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
Addiyi
Alcortin A
Auvi-Q
Avastin (oncology) (1/1/2020)
 
Benlysta
Cablivi (effective 1/1/2020)
Cetirizine  (4/1/2020)
 
Dojolvi
 
Emflaza
Evrysdia
 
Exondys 51
Feraheme
Gamifant  
Givosiran (4/1/2020)
 
Gocovri
Herceptin (1/1/2020)
 
Inflectra  
Ingrezza
Injectafer
Isturisa
 
Jublia  
Kesimpta
 
Krystexxa (10/1/2019)
 
Kymriah
Lutathera  
Luxturna
Micera  
Nexletol (4/1/2020)  
Nuplazid  
Ocaliva
 
Palforzia (1/31/2020)
 
Praluent  
Radicava  
Remicade
Repatha
Rituxan (4/1/2019)
 
Sinuva  
Spinraza
Spravato  
Supprelin LA
 
Synagis
 
Tecartus
 
Translarna
Tysabri
Ultomiris
Vyleesi
Vyondys 53 (golodirsen)  
Yescarta  
Zeposia
 
Zinbryta
Zolgensma  
Zostafax
Zulresso