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Drug Exclusion List | Pharmaceutical Benefits

Drug Exclusion List

 

Brand Name
Generic Name
Abrstral
Accucaine
Acthar Adrencorticotropic Hormone
Active-PAC Kit
Adlyxin  
Adzebys XR ODT
Alcortin A Hydrocortisone/Iodoquin/Aloe 2
Allzital
Altoprev  
Alvesco
Amrix  
Antara
Apidra  
Apidra Solostar
Aptensio XR  
Arestin
Auvi-Q  
Basaglar
Beau RX  
Beconase AQ
Belbuca  
Bepreve
Bevespi Aerosphere  
Binosto
Bydureon  
Byetta
Capxib  
Cimzia Certolizumab
Cinqair Reslizumab
Daklinza
Daxbia  
Delzicol
Dermapak Plus  
Dermasorb Xm
Dipentum  
Duexis
Durlaza  
Edluar
Emadine  
Emflaza
Eprosartan  
Estrogel
Evekeo Amphetamine Sulfate
Evzio
Exondys 51 Eteplirsen
Extavia
Farxiga  
Fentora
Fexmid  
Flexepax
Flovent Diskus  
Flovent HFA
Flumist Quad 2016-2017 Flu Vacc Qv Live 2016(2-49 Yrs)
Forfivo Xl
Fortesta  
Genotropin
Glumetza  
Gonitro
Gralise  
Horizant
Humatrope  
Hycofenix
Intermezzo Zolpidem
Intron-A Interferon Alfa 2B
Irenka  
Kadian Morphine
Kazano  
Keralac Urea Cream
Kevzara Sarilumab
Khedezla Desvenlafaxine
Kombiglyze XR  
Lastacaft
Lazanda  
Levemir
Levitra  
Locort
Methaver  
Motofen Difenoxin HCL/Atropine Sulfate
Naprelan  
Natesto
Nesina  
Noritate
Novolin  
Novolog
Novolog Flexpen  
Nuplazid Pimavanserin
Nutropin  
Nyata
Ocrevus Ocrelizumab
Omeprazole/Sodium Bicarbonate Omeprazole/Sodium Bicarbonate
Omnaris  
Onglyza
Onsolis  
Onzetra
Oseni  
Pancreaze
Pazeo  
Pedipak
Pennsaid  
Pertzye
Pexeva  
Prestalia
Proventil HFA  
Qsymia
Rayos  
Rozerem
Saizen  
Sarilumab Sarilumab
Seebri Neohaler  
Siliq Brodalumab
Simponi Aria Golimumab
Smartrx Gaba Kit
Smartrx Gaba -V Kit  
Soliqua
Spinraza  
Staxyn
Stendra  
Subsys
Synerderm  
Tanzeum
Testim  
Ticalast
Ticanase  
Tirosint
Tivorbex  
Tresiba
Treximet  
Tudorza Pressair
Tysabri  
Ure-K
Urevaz  
Utibron
Utopic  
Veltin
Viekira Pak  
Vimovo
Vivlodex  
Vogelxo
Xigduo XR  
Xultophy
Yervoy Ipilimumab
Yosprala
Zembrace Symtouch  
Zetonna
Zioptan  
Zipsor
Zolpimist  
Zomacton
Zonacort  
Zorvolex
Zuplenz