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% cream adapalene 0.1% gel adapalene 0.1% lotion Altoprev Amrix Antara ApexiCon E Beconase AQ Belsomra Binosto budesonide AQ Byvalson Cambia packets Carac Claravis, Myorisan, and Zenatane cyclobenzaprine tablet gemfibrozil and fenofibrate desoximetasone 0.05% cream and triamcinolone 0.5% cream diphenhydramine, doxepin, and trazodone alendronate 70 mg Bystolic plus valsartan diclofenac tablet fluorouracil 0.5% external cream
High-Cost Exclusions Centany Clindagel clindamycin/ tretinoin clocortolone pivalate cream clocortolone pivalate pump Cloderm cream Cloderm pump Clorpres Cordran 0.05% ointment Cordran tape Cuprimine Daxbia Dexilant Differin 0.1% cream Differin 0.1% gel Differin 0.1% lotion diflorasone diacetate cream diflorasone diacetate ointment Doryx Duexis mupirocin 2% external ointment chlorthalidone plus clonidine Depen Titratabs (penicillamine) cephalexin 250 mg or cephalexin 500 mg desoximetasone 0.05% cream and triamcinolone 0.5% cream desoximetasone 0.25% ointment and fluocinonide 0.05% ointment ibuprofen plus famotidine
High-Cost Exclusions Durlaza Dutoprol Dymista Edarbi Edarbyclor Edluar Emflaza esomeprazole magnesium esomeprazole strontium Fabior Flector fluocinonide 0.1% cream flurandrenolide 0.05% ointment Fortamet Glumetza Gonitro Gralise Halog cream Halog ointment Horizant Inderal XL aspirin 81 mg metoprolol plus HCTZ irbesartan, losartan, valsartan, and olmesartan valsartan/ HCTZ, irbesartan/ HCTZ, and losartan/ HCTZ prednisone, prednisolone, and methylprednisolone medications, such as Nexium 24 HR. medications, such as Nexium 24 HR. diclofenac topical gel and diclofenac topical solution halobetasol 0.05% cream and clobetasol 0.05% cream nitroglycerin SL (sublingual) tablet gabapentin desoximetasone 0.25% cream and betamethasone AF 0.05% cream fluocinonide 0.05% ointment, desoximetasone 0.25% ointment, and betamethasone dipropionate 0.05% ointment gabapentin propranolol HCL ER
High-Cost Exclusions InnoPran XL Intermezzo Istalol Lescol XL Livalo Locort 11 day Locort 7 day Lovaza metformin ER modified release metformin ER osmotic release Minolira mometasone nasal Morgidox Nalfon Naprelan Nasonex Neuac Nexium Noctiva omeprazole- sodium bicarbonate propranolol HCL ER timolol eye drops prescription or over-the-counter (OTC) omega-3 fatty acids fenoprofen naproxen ER (extended release) tablet medications, such as Nexium 24 HR. oxybutynin, desmopressin nasal spray, and desmopressin tablets
High-Cost Exclusions omeprazole- sodium bicarbonate packet Omnaris Onexton Pandel cream Pennsaid Prestalia Prevacid SoluTab Prilosec packet Protonix packet Psorcon cream Qnasl Rayos Rhinocort AQ Rozerem Solodyn Sprix Targadox Tazorac Gel Tekturna Tekturna HCT hydrocortisone butyrate 0.1% cream, fluocinolone 0.025% cream, and betamethasone valerate 0.1% cream diclofenac topical gel and solution perindopril plus amlodipine medications, such as Prevacid 24 HR. desoximetasone 0.05% cream and triamcinolone 0.5% cream prednisone, prednisolone, and methylprednisolone over-the-counter (OTC) melatonin diclofenac tablet, etodolac, meloxicam, and nabumetone irbesartan, losartan, valsartan, and olmesartan valsartan/ HCTZ, irbesartan/ HCTZ, and losartan/ HCTZ
High-Cost Exclusions Texacort Timoptic Ocudose Tivorbex Topicort spray Tretin-X Trianex ointment Triglide Vanos cream Vascepa Veltin Veramyst Vibramycin Vimovo Vivlodex Xerese Zegerid Zegerid Packet Zetonna Ziana Zipsor timolol eye drops indomethacin tablet desoximetasone 0.05% gel and fluocinonide 0.05% solution generic tretinoin triamcinolone 0.025% ointment and triamcinolone 0.1% ointment gemfibrozil and fenofibrate halobetasol 0.05% cream and clobetasol 0.05% cream prescription or over-the-counter (OTC) omega-3 fatty acids naproxen plus esomeprazole meloxicam tablet topical acyclovir plus topical hydrocortisone diclofenac tablet
High-Cost Exclusions 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 diclofenac tablet imiquimod non-unit-dose equivalent medication individual drug products as appropriate Questions? Call the Customer Service number on your member ID card.