High-Cost Drug Exclusions
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- Allan Lamb
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1 PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary. Please visit your health plan s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service at the number listed on the back of your member ID card. Absorica Acanya AcipHex Sprinkles Acticlate Aczone adapalene 0.1% lotion, solution Altoprev Amrix Anastia lotion ApexiCon E Astero Atelvia Amnesteem, Claravis, Myorisan, Zenatane esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole adapalene 0.1% gel, adapalene 0.1% cream, OTC Differin 0.1% Gel cyclobenzaprine tablet desoximetasone 0.05% cream, triamcinolone 0.5% cream alendronate, ibandronate, risedronate IR (immediate-release) 2019
2 Beconase AQ Belsomra Binosto Byvalson Cambia packets Carac carbinoxamine 6mg tablet Centany Cidaleaze Clindagel clindamycin 1% topical gel (generic for Clindagel) clindamycin-benzoyl peroxide % (generic for Acanya) clindamycin-tretinoin clocortolone pivalate cream, pump Cloderm cream, pump Clorpres Cordran 0.05% ointment, tape CoreMino Cuprimine dapsone 5% gel Daxbia Desonate gel diphenhydramine, doxepin, eszopiclone, trazodone, zaleplon, zolpidem alendronate 70mg Bystolic + valsartan diclofenac tablet fluorouracil 0.5% external cream carbinoxamine 4mg tablet mupirocin 2% external ointment mometasone 0.1% cream, triamcinolone 0.1% cream mometasone 0.1% cream, triamcinolone 0.1% cream chlorthalidone + clonidine hydrocortisone 0.5% ointment, fluocinolone 0.025% ointment, triamcinolone 0.1% ointment Depen Titratabs (penicillamine) cephalexin 250mg, cephalexin 500mg desonide cream, lotion, ointment 2019
3 desoximetasone spray Dexilant Differin 0.1% lotion diflorasone diacetate cream diflorasone diacetate ointment Doryx, Doryx MPC doxycycline DR doxycycline hyclate 50mg, 75mg, 150mg tablet (generic for Acticlate, Targadox) Duexis Durlaza Dutoprol Dymista Ecoza Edarbi Edarbyclor Edluar EHA lotion Emflaza Ertaczo esomeprazole strontium desoximetasone 0.05% gel, fluocinonide 0.05% solution esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole adapalene 0.1% gel, adapalene 0.1% cream, OTC Differin 0.1% Gel desoximetasone 0.05% cream, triamcinolone 0.5% cream desoximetasone 0.25% ointment, fluocinonide 0.05% ointment ibuprofen + famotidine aspirin 81mg metoprolol + hydrochlorothiazide econazole 1% cream irbesartan, losartan, olmesartan, telmisartan, valsartan irbesartan-hctz, losartan-hctz, olmesartan-hctz, telmisartan-hctz, valsartan- HCTZ eszopiclone, trazodone, zolpidem, zaleplon methylprednisolone, prednisolone, prednisone terbinafine cream/ tablet lansoprazole, omeprazole, pantoprazole, OTC medications such as Nexium 24HR 2019
4 Exelderm 1% cream, solution Extina Fabior Flector fluocinonide 0.1% cream flurandrenolide 0.05% ointment fluvastatin capsule fluvastatin ER tablet Fortamet Glumetza Gocovri Gonitro Gralise Halog cream Halog ointment Horizant imiquimod 3.75% cream Inderal XL Indocin InnoPran XL Intermezzo Isordil 40mg tablet Istalol (once daily) eye drops terbinafine cream/ tablet ketoconazole cream, shampoo diclofenac topical gel, solution clobetasol 0.05% cream, halobetasol 0.05% cream hydrocortisone 0.5% ointment, fluocinolone 0.025% ointment, triamcinolone 0.1% ointment metformin, metformin ER (non-osmotic, non-modified release) metformin, metformin ER (non-osmotic, non-modified release) amantadine, Osmolex ER nitroglycerin SL (sublingual) tablet gabapentin betamethasone AF 0.05% cream, desoximetasone 0.25% cream betamethasone dipropionate 0.05% ointment, desoximetasone 0.25% ointment, fluocinonide 0.05% ointment gabapentin imiquimod 5% cream propranolol ER indomethacin propranolol ER eszopiclone, trazodone, zolpidem, zaleplon isosorbide dinitrate timolol maleate (twice daily) eye drops [generic for Timoptic] 2019
5 ketoconazole 2% foam Ketodan lansoprazole ODT (orally disintegrating tablet) LDO Plus Lescol Lescol XL Lexette Lido-K 3% lotion lidocaine 3% cream lidocaine 3.88% cream lidocaine 4.12% cream lidocaine 3% lotion lidocaine-tetracaine cream 7-7% LidoDose Lidopin 3% cream Lidopin 3.25% cream LidoRx Lidotral 3.88% cream Lidotrex Lidovex Lidovin Lidozion Lidozol Livalo ketoconazole cream, shampoo ketoconazole cream, shampoo lansoprazole, omeprazole, pantoprazole, OTC medications such as Prevacid 24HR halobetasol cream, ointment lidocaine-prilocaine cream, lidocaine ointment/ gel/ patch 2019
6 Lovaza luliconazole cream Luzu metformin ER modified release metformin ER osmotic release metoclopramide ODT (orally disintegrating tablet) metoprolol-hctz ER (generic for Dutoprol) minocycline ER Minolira mometasone nasal Morgidox Naftin gel Nalfon Naprelan Nasonex Neuac Nocdurna Noctiva prescription or OTC omega-3 fatty acids terbinafine cream/ tablet terbinafine cream/ tablet metformin, metformin ER (non-osmotic, non-modified release) metformin, metformin ER (non-osmotic, non-modified release) metoclopramide IR (immediate-release) [Reglan] metoprolol + hydrochlorothiazide naftifine cream fenoprofen naproxen ER tablet desmopressin nasal spray, desmopressin tablet, oxybutynin, tolterodine ER, tolterodine IR (immediate-release), trospium IR desmopressin nasal spray, desmopressin tablet, oxybutynin, tolterodine ER, tolterodine IR (immediate-release), trospium IR 2019
7 Numbonex lotion omeprazole-sodium bicarbonate capsule, packet Omnaris Onexton Oxistat 1% lotion Pandel cream Pennsaid Pliaglis Plixda pads Prestalia Prevacid SoluTab Prilosec packet Protonix packet Psorcon cream Qnasl Rayos risedronate DR Rozerem Sernivo external spray Solodyn Sprix esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, OTC medications such as Zegerid OTC oxiconazole cream (generic), terbinafine tablet betamethasone valerate 0.1% cream, fluocinolone 0.025% cream, hydrocortisone butyrate 0.1% cream diclofenac topical gel, solution lidocaine-prilocaine cream, lidocaine ointment/ gel/ patch adapalene 0.1% gel, adapalene 0.1% cream, OTC Differin 0.1% Gel perindopril + amlodipine esomeprazole, omeprazole, lansoprazole, pantoprazole, rabeprazole, OTC medications such as Prevacid 24HR esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole desoximetasone 0.05% cream, triamcinolone 0.5% cream methylprednisolone, prednisolone, prednisone alendronate, ibandronate, risedronate IR (immediate-release) eszopiclone, trazodone, zolpidem, zaleplon, OTC melatonin betamethasone cream, lotion, ointment diclofenac tablet, etodolac, meloxicam, nabumetone 2019
8 sumatriptan-naproxen (generic for Treximet) Targadox Tazorac Gel Texacort timolol maleate (once daily) eye drops [generic for Istalol] Timoptic Ocudose Tivorbex Topicort spray Tranzarel Treximet Trianex ointment Ultravate 0.05% lotion Vanos cream Vascepa Veltin Verdeso Vibramycin Vimovo Vivlodex Vusion Xerese sumatriptan + naproxen fluocinolone 0.025% ointment, hydrocortisone 0.5% ointment, triamcinolone 0.1% ointment timolol maleate (twice daily) eye drops [generic for Timoptic] timolol maleate (twice daily) eye drops [generic for Timoptic] indomethacin desoximetasone 0.05% gel, fluocinonide 0.05% solution sumatriptan + naproxen triamcinolone 0.025% ointment, triamcinolone 0.1% ointment halobetasol cream, ointment clobetasol 0.05% cream, halobetasol 0.05% cream prescription or OTC omega-3 fatty acids desonide cream, lotion, ointment naproxen + esomeprazole meloxicam tablet clotrimazole 1% cream, ketoconazole 2% cream, miconazole topical cream/ ointment, nystatin cream/ ointment/ powder topical acyclovir + topical hydrocortisone 2019
9 Xhance Ximino Xolegel Zegerid capsule, packet Zetonna Ziana Zipsor zolpidem SL (sublingual) tablet [generic for Intermezzo] Zolpimist Zorvolex Zuplenz Zyclara Zypitamag Institutional and Clinic Packs (e.g. medications packaged as unit dose) Therapy Packs ketoconazole cream, shampoo esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, OTC medications such as Zegerid OTC diclofenac tablet eszopiclone, trazodone, zaleplon, zolpidem eszopiclone, trazodone, zaleplon, zolpidem diclofenac tablet granisetron, ondansetron, ondansetron ODT (orally disintegrating tablet) imiquimod 5% cream non-unit-dose equivalent medication individual drug products as appropriate Questions? Call the Customer Service number on your member ID card. 2019
High-Cost Drug Exclusions
Pharmacy Services High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
High-Cost Drug Exclusions
PHARMACY SERVICES High-Cost Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at
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Drugs That Require Step Therapy (ST) Step Therapy Medications
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UWSP Student Health Service Pharmacy Formulary 1/22/2015
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PORTFOLIO Q June 2014 Availability of products is subject to patent restrictions in countries where applicable patents are in effect 1/5
Abiraterone Tablet 250 mg Q4 2015 Acetylsalicylic Acid Tablet GR 100 mg Available Aciclovir Cream 5% - 2 Grs Q4 2014 Alendronic Acid Tablet 70 mg Available Amisulpride Tablet 50 ; 100 ; 200 ; 400 mg Available
2019 PacificSource Health Plans Step Therapy Criteria. Last Modified: 02/22/2019 (All criteria reviewed at least once per year)
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Medication Policy Manual. Topic: Dupixent, dupilumab Date of Origin: March 10, Committee Approval: March 10, 2017 Next Review Date: May 2018
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All Pharmacy and Prescribing Providers. Subject: State Maximum Allowable Cost (MAC) Updates
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Hundreds of Choices. More Savings Every Day. 8 and $ 12 Generics Also Available. Based on 30-day supply at commonly prescribed doses
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Allergies & Cold and Flu $4, 30-day $10, 90-day Benzonatate 100mg cap 14 42 Loratadine 10mg tab 30 90 Promethazine DM syrup 120ml 360ml Antibiotic Treatments Amoxicillin 125mg/5ml susp (80ml bottle) 1
The safety and effectiveness of Dupixent in pediatric patients have not been established (1).
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.90.30 Subject: Dupixent Page: 1 of 6 Last Review Date: September 15, 2017 Dupixent Description Dupixent
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1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
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Avoid paying too much for your prescriptions
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Prior Authorization List
Certain medications require prior authorization, which means approval is needed before the prescription can be filled. If approval is not received, the drug may not be covered. The following prescription