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Drug Exclusion List | Pharmaceutical Benefits

Drug Exclusion List

 

Brand Name
Generic Name
 Abstral  Fentanyl
 Addyi  Flibanserin
 Alcortin-A  Iodoquinal-Hydrocortisone-Aloe
 Altoprev  Lovastatin Extended-Release
 Alvesco  Ciclesonide
 Amrix  Cyclobenzaprine Extended-Release
 Antara  Fenofibrate
 Apidra  Insulin
 Aptensio XR  Methylphenidate Extended-Release
 Arestin  Minocycline
 Asacol HD  Mesalamine Delayed-Release
 Aubagio  Teriflunomide
 Auvi-Q  Epinephrine Injection
 Bayer (Contour) Test Strips/Bayer Blood Glucose Test Strips  
 Beau RX  
 Beconase AQ  Beclomethasone Nasal
 Benzaclin Pump  Clindamycin, Benzoyl Peroxide
 Betaseron  Interferon Beta-1B
 Binosto  Alendronate
 Bydureon  Exenatide Extended-Release
 Byetta  Exenatide
 Cimzia  Certolizumab Pegol
 Cinquair  Reslizumab
 Delzicol  Mesalamine
 Denavir Cream  Penciclovir
 Dermacinrx  Triamcinolone 0.1%/Dimethicone 5%
 Dermacinrx Purefolix  Folic Acid/Vitamin D
 Dermapak Plus  Zinc Oxide/Menthol/Tretinoin
 Dermasilkrx  Triamcinolone Acetonide Cream/Dimethicone Cream
 Desvenlafaxine ER Tablet  Desvenlafaxine
 Deutetrabenazine  
 Dexilant  Dexlansoprazole
 Diclopack  Diclofenac Sodium
 Dipentum  Olsalazine
 Duexis  Famotidine/Ibuprofen
 Durlaza  Aspirin
 Edarbi  Azilsartan Medoxomil
 Edarbyclor  Azilsartan Medoxomil and Chlorthalidone
 Edluar  Zolpidem Tartrate
 Eprosartan  Eprosartan
 Estrogel  Estradiol
 Evekeo  Amphetamine Sulfate
 Extavia  Interferon Beta-1B
 Farxiga  Dapagliflozin
 Fentora  Fentanyl Citrate
 Fexmid  Cyclobenzaprine
 Flector Patch  Diclofenac
 Flexepacx  Cyclobenzaprine
 Flovent Diskus  Fluticasone Propionate
 Flovent HFA  Fluticasone Propionate HFA
 Forfivo XL  Bupropion Hydrochloride
 Fortesta  Testosterone
 Frova  Frovatriptan
 Genotropin  Somatropin
 Glumetza  Metformin
 Gralise  Gabapentin
 Horizant  Gabapentin Enacarbil Extended-Release
 Humatrope  Somatropin
 Hycofenix  Hydrocodone/Pseaudoephedrine/Guaifenesin
 Intermezzo  Zolpidem Tartrate
 Irenka  Duloxetine
 Jardiance  Empagliflozen
 Kadian  Morphine
 Kazano  Alogliptin and Metformin
 Khedezla  Desvenlafaxine
 Kombiglyze XR  Saxagliptin and Metformin
 Lazanda  Fentanyl Citrate
 LDO Plus  Lidocaine HCI
 Lescol XL  Fluvastatin
 Levemir  Insulin Detemir
 Levitra  Vardenafil
 Levorphanol
 Lidorx KIT  Lidocaine
 Livalo  Pitavastatin
 Mitagare  Colchicine
 Naprelan  Naproxen
 Napropack Cool  Naproxen
 Napropax  Naproxen
 Natesto  Testosterone
 Nesina  Alogliptin
 Norditropin  Somatropin
 Noritate  Metronidazole
 Novolin  Insulin
 Novolog  Insulin
 Nucala  Mepolizumab
 Nuplazid  Pimavanserin
 Nutropin  Somatropin
 Nutropin AQ  Somatropin
 Nuvigil  Armodafinil
 Omeprazole-Sodium Bicarbonate  
 Omnaris  Ciclesonide
 Onsolis  Saxagliptin
 Oracea  Doxycycline ER
 Oseni  Alogliptin and Pioglitazone
 Pancreaze  Lipase/Protease/Amylase
 Pediapalm  Lanolin, Ammonium Lactate, Glycerin
 Pedipak  Ciclopirox
 Pennsaid  Diclofenac
 Pertyze  Lipase/Protease/Amylase
 Pexeva  Paroxetine Mesylate
 Praluent  Alirocumab
 Praulent  Alirocumab
 Prestalia  Amlodipine/Perondopril
 Proventil HFA  Albuterol Sulfate
 Qsymia  Phentermine and Topiratmate Extended-Release
 Rayos  Prednisone
 Reclast-Zeledronic Acid (Brand Excluded - Generic Covered)  
 Repatha  Evolocumab
 Roche (Accu-chek) Test Strips/Roche Blood Glucose Test Strips  
 Rozerem  Ramelteon
 Sabril  Vigabatrin
 Saizen  Somatropin
 Seebri Neohaler  Glycopyrrolate
 Silapak  Triamcinolone 0.1% / Dimethicone 5%
 Silazone  Triamcinolone 0.1% / Dimethicone 5%
 Simponi  Grolimumab
 Sinelee Patch  Capsaicin-Menthol
 Staxyn  Vardenafil
 Subsys  Fentanyl Citrate
 Symbicort  Budesonide/Formoterol Fumarate
 Tanzeum  Albiglutide
 Testim  Testosterone
 Teveten  Eprosartan
 Teveten HCT  Eprosartan/Hydrochlorothiazide
 Tev-tropin  Somatropin
 Tirosint  Levothyroxine
 Tivorbex  Indomethacin
 Tresiba  Insulin Degludec Injection
 Treximet  Sumatriptan-Naproxen
 Tudorza  Aclidinium Bromide
 Utibron  Indacaterol/Glycopyrrolate
 Veltin  Clindamycin / Tretinoin
 Veramyst  Fluticasone Furoate
 Viekira Pak  Ombitasvir/Paraitaprevir/Ritonavir Tablets Co-packaged With Dasabuvir Tablets
 Vimovo  Naproxen/Esomeprazole
 Vogelxo  Testosterone
 Xenazine  Tetrabenazine
 Whytedermtd Pak  Triamcinolone 0.1%/Dimethicone 5%
 Xigduo XR  Dapagliflozin/Metformin
 Xopenex HFA  Levalbuterol
 Zetonna  Ciclesonide
 Zinbryta  Daclizumab
 Zioptan  Tafluprost Opthalmic
 Zipsor  Diclofenac
 Zolpimist  Zolpidem Tartrate
 Zomacton  Somatropin (rDNA Origin)
 Zorvolex  Diclofenac
 Zubsolv  Buprenorphine/Naloxone
 Zuplenz  Ondansetron