Drug Exclusion List | Pharmaceutical Benefits

Drug Exclusion List

 


These exclusions are in addition to those listed on the MedImpact exclusion document.

Brand Name
Generic Name
Abstral
Adakveo
Addiyi
Alcortin A
Andexxa
Auvi-Q
Avastin (oncology) 
 
Avsola
Benlysta
Beovu
Cablivi
Cetirizine 
 
Dojolvi
 
Emflaza
Evrysdi
 
Exondys 51
Feraheme
Flolan  
Gamifant  
Givlaari
 
Givosiran
 
Gocovri
Herceptin
 
Inflectra  
Ingrezza
Injectafer
Isturisa
 
Jublia  
Kesimpta
 
Kybella
 
Krystexxa 
 
Kymriah
Lutathera  
Luxturna
Macugen  
Micera  
Nexletol  
Nuplazid  
Ocaliva
 
Palforzia 
 
Praluent  
Radicava  
Repatha
Rituxan 
 
Reblozyl
 
Sinuva  
Spinraza
Spravato  
Supprelin LA
 
Synagis
 
Tecartus
 
Tepezza
 
Translarna
Tysabri
Vyepti  
Vyleesi
Vyondys 53 (golodirsen)  
Xembify  
Yescarta  
Zeposia
 
Zinbryta
Zolgensma  
Zostafax
Zulresso