XR Epclusa, Harvoni, Mavyret, Vosevi WIXELA INHUB Advair Diskus/HFA, Breo Ellipta, Symbicort XOPENEX HFA ProAir HFA, ProAir Respiclick, Ventolin HFA ZELNORM Linzess 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, ABSORICA LD generic isotretinoin capsules ABSTRAL fentanyl citrate lozenge ACUICYN OTC OCuSOFT lid scrub, ocular antibiotics, OTC artificial tears ACTICOAT, ACTICOAT 7, ACTICOAT OTC and other silver products FLEX 3, ACTICOAT FLEX 7, ACTICOAT SURGICAL 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 ALLEVYN, ALLEVYN ADHESIVE, OTC and other foam bandage products ALLEVYN HEEL ALLEVYN AG, ALLEVYN AG ADHESIVE, OTC and other foam bandage and silver products ALLEVYN AG GENTLE ALLZITAL generic butalbital/acetaminophen (50mg-325mg tablet) ALZAIR Chloraseptic Allergen Block AMRIX cyclobenzaprine (5mg or 10mg) MedImpact Healthcare Systems, Inc. Page 3 pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions 4-1-20 Excluded Drug Preferred Alternative AMZEEQ Oral doxy/minocycline, topical antibiotics for acne (e.g. dapsone, clindamycin) ANTARA fenofibrate, micronized/nanocrystallized APEXICON E Generic high potency topical steroid (e.g., fluocinonide 0.05%, betamethasone dipropionate 0.05%) APLENZIN bupropion extended release, bupropion AQUORAL OTC saliva mouthwash, powder, or spray/pump ASPIRIN/OMEPRAZOLE OTC aspirin, OTC 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) AUVI-Q Epi-Pen, generic epinephrine autoinjector, Symjepi 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 BESER (fluticasone, emollient no 65) Fluticasone 0.05% lotion/cream, OTC emollient BIAFINE OTC hyaluronate products, OTC wound dressings, barrier creams BINOSTO alendronate, ibandronate BIONECT OTC hyaluronate products BIOSTEP OTC collagen dressings BIOSTEP AG OTC collagen dressings and silver 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; generic betamethasone augmented 0.05%; generic fluocinonide BUTALBITAL-ACETAMINOPHEN generic butalbital/acetaminophen (50mg-325mg tablet) (50MG-300MG CAPSULE) CAMBIA Diclofenac oral tablets, other generic NSAIDs CAROSPIR generic spironolactone tablets CELACYN OTC Mederma, OTC Scarguard MD, OTC ScarAway CELACYN POST PROCEDURE OTC moisturizing creams/cleansers MedImpact Healthcare Systems, Inc. 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MedImpact Drug Exclusions 4-1-20 Excluded Drug Preferred Alternative 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) CICATRACE PAD, DERM-SILK Standard dressings CONSENSI Generic amlodipine and celecoxib (individually) CONZIP generic tramadol extended-release capsules or tablets COREMINO generic immediate-release minocycline capsules or tablets, doxycycline DENAVIR Generic oral acyclovir, famciclovir, and valacyclovir 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 DIFLORASONE DIACETATE Generic high to super-high potency topical steroid (e.g., CREAM/OINTMENT fluocinonide, betamethasone dipropionate) DIMENTHO Generic diclofenac topical preparations and OTC topical counterirritants DOXYCYCLINE (SELECTED Generic doxycyclines STRENGTHS) DUEXIS famotidine & ibuprofen DULOXETINE HCL generic duloxetine DURLAZA RX/OTC aspirin, clopidogrel DUTOPROL generic metoprolol, hydrochlorothiazide DXEVO Generic dexamethasone tablets EDLUAR eszopiclone, zaleplon, zolpidem ELETONE OTC emollients or creams, OTC generic hydrocortisone ENDOFORM OTC collagen dressings 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 EPISIL OTC saliva substitutes MedImpact Healthcare Systems, Inc. Page 5 pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved. MedImpact Drug Exclusions 4-1-20 Excluded