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. 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 Antara Claravis, Myorisan, Zenatane over-the-counter (OTC) Differin 0.1% External Gel, prescription adapalene 0.1% gel, prescription adapalene 0.1% cream cyclobenzaprine tablet gemfibrozil, fenofibrate ApexiCon E Beconase AQ Belsomra Binosto budesonide AQ Byvalson Cambia packets Carac desoximetasone 0.05% cream, triamcinolone 0.5% cream diphenhydramine, doxepin, trazodone alendronate 70mg Bystolic plus valsartan diclofenac tablet fluorouracil 0.5% external cream
Centany Clindagel clindamycin topical gel 1% (generic for Clindagel) clindamycin-benzoyl peroxide 1.2-2.5% (generic for Acanya) clindamycin-tretinoin clocortolone pivalate cream clocortolone pivalate pump Cloderm cream Cloderm pump Clorpres Cordran 0.05% ointment Cordran tape Cuprimine dapsone 5% gel Daxbia desoximetasone spray Dexilant Differin 0.1% lotion diflorasone diacetate cream diflorasone diacetate ointment Doryx doxycycline hyclate 50mg tablet (generic for Targadox) Duexis Durlaza Dutoprol mupirocin 2% external ointment chlorthalidone plus clonidine Depen Titratabs (penicillamine) cephalexin 250mg, cephalexin 500mg desoximetasone 0.05% gel, fluocinonide 0.05% solution over-the-counter (OTC) Differin 0.1% External Gel, prescription adapalene 0.1% gel, prescription adapalene 0.1% cream desoximetasone 0.05% cream, triamcinolone 0.5% cream desoximetasone 0.25% ointment, fluocinonide 0.05% ointment ibuprofen plus famotidine aspirin 81mg metoprolol plus HCTZ
Dymista Edarbi Edarbyclor Edluar Emflaza esomeprazole strontium Fabior Flector fluocinonide 0.1% cream flurandrenolide 0.05% ointment Fortamet Glumetza Gocovri Gonitro Gralise Halog cream Halog ointment Horizant imiquimod 3.75% cream Inderal XL InnoPran XL Intermezzo Istalol (once daily) eye drops lansoprazole ODT Lescol XL irbesartan, losartan, valsartan, olmesartan valsartan-hctz, irbesartan-hctz, losartan-hctz prednisone, prednisolone, methylprednisolone, as well as overthe-counter (OTC) medications, such as Nexium 24 HR diclofenac topical gel, diclofenac topical solution halobetasol 0.05% cream, clobetasol 0.05% cream amantadine nitroglycerin SL (sublingual) tablet gabapentin desoximetasone 0.25% cream, betamethasone AF 0.05% cream fluocinonide 0.05% ointment, desoximetasone 0.25% ointment, betamethasone dipropionate 0.05% ointment gabapentin imiquimod 5% cream propranolol HCL ER propranolol HCL ER timolol maleate (twice daily) eye drops [generic for Timoptic], as well as overthe-counter (OTC) medications, such as Prevacid 24 HR
Lexette Livalo Locort 11 day Locort 7 day Lovaza metformin ER modified release metformin ER osmotic release metoprolol-hctz ER (generic for Dutoprol) Minolira mometasone nasal Morgidox Nalfon Naprelan Nasonex Neuac Nexium Nocdurna Noctiva omeprazole-sodium bicarbonate omeprazole-sodium bicarbonate packet Omnaris Onexton Pandel cream Pennsaid halobetasol cream, ointment prescription or over-the-counter (OTC) omega-3 fatty acids metoprolol plus HCTZ fenoprofen naproxen ER (extended tablet, as well as overthe-counter (OTC) medications such as Nexium 24 HR oxybutynin, desmopressin nasal spray, desmopressin tablets oxybutynin, desmopressin nasal spray, desmopressin tablets, as well as overthe-counter (OTC) medications such as Zegerid OTC, as well as overthe-counter (OTC) medications such as Zegerid OTC hydrocortisone butyrate 0.1% cream, fluocinolone 0.025% cream, betamethasone valerate 0.1% cream diclofenac topical gel, solution
Plixda pads Prestalia Prevacid SoluTab Prilosec packet Protonix packet Psorcon cream Qnasl Rayos Rozerem Solodyn Sprix Targadox Tazorac Gel Texacort timolol maleate (once daily) eye drops [generic for Istalol] Timoptic Ocudose Tivorbex Topicort spray Trianex ointment Triglide Vanos cream Vascepa Veltin Veramyst Vibramycin adapalene 0.1% gel, adapalene 0.1% cream, OTC Differin 0.1% Gel perindopril plus amlodipine, as well as overthe-counter (OTC) medications, such as Prevacid 24 HR desoximetasone 0.05% cream, triamcinolone 0.5% cream prednisone, prednisolone, methylprednisolone over-the-counter (OTC) melatonin diclofenac tablet, etodolac, meloxicam, nabumetone timolol maleate (twice daily) eye drops [generic for Timoptic] timolol maleate (twice daily) eye drops [generic for Timoptic] indomethacin tablet desoximetasone 0.05% gel, fluocinonide 0.05% solution triamcinolone 0.025% ointment, triamcinolone 0.1% ointment gemfibrozil, fenofibrate halobetasol 0.05% cream, clobetasol 0.05% cream prescription or over-the-counter (OTC) omega-3 fatty acids
Vimovo Vivlodex Xerese Xhance Ximino Zegerid Zegerid Packet Zetonna Ziana Zipsor zolpidem SL Zolpimist Zonacort 11 day Zonacort 7 day Zorvolex Zyclara Zypitamag Institutional and Clinic Packs (e.g. medications packaged as unit dose) Therapy Packs naproxen plus esomeprazole meloxicam tablet topical acyclovir plus topical hydrocortisone esomeprazole magnesium, omeprazole, pantoprazole, lansoprazole, as well as over-the-counter (OTC) medications such as Zegerid OTC esomeprazole magnesium, omeprazole, pantoprazole, lansoprazole, as well as over-the-counter (OTC) medications such as Zegerid OTC diclofenac tablet diclofenac 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.