2027 Express Scripts National Preferred Formulary

EXPRESS SCRIPTS PHARMACY BENEFIT SERVICES 2027 National Preferred Formulary The following is a list of the most commonly prescribed medications covered on the National Preferred Formulary prescription drug list (PDL). It represents an abbreviated version of the PDL that is at the core of your prescription plan. The PDL is not all-inclusive and does not guarantee coverage. In addition to using this PDL, you are encouraged to ask your physician to prescribe generic medications whenever appropriate. Please note: Brand-name medications may move to nonformulary status if a generic equivalent version becomes available during the plan year. Not all the medications listed are covered by all prescription plans; check your benefit materials for the specific medications covered and the copays for your prescription plan. For specific questions about your coverage, please call the phone number printed on your prescription ID card.

aripiprazole ARISTADA, ARISTADA INITIO ARMOUR THYROID ASMANEX HFA ASMANEX TWISTHALER atenolol

CAMZYOS* CARBAGLU* carbidopa/levodopa carvedilol cefdinir cefuroxime axetil celecoxib cephalexin CEQUR SIMPLICITY

KEY * Specialty Medication Brand-name medications are listed in CAPITAL letters Generic medications are listed in lower case letters

atomoxetine atorvastatin AUGTYRO* AUVI-Q

CERDELGA* CEREZYME* CETROTIDE* chlorhexidine gluconate chlorthalidone CIBINQO* ciclopirox 8% topical solution CIMDUO* CIMERLI* CINRYZE* ciprofloxacin ciprofloxacin/dexamethasone otic citalopram

AVONEX* AVSOLA* AVTOZMA IV* AZASITE azathioprine* azelaic acid azelastine nasal azithromycin AZSTARYS

A ABILIFY ASIMTUFII ABILIFY MAINTENA ACCU-CHEK: FASTCLIX, SOFTCLIX LANCETS acetaminophen/codeine acyclovir

ADALIMUMAB-ADAZ* ADALIMUMAB-ADBM (by Boehringer Ingelheim & Quallent)* ADBRY* ADEMPAS* ADVAIR HFA ADVATE* ADYNOVATE* AFSTYLA* AIMOVIG AIRSUPRA AJOVY albuterol nebulization solution albuterol sulfate hfa (all manufacturers covered except Prasco)

B baclofen BAFIERTAM* BAQSIMI BARACLUDE SOLUTION

clarithromycin clindamycin hcl clindamycin phosphate topical clindamycin phosphate/benzoyl peroxide clobetasol propionate 0.05% topical clomiphene citrate clonazepam clonidine hcl tablets (except 0.05mg) clopidogrel clotrimazole/betamethasone dipropionate codeine/guaifenesin colchicine COMBIPATCH COMBIVENT RESPIMAT COSENTYX SC* COTELLIC* CREON

BAXDELA BELBUCA benazepril BENEFIX* benzonatate betamethasone dipropionate BETASERON* BIKTARVY* BILDYOS* BILPREVDA* bisoprolol 5mg, 10mg bisoprolol/hctz BOSULIF CAPSULES* BRAFTOVI* BREO ELLIPTA BREZTRI AEROSPHERE brimonidine drops BRINSUPRI* BRIXADI* brompheniramine/pseudoephedrine/ dextromethorphan budesonide nebulization suspension budesonide/formoterol inhaler buprenorphine/naloxone bupropion bupropion er 150mg, 300mg buspirone 5mg, 7.5mg, 10mg, 15mg, 30mg butalbital/acetaminophen/caffeine

ALECENSA* alendronate alfuzosin er ALHEMO* allopurinol alprazolam ALPROLIX* ALTUVIIIO* ALUNBRIG* ALYFTREK* amiodarone amitriptyline amlodipine

CRINONE 8%* cyanocobalamin cyclobenzaprine cyclosporine drops cyproheptadine

D DANZITEN* dapagliflozin dapagliflozin/metformin er dasatinib* deferiprone* DELSTRIGO* DESCOVY* desloratadine tablets desonide desvenlafaxine succinate er dexamethasone

amlodipine/benazepril amlodipine/olmesartan amlodipine/valsartan amoxicillin amoxicillin/clavulanate anastrozole ANDEMBRY* ANORO ELLIPTA

C CABENUVA* CABOMETYX* CALQUENCE*

ANZUPGO* APRETUDE* ARALAST NP* ARIKAYCE*

(continued)

DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR dexmethylphenidate dexmethylphenidate er dextroamphetamine/amphetamine dextroamphetamine/amphetamine er diazepam

ERIVEDGE* ERLEADA* erythromycin eye ointment ERZOFRI escitalopram tablets, solution esomeprazole magnesium dr ESPEROCT* estradiol cream, vaginal inserts estradiol patches estradiol tablets estradiol/norethindrone acetate eszopiclone

FRAGMIN* FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX,FREESTYLE LITE FREESTYLE LIBRE: READER, SENSOR FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE PRECISION NEO FRUZAQLA*

diclofenac sodium dr diclofenac sodium er dicyclomine 10mg, 20mg digoxin DILANTIN 30MG diltiazem er capsules dimethyl fumarate* diphenoxylate/atropine

FULPHILA* furosemide FYCOMPA fyremadel*

ethinyl estradiol/desogestrel ethinyl estradiol/drospirenone ethinyl estradiol/drospirenone/levomefolate ethinyl estradiol/ethynodiol ethinyl estradiol/etonogestrel vaginal ring ethinyl estradiol/levonorgestrel ethinyl estradiol/levonorgestrel/iron ethinyl estradiol/norelgestromin patches ethinyl estradiol/norethindrone ethinyl estradiol/norethindrone acetate ethinyl estradiol/norethindrone/iron ethinyl estradiol/norgestimate ethinyl estradiol/norgestrel

G gabapentin GAMMACORE

divalproex dr divalproex er donepezil DOPTELET, DOPTELET SPRINKLE* dorzolamide/timolol drops DOVATO* doxazosin doxepin capsules, solution, tablets doxycycline hyclate capsules, tablets (except 80mg) doxycycline monohydrate DROPLET: LANCETS, GENTEEL LANCING DEVICE DUAVEE DULERA duloxetine dr 20mg, 30mg, 40mg, 60mg

GAVRETO* gemfibrozil GENOTROPIN* GENVOYA* GLASSIA* glatopa* glimepiride 1mg, 2mg, 4mg glipizide 5mg, 10mg glipizide er glucagon emergency kit (all manufacturers covered except Fresenius) glyburide GLYXAMBI GONAL-F, GONAL-F RFF REDI-JECT* H HAEGARDA* HARVONI* HERCESSI* HUMALOG CARTRIDGE, U-100 KWIKPEN, U-200 KWIKPEN, JUNIOR KWIKPEN HUMALOG MIX HUMULIN HUMULIN MIX hydralazine hydrochlorothiazide hydrocodone/acetaminophen hydrocodone/chlorpheniramine polistirex er hydrocortisone topical hydromorphone hydroxychloroquine hydroxyzine hcl hydroxyzine pamoate GRASTEK guanfacine guanfacine er GVOKE

EUCRISA EYSUVIS ezetimibe ezetimibe/simvastatin

F FABHALTA* FABRAZYME*

DUPIXENT* DYSPORT*

famotidine FASENRA* fenofibrate capsules (43mg, 67mg, 134mg, 200mg) fenofibrate tablets (48mg, 54mg, 145mg, 160mg) fenofibric acid dr FENSOLVI* fentanyl patches FETZIMA FILSPARI* FINACEA FOAM

E EBGLYSS* eletriptan ELFABRIO* ELIQUIS, ELIQUIS SPRINKLE ELOCTATE* EMBECTA PEN NEEDLES EMBECTA SYRINGES

EMGALITY EMPAVELI* emtricitabine/tenofovir disoproxil fumarate* EMVERM enalapril ENBREL* ENDOMETRIN* enoxaparin* ENSACOVE* ENSTILAR ENTYVIO IV* EPCLUSA* EPIDIOLEX* epinephrine auto-injector (by Mylan, Teva) EPYSQLI* ergocalciferol

finasteride fingolimod* flecainide

FLECTOR fluconazole fluocinolone fluocinonide fluoxetine fluticasone nasal fluticasone/salmeterol inhalation powder fluvoxamine

HYMPAVZI* hyoscyamine

fluvoxamine er folic acid tablets FOUNDAYO

(continued)

lamotrigine chewable dispersible tablets, tablets lamotrigine er lansoprazole dr LANTUS latanoprost drops LEDIPASVIR/SOFOSBUVIR* LENVIMA* letrozole levetiracetam er levetiracetam solution, tablets levocetirizine levofloxacin levothyroxine tablets levoxyl LICART lidocaine patches LINZESS liothyronine liraglutide lisdexamfetamine lisinopril lisinopril/hctz lithium carbonate lithium carbonate er

metoclopramide metoprolol succinate er

I ibandronate IBRANCE* IBTROZI* ibuprofen ICLUSIG* icosapent ethyl

metoprolol tartrate (except 12.5mg) metronidazole 250mg, 500mg tablets metronidazole topical metronidazole vaginal MICROLET: LANCETS, NEXT LANCING DEVICE MIEBO MINIMED: INSULIN PUMP, PUMP INFUSION SETS, PARADIGM RESERVOIR minocycline minoxidil mirabegron er MIRENA* mirtazapine

ICOTYDE* IDELVION* IDVYNSO* ILET: PUMP, SUPPLIES IMKELDI* IMULDOSA* INBRIJA* INCRUSE ELLIPTA

indomethacin INFLIXIMAB* INGREZZA, INGREZZA SPRINKLE* INLYTA* INSULIN GLARGINE U-300 INSULIN GLARGINE-YFGN (by Biocon) INSULIN LISPRO INSULIN LISPRO PROTAMINE MIX

MIRVASO MITIGARE modafinil

mometasone MONOVISC* montelukast morphine sulfate er MOUNJARO MOVANTIK moxifloxacin drops MULTAQ mupirocin mycophenolate mofetil* MYFEMBREE MYHIBBIN*

INVEGA HAFYERA INVEGA SUSTENNA INVEGA TRINZA ipratropium bromide nasal ipratropium/albuterol sulfate nebulization solution IQIRVO* irbesartan isosorbide mononitrate er isotretinoin

LOKELMA lorazepam LORBRENA* losartan losartan/hctz loteprednol drops lovastatin LUMRYZ ER* LUPKYNIS* LUPRON DEPOT* lurasidone LYNPARZA*

N nabumetone naltrexone NAMZARIC naproxen naproxen sodium NASCOBAL NAYZILAM nebivolol NEFFY NEMLUVIO* neomycin/polymyxin/dexamethasone drops, eye ointment neomycin/polymyxin/hydrocortisone otic

J JAKAFI, JAKAFI XR* JANUMET XR JARDIANCE JASCAYD* JIVI* JULUCA* K KERENDIA KESIMPTA* ketoconazole topical

M magnesium sulfate/potassium sulfate/sodium sulfate solution MAYZENT* meclizine medroxyprogesterone

MEKINIST* MEKTOVI* meloxicam capsules, tablets MERILOG mesalamine dr metaxalone 400mg, 800mg metformin 500mg, 850mg, 1000mg metformin er methimazole methocarbamol 500mg, 750mg methotrexate methylphenidate methylphenidate er capsules, tablets (except 45mg, 63mg) methylprednisolone

NEXLETOL NEXLIZET NGENLA* niacin er nifedipine er NINLARO* nitrofurantoin macrocrystal nitroglycerin NITYR* NIVESTYM* norethindrone norethindrone acetate

ketorolac KISQALI* KITABIS PAK* KLOXXADO KOVALTRY* KYLEENA*

L labetalol 100mg, 200mg, 300mg lacosamide LAGEVRIO (EUA)

(continued)

nortriptyline NOVOEIGHT* NUBEQA* NUCALA* NUEDEXTA NURTEC ODT nystatin nystatin topical

PIVOT: PUMP, SUPPLY KITS PLEGRIDY* polymyxin/trimethoprim drops potassium chloride er pramipexole pravastatin prazosin PRECISION XTRA: METERS, TEST STRIPS, B-KETONE STRIPS prednisolone prednisolone acetate drops prednisolone sodium phosphate

S sacubitril/valsartan SAPHNELO SC* SCEMBLIX*

scopolamine patches SEMGLEE (YFGN) sertraline SEVENFACT* sildenafil SIMLANDI* SIMPONI 100 MG (for Ulcerative Colitis only)* simvastatin sitagliptin phosphate SKYLA* SKYRIZI* sodium oxybate* SOFOSBUVIR/VELPATASVIR*

O OCREVUS, OCREVUS ZUNOVO*

ODACTRA ODEFSEY* ODOMZO* ofloxacin drops ofloxacin otic OGIVRI*

prednisone pregabalin PREGNYL* PREMARIN CREAM prenatal vitamins prochlorperazine maleate PROCRIT* progesterone micronized PROLASTIN C* promethazine promethazine/dextromethorphan propranolol propranolol er Q quetiapine (except 150mg) QULIPTA QVAR REDIHALER R rabeprazole dr tablets RADICAVA ORS* RAGWITEK raloxifene ramipril RASUVO REBIF* RECTIV RELISTOR SC REPATHA RESTASIS MULTIDOSE RETACRIT* REZDIFFRA* RHAPSIDO RINVOQ ER, RINVOQ LQ* risperidone

olanzapine olmesartan olmesartan/hctz omega-3 acid ethyl esters omeprazole dr OMNIPOD 5: KITS, PODS OMNIPOD DASH: KITS, PODS OMNITROPE* OMVOH* ondansetron odt 4mg, 8mg ondansetron solution, tablets

solifenacin SOLIQUA SOLOSEC SOMATULINE DEPOT* SOMAVERT* SOTYKTU* SPIRIVA RESPIMAT spironolactone SPRAVATO* STIOLTO RESPIMAT

STIVARGA* STRENSIQ* STRIVERDI RESPIMAT SUBLOCADE* sucralfate tablets sulfamethoxazole/trimethoprim sumatriptan SUNOSI SUPPRELIN LA* SYMFI* SYMPROIC SYMTUZA* SYNJARDY, SYNJARDY XR

OPSYNVI* ORALAIR* ORENITRAM ER* ORIAHNN ORILISSA ORTHOVISC* oseltamivir OTEZLA, OTEZLA XR* OVIDREL*

oxcarbazepine oxybutynin er oxycodone capsules, uncoated tablets oxycodone/acetaminophen OZEMPIC OZEMPIC TABLETS P PANCREAZE pantoprazole dr paroxetine hcl PAXLOVID peg 3350/ascorbic acid powder packets penicillin v potassium PENTASA 250MG CAPSULES PHEBURANE* phenazopyridine PHESGO*

T TABRECTA* tacrolimus topical tadalafil

TAFINLAR* TAGRISSO* TAKHZYRO* TALICIA TALTZ* TALZENNA* tamoxifen tamsulosin er TANDEM MOBI CARTRIDGE, KIT, SYSTEM TANDEM T:SLIM CARTRIDGE, KIT TAVALISSE* TECHLITE LANCETS telmisartan

rizatriptan roflumilast ropinirole rosuvastatin ROZLYTREK* RUCONEST* RUXIENCE* RYBELSUS

PIFELTRO* pioglitazone PIQRAY*

RYDAPT* RYKINDO

terazosin terbinafine terconazole vaginal teriflunomide* teriparatide* testosterone cypionate testosterone gel, solution TEZSPIRE* thyroid pork (except 16.25mg, 32.5mg, 65mg, 97.5mg, 130mg) ticagrelor timolol maleate drops tiotropium inhaler tizanidine tablets TOBI PODHALER* tobramycin drops tobramycin/dexamethasone drops topiramate er topiramate tablets

U UBRELVY UPTRAVI TABLETS* USTEKINUMAB-TTWE (by Quallent)* UZEDY

X XACIATO XALKORI* XARELTO XDEMVY* XHANCE XIFAXAN XIIDRA

V valacyclovir valsartan tablets valsartan/hctz VALTOCO VANRAFIA* varenicline VARUBI

XOLAIR* XTANDI* XYNTHA, XYNTHA SOLOFUSE* XYOSTED XYWAV*

Y YESINTEK* YEZTUGO* YONSA* YUPELRI YUTREPIA*

VELSIPITY* VELTASSA VEMLIDY venlafaxine hcl venlafaxine hcl er verapamil er (120mg, 180mg, 240mg, 360mg) VERQUVO VERZENIO* VGO VIBERZI

torsemide TOUJEO tramadol 50mg, 100mg tranexamic acid trazodone TRELEGY ELLIPTA TREMFYA* treprostinil* TRESIBA tretinoin topical triamcinolone topical

Z ZELBORAF* ZEMAIRA* ZENPEP ZEPATIER* ZEPBOUND PEN ZEPOSIA* ZIEXTENZO* ZIRABEV* zolpidem er zolpidem tablets, sl tablets ZORYVE CREAM ZUBSOLV ZURZUVAE* ZYKADIA* ZYMFENTRA*

vilazodone VIOKACE VITRAKVI* VIVITROL* VIZIMPRO* VOSEVI* VOYDEYA* VOYXACT* VTAMA VUMERITY* VYLEESI* VYNDAMAX* VYNDAQEL*

triamterene/hctz TRIJARDY XR TRIPTODUR* TRIUMEQ* TRIVIDIA METERS: TRUE METRIX AIR, TRUE METRIX, TRUE METRIX GO, TRUENESS TRIVIDIA TEST STRIPS: TRUE METRIX, TRUENESS TRUEPLUS LANCETS

W warfarin WEGOVY HD WEGOVY PENS WEGOVY TABLETS WYNZORA

TRULANCE TRULICITY TRUQAP* TRYNGOLZA* TWIIST: KITS

TYENNE* TYMLOS* TYRUKO* TYSABRI* TYVASO, TYVASO DPI*

Go to express-scripts.com/2027drugs for a full list of prescription drug list exclusions with their covered alternatives or log on to compare medication prices. Costs for covered alternatives may vary. THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2027, THROUGH DECEMBER 31, 2027. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com.

EXPRESS SCRIPTS PHARMACY BENEFIT SERVICES 2027 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the National Preferred Formulary prescription drug list (PDL). If you’re currently using one of the excluded medications, please ask your physician to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare medication prices. Not all the medications listed are covered by all prescription plans; check your benefit materials for the specific medications covered and the copays for your plan. For specific questions about your coverage, please call the number on your prescription ID card. If there is a clinical reason, identified by your physician, that requires you to continue taking your current medication, your physician can request a coverage review by visiting the Express Scripts online portal at esrx.com/PA. Express Scripts Pharmacy Benefit Services manages your prescription plan for your employer, plan sponsor, health plan or benefit fund.

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

ANTIINFECTIVES Antibiotic Agents (Oral)

FIRVANQ, VANCOMYCIN 25MG/ML SOLUTION vancomycin capsules, vancomycin 50mg/ml solution LIKMEZ, METRONIDAZOLE 125MG TABLETS metronidazole 250mg or 500mg tablets SIVEXTRO linezolid tablets or suspension

Antibiotic Agents for Urinary Tract Infections

fosfomycin, BLUJEPA, ORLYNVAH, PIVYA

amoxicillin/clavulanate, cefadroxil, ciprofloxacin, levofloxacin, nitrofurantoin macrocrystal, nitrofurantoin mono/macro, sulfamethoxazole/ trimethoprim, trimethoprim

NITROFURANTOIN 50MG/5ML SUSPENSION nitrofurantoin 25mg/5ml suspension

Antifungal Agents (Oral)

TOLSURA

itraconazole

Antivirals

penciclovir cream, DENAVIR, XERESE

acyclovir oral or cream, famciclovir, valacyclovir

Chagas Disease Agents

LAMPIT

BENZNIDAZOLE

AUTONOMIC AND CENTRAL NERVOUS SYSTEM Alzheimer’s Agents

KISUNLA, LEQEMBI, LEQEMBI IQLIK

Coverage may be approved for the treatment of Alzheimer’s under certain conditions.

ZUNVEYL

donepezil, galantamine tablets, galantamine er, rivastigmine

Amyotrophic Lateral Sclerosis (ALS) Agents

QALSODY

Coverage may be approved for the treatment of Amyotrophic Lateral Sclerosis (ALS) under certain conditions.

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Anticonvulsants

FINTEPLA

DIACOMIT, EPIDIOLEX

GABARONE, RELGAABI 200MG

gabapentin capsules (100mg, 300mg, 400mg), solution, tablets levetiracetam oral solution, levetiracetam tablets diazepam rectal gel, NAYZILAM, VALTOCO

LEVETIRACETAM ODT

LIBERVANT MOTPOLY XR

lacosamide

PRIMIDONE 125MG TABLETS SUBVENITE SUSPENSION

primidone 50mg or 250mg tablets

lamotrigine chewable dispersible tablets, lamotrigine odt

TOPIRAMATE 50MG SPRINKLE CAPSULES

topiramate solution, topiramate 25mg sprinkle capsules vigabatrin powder packets

VIGAFYDE ZONISADE

zonisamide

Antimigraine Agents

BREKIYA, TRUDHESA

dihydroergotamine nasal, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan tablets

zolmitriptan 5mg nasal, ONZETRA XSAIL, ZOLMITRIPTAN 2.5MG NASAL, ZOMIG NASAL sumatriptan/naproxen sodium, TREXIMET

sumatriptan nasal

etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam capsules or tablets, nabumetone, naproxen or oxaprozin plus almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan tablets

VYEPTI

AIMOVIG, AJOVY, EMGALITY

ZAVZPRET

eletriptan, naratriptan, rizatriptan, sumatriptan, NURTEC ODT, UBRELVY Coverage may be approved for the treatment of Parkinson’s Disease under certain conditions.

Antiparkinsonism Agents

APOKYN

CARBIDOPA/LEVODOPA ER CAPSULES, ONAPGO, VYALEV

carbidopa/levodopa er tablets

DHIVY

carbidopa/levodopa

GOCOVRI ER

amantadine

NOURIANZ

cabergoline, entacapone, pramipexole, rasagiline, ropinirole

XADAGO, ZELAPAR

rasagiline, selegiline

Antipsychotics (Oral)

BYSANTI, COBENFY, FANAPT

aripiprazole, asenapine, lurasidone, olanzapine, paliperidone er, quetiapine (except 150mg), risperidone, ziprasidone

OPIPZA

aripiprazole odt or oral solution quetiapine 50mg or 100mg tablets baclofen solution, suspension or tablets metaxalone 400mg or 800mg tablets tizanidine 2mg, 4mg or 6mg capsules, tizanidine tablets

QUETIAPINE 150MG TABLETS

Antispasmodic Agents

LYVISPAH, OZOBAX

METAXALONE 640MG TABLETS

ONTRALFY, TIZANIDINE HCL 8MG CAPSULES, ZANAFLEX 8MG CAPSULES

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Anxiolytic Agents

BUCAPSOL, BUSPIRONE 2.5MG AND 12.5MG buspirone 5mg, 7.5mg, 10mg, 15mg, 30mg LOREEV XR lorazepam tablets

Central Nervous System Stimulants

ARYNTA, DYANAVEL XR, XELSTRYM

amphetamine er odt, dextroamphetamine er, dextroamphetamine/amphetamine, lisdexamfetamine dexmethylphenidate er, methylphenidate cd, methylphenidate er capsules or tablets (except 45mg, 63mg), methylphenidate la, AZSTARYS

METHYLPHENIDATE ER 45MG AND 63MG, QUILLICHEW ER, QUILLIVANT XR, RELEXXII ER

ONYDA XR

clonidine er tablets atomoxetine capsules

Central Nervous System Non-Stimulants Duchenne Muscular Dystrophy (DMD) Agents

ATOMOXETINE SOLUTION, ATONCY

AGAMREE

prednisolone solution/syrup, prednisolone tablets, prednisone solution, prednisone tablets

AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53

No alternatives recommended

DUVYZAT, ELEVIDYS

Coverage may be approved for the treatment of Duchenne Muscular Dystrophy under certain conditions. tetrabenazine, INGREZZA, INGREZZA SPRINKLE KESIMPTA, OCREVUS, OCREVUS ZUNOVO dimethyl fumarate, fingolimod, teriflunomide, BAFIERTAM, MAYZENT, VUMERITY, ZEPOSIA (for Multiple Sclerosis only) tramadol 50mg and 100mg, tramadol er tablets hydromorphone, morphine sulfate, oxycodone capsules, oxycodone uncoated tablets, oxymorphone hydrocodone/acetaminophen, morphine sulfate, oxycodone uncoated tablets, tramadol 50mg and 100mg, tramadol/acetaminophen hydrocodone bitartrate er, hydromorphone er, morphine sulfate er, oxymorphone hcl er

Movement Disorders Therapy Multiple Sclerosis Agents

AUSTEDO, AUSTEDO XR

BRIUMVI

GILENYA, PONVORY, TASCENSO ODT

Narcotic Analgesics and Combinations

CONZIP, TRAMADOL 25MG AND 75MG, TRAMADOL ER CAPSULES, TRAMADOL SOLUTION

levorphanol

NUCYNTA

NUCYNTA ER, OXYCODONE ER, OXYCONTIN, TAPENTADOL ER, XTAMPZA ER

OXYCODONE COATED TABLETS, ROXYBOND oxycodone uncoated tablets PRIMLEV, PROLATE SOLUTION oxycodone/acetaminophen

Narcotic Antagonists

ZIMHI, ZURNAI

naloxone nasal or syringes, KLOXXADO

Niemann-Pick Disease Type C Agents Orphenadrine-Containing Analgesics

MIPLYFFA

AQNEURSA

orphenadrine/aspirin/caffeine, NORGESIC, NORGESIC FORTE

orphenadrine citrate er

Rett Syndrome Agents

DAYBUE, DAYBUE STIX

Coverage may be approved for the treatment of Rett Syndrome under certain conditions.

Sedative-Hypnotic Agents

DORAL, QUAZEPAM

estazolam, lorazepam

ZOLPIDEM 7.5MG CAPSULES ESCITALOPRAM CAPSULES

eszopiclone, zaleplon, zolpidem tablets

Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants

citalopram, escitalopram tablets, fluoxetine, fluvoxamine, paroxetine hcl, sertraline, vilazodone desvenlafaxine er, duloxetine dr (20mg, 30mg, 40mg, 60mg), venlafaxine hcl er, FETZIMA

DRIZALMA SPRINKLE, VENLAFAXINE BESYLATE ER

Tricyclic Antidepressants

protriptyline

desipramine, nortriptyline

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Miscellaneous Antidepressants

APLENZIN, BUPROPION XL 450MG, FORFIVO XL bupropion xl 150mg or 300mg EXXUA ER Generic Antidepressant Agents RALDESY trazodone tablets

Miscellaneous Autonomic Agents

NORTHERA

atomoxetine, dihydroergotamine injection or nasal, fludrocortisone tablets, indomethacin capsules or injection, midodrine tablets, pyridostigmine tablets

CARDIOVASCULAR ACE Inhibitors

QBRELIS

lisinopril

CLONIDINE HCL 0.05MG, CLONIDINE ER 0.17MG, JAVADIN, NEXICLON XR

clonidine patches, clonidine hcl tablets (0.1mg, 0.2mg, 0.3mg)

Alpha-Adrenergic Agonists

Angiotensin Receptor Blockers (ARBs) and Combinations

ARBLI

losartan tablets

EDARBYCLOR

candesartan/hctz, irbesartan/hctz, losartan/hctz, olmesartan/hctz, telmisartan/hctz, valsartan/hctz, chlorthalidone plus valsartan tablets amlodipine/olmesartan, amlodipine/valsartan

telmisartan/amlodipine VALSARTAN SOLUTION

valsartan tablets

WIDAPLIK

amlodipine and indapamide plus candesartan, irbesartan, losartan, olmesartan, telmisartan or valsartan tablets dabigatran, rivaroxaban, ELIQUIS, ELIQUIS SPRINKLE, XARELTO

Anticoagulants

PRADAXA, SAVAYSA

Beta Blockers and Combinations

BISOPROLOL 2.5MG TABLETS

bisoprolol 5mg or 10mg propranolol solution

HEMANGEOL

INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE LABETALOL 400MG TABLETS

propranolol er

metoprolol succinate er

labetalol 100mg, 200mg or 300mg tablets metoprolol tartrate (except 12.5mg)

LOPRESSOR SOLUTION, LOPRESSOR 12.5MG TABLETS, METOPROLOL TARTRATE 12.5MG TABLETS

Calcium Channel Blockers

CONJUPRI, LEVAMLODIPINE diltiazem er tablets, CARDIZEM LA KATERZIA, NORLIQVA, SDAMLO

amlodipine, felodipine er, nifedipine er

diltiazem er capsules

amlodipine

nisoldipine, SULAR

amlodipine, felodipine er

verapamil er pm (100 mg, 200mg, 300mg)

verapamil er (120mg, 180mg, 240mg, 360mg)

Diuretics

ENBUMYST, FUROSCIX, LASIX ONYU, SOAANZ bumetanide, ethacrynic acid, furosemide, torsemide HEMICLOR, THALITONE chlorthalidone INZIRQO hydrochlorothiazide capsules or tablets

Endothelin Receptor Antagonists

TRYVIO

Generic Anti-Hypertensive Agents (Categories include: ACE Inhibitors, Alpha- Adrenergic Blockers, Angiotensin Receptor Blockers [ARBs], Beta Blockers, Calcium Channel Blockers, Central Alpha-Adrenergic Agonists, Direct Renin Inhibitors, Direct Vasodilators and Diuretics) fenofibrate capsules (43mg, 67mg, 134mg, 200mg), fenofibrate tablets (48mg, 54mg, 145mg, 160mg), fenofibric acid dr

Fenofibrates

fenofibrate capsules (130mg), fenofibrate tablets (40mg, 120mg), FENOFIBRATE CAPSULES (50MG, 150MG), LIPOFEN

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

HMG and Cholesterol Inhibitor Combinations

fluvastatin, fluvastatin er, ALTOPREV, ATORVALIQ, LESCOL XL, ZYPITAMAG

atorvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin ezetimibe plus atorvastatin or rosuvastatin

ROSUVASTATIN/EZETIMIBE

Obstructive Hypertrophic Cardiomyopathy Agents

MYQORZO

CAMZYOS REPATHA

PCSK9 and siRNA Inhibitors

LEQVIO, LEROCHOL, PRALUENT

Pulmonary Arterial Hypertension (PAH) Agents

TADLIQ

sildenafil oral suspension, sildenafil 20mg tablets, tadalafil 20mg tablets Coverage may be approved for the treatment of Pulmonary Arterial Hypertension (PAH) under certain conditions.

WINREVAIR

Sodium Glucose Co-Transporter-1 and 2 Inhibitors Miscellaneous Cardiovascular Agents

INPEFA

dapagliflozin, JARDIANCE

CORLANOR SOLUTION

ivabradine, atenolol, bisoprolol 5mg or 10mg, carvedilol, metoprolol succinate er, metoprolol tartrate (except 12.5mg), propranolol

LODOCO

colchicine

NORPACE, NORPACE CR DRYSOL, QBREXZA, SOFDRA

amiodarone, quinidine sulfate, sotalol Over-the-Counter aluminum chloride containing products

DERMATOLOGICAL Agents for Hyperhidrosis Oral Agents for Acne

ABSORICA LD

isotretinoin

DORYX DR 80MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80MG

doxycycline hyclate, doxycycline monohydrate

MINOCYCLINE ER CAPSULES, XIMINO

minocycline er tablets

Rosacea Agents (Oral)

EMROSI

Oral: minocycline Topical: azelaic acid, ivermectin, metronidazole azelaic acid, ivermectin topical, metronidazole topical, sodium sulfacetamide/sulfur 10-5% cream, FINACEA FOAM

Rosacea Agents (Topical)

EPSOLAY, ZILXI

NORITATE

metronidazole topical

Topical Agents for Acne

CABTREO, TWYNEO

adapalene, adapalene/benzoyl peroxide, benzoyl peroxide gel, clindamycin phosphate topical, clindamycin phosphate/benzoyl peroxide, tretinoin, tretinoin micro

CLENIA PLUS, SULFACETAMIDE/SULFUR 8%-4% CLEANSER, SULFACETAMIDE/SULFUR 10%-1% EMULSION, SULFACETAMIDE/SULFUR 9%-4.25% SUSPENSION, ZMA CLEAR

sulfacetamide/sulfur 10-5% cleanser, sulfacetamide/sulfur 10-5% cream

DAPSONE 7.5% GEL (TUBE)

azelaic acid, dapsone 5% (tube) or 7.5% gel (pump), clindamycin phosphate topical, erythromycin topical, FINACEA FOAM

FABIOR, TAZAROTENE FOAM

tazarotene cream or gel, tretinoin

WINLEVI

azelaic acid, clindamycin phosphate, clindamycin phosphate/tretinoin, dapsone, erythromycin gel, tretinoin fluorouracil 5% cream, fluorouracil 2% or 5% solution, imiquimod

Topical Agents for Actinic Keratosis

CARAC, FLUOROURACIL 0.5% CREAM, KLISYRI, ZYCLARA

Topical Antibiotics

XEPI

mupirocin

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Topical Antifungals

ciclopirox 8% treatment kit

ciclopirox 8% topical solution, tavaborole topical solution clotrimazole, ketoconazole, miconazole, nystatin

MICONAZOLE/ZINC OXIDE/PETROLATUM, VUSION naftifine, oxiconazole, ECONAZOLE FOAM, ECOZA, ERTACZO, LULICONAZOLE, LUZU, NAFTIN, OXISTAT, SULCONAZOLE, XOLEGEL clocortolone, diflorasone, diflorasone/emollient, flurandrenolide, halcinonide, CLOBETASOL 0.025%, HALOBETASOL LOTION, IMPOYZ, SERNIVO, ULTRAVATE, VERDESO

ciclopirox, clotrimazole, econazole cream, ketoconazole

Topical Corticosteroids

generic topical corticosteroids except those listed in the exclusion column

Vitamin D Analogs (Topical) Miscellaneous Topical Dermatological Agents

CALCIPOTRIENE FOAM, SORILUX

calcipotriene cream, ointment or solution

ALCORTIN A

generic topical corticosteroids except those listed in the exclusion column for Topical Corticosteroids plus mupirocin

crotamiton

permethrin

doxepin cream

alclometasone cream and ointment; desonide cream and ointment; fluocinolone body oil, cream, ointment and solution; hydrocortisone 1% cream and ointment, 2.5% cream, lotion, ointment and solution; hydrocortisone valerate cream and ointment lidocaine cream, lidocaine/prilocaine cream fluocinolone, hydroquinone, tretinoin imiquimod 5% cream, podofilox gel or solution

PLIAGLIS TRI-LUMA VEREGEN

ZTLIDO

lidocaine 5% patch

DIABETES Biguanide Agents

metformin 625mg, 750mg tablets; METFORMIN 625MG TABLETS ASCENSIA (CONTOUR) ELI LILLY (TEMPO) LIFESCAN (ONETOUCH SOLUTIONS STARTER, ULTRA, ULTRA2, VERIO, VERIO FLEX) ROCHE (ACCU-CHEK) ALL OTHER METERS AND TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

metformin 500mg, 850mg or 1,000mg tablets

Blood Glucose Meters and Test Strips

ABBOTT FREESTYLE KITS/METERS (FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE,FREESTYLE INSULINX, FREESTYLE LITE) ABBOTT FREESTYLE TEST STRIPS (FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE PRECISION NEO) ABBOTT PRECISION XTRA METERS, TEST STRIPS TRIVIDIA METERS (TRUE METRIX AIR, TRUE METRIX, TRUE METRIX GO, TRUENESS) TRIVIDIA TEST STRIPS (TRUE METRIX, TRUENESS) DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR

Continuous Glucose Monitoring Systems

EVERSENSE 365: SENSOR, TRANSMITTER

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Diabetic Pen Needles and Syringes

PEN NEEDLES AND SYRINGES BY: ARKRAY HOME AIDE DIAGNOSTICS HTL-STREFA NOVO NORDISK OWEN MUMFORD PRODIGY DIABETES CARE SIMPLE DIAGNOSTICS TRIVIDIA (NIPRO DIAGNOSTICS) ULTIMED ALL OTHER DIABETIC PEN NEEDLES AND SYRINGES THAT ARE NOT LISTED AS PREFERRED

EMBECTA PEN NEEDLES EMBECTA SYRINGES

Diabetic Supply Kits

BIGFOOT UNITY PROGRAM KIT

DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors and Combinations

ALOGLIPTIN, BRYNOVIN, NESINA, SITAGLIPTIN, TRADJENTA, ZITUVIO ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, SITAGLIPTIN/METFORMIN, SITAGLIPTIN/METFORMIN ER, ZITUVIMET, ZITUVIMET XR

saxagliptin, sitagliptin phosphate

saxagliptin/metformin, sitagliptin phosphate/ metformin, JANUMET XR

ALOGLIPTIN/PIOGLITAZONE

pioglitazone plus saxagliptin or sitagliptin phosphate

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations

QTERN, STEGLUJAN

GLYXAMBI

Glucose-Elevating Drugs

GLUCAGON EMERGENCY KIT (by Fresenius), ZEGALOGUE

glucagon emergency kit (all manufacturers covered except Fresenius), BAQSIMI, GVOKE

Insulin (Basal) and Glucagon-Like Peptide-1 (GLP- 1) Agonist Combinations

XULTOPHY

SOLIQUA

Insulins

U-100: ADMELOG, APIDRA, FIASP, HUMALOG VIAL, INSULIN ASPART, KIRSTY, LYUMJEV, NOVOLOG, RELION NOVOLOG U-200: LYUMJEV Inhalation: AFREZZA U-100: BASAGLAR, BASAGLAR TEMPO, INSULIN DEGLUDEC, INSULIN GLARGINE-YFGN (by Civica), LEVEMIR, REZVOGLAR U-200: INSULIN DEGLUDEC INSULIN ASPART PROTAMINE, NOVOLOG MIX, RELION NOVOLOG MIX NOVOLIN, NOVOLIN MIX, RELION NOVOLIN, RELION NOVOLIN MIX BRENZAVVY, INVOKANA, STEGLATRO INVOKAMET, INVOKAMET XR, SEGLUROMET

U-100: HUMALOG (CARTRIDGE, KWIKPEN, JUNIOR KWIKPEN), INSULIN LISPRO, MERILOG U-200: HUMALOG KWIKPEN

U-100: INSULIN GLARGINE-YFGN (by Biocon), LANTUS, SEMGLEE (YFGN), TRESIBA U-200: TRESIBA U-300: INSULIN GLARGINE, TOUJEO HUMALOG MIX, INSULIN LISPRO PROTAMINE MIX

HUMULIN, HUMULIN MIX

Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors and Combinations

dapagliflozin, JARDIANCE

dapagliflozin/metformin ext-release, SYNJARDY, SYNJARDY XR

Sulfonylurea Agents

GLIMEPIRIDE 3MG TABLETS

glimepiride 1mg, 2mg or 4mg tablets glipizide 5mg and 10mg tablets

GLIPIZIDE 2.5MG AND 15MG TABLETS

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

EAR/NOSE Nasal Antihistamines and Combination Products

azelastine/fluticasone nasal, DYMISTA

azelastine nasal plus flunisolide nasal, fluticasone nasal, mometasone nasal or XHANCE flunisolide nasal, fluticasone nasal, mometasone nasal, XHANCE

Nasal Steroids

OMNARIS, QNASL

Otic Antibiotics and Combination Products

CETRAXAL

ciprofloxacin otic, ofloxacin otic

CIPROFLOXACIN/FLUOCINOLONE OTIC

ciprofloxacin/dexamethasone otic, ciprofloxacin/ hydrocortisone otic

ENDOCRINE Cushing’s Agents

ISTURISA RECORLEV LOARGYS

ketoconazole tablets, SIGNIFOR

ketoconazole tablets

Enzyme Replacement Agents

Coverage may be approved for the treatment of Hyperargininemia under certain conditions.

Familial Chylomicronemia Syndrome Agents Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty)

REDEMPLO

TRYNGOLZA

LUPRON DEPOT-PED

FENSOLVI, SUPPRELIN LA, TRIPTODUR

Growth Hormones

HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ NUSPIN, ZOMACTON

GENOTROPIN, OMNITROPE

SKYTROFA, SOGROYA

GENOTROPIN, OMNITROPE, NGENLA

Phenylketonuria Agents

SEPHIENCE BYNFEZIA

sapropterin octreotide

Somatostatin Analogs and Other Related Medications

LANREOTIDE, PALSONIFY, SANDOSTATIN LAR DEPOT

lanreotide (generic), octreotide er, SOMATULINE DEPOT

SIGNIFOR LAR

For Acromegaly: lanreotide (generic), octreotide er, SOMATULINE DEPOT For Cushing’s Disease: SIGNIFOR testosterone cypionate, testosterone enanthate, XYOSTED

Testosterone Products

AVEED, AZMIRO

KYZATREX, NATESTO, TLANDO

testosterone gel, testosterone solution

Thyroid Replacement Therapy

ADTHYZA 16.25MG, 32.5MG, 65MG, 97.5MG, 130MG

levothyroxine tablets, thyroid pork (except 16.25mg, 32.5mg, 65mg, 97.5mg, 130mg), ARMOUR THYROID

LEVOTHYROXINE CAPSULES, THYQUIDITY, TIROSINT, TIROSINT-SOL

levothyroxine tablets

Miscellaneous Endocrine Agents

CORTROPHIN GEL

No alternatives recommended

DESMODA

desmopressin nasal, desmopressin tablets

GASTROINTESTINAL Antidiarrheal Agents Antiemetics (Injectable)

opium tincture, MYTESI

diphenoxylate/atropine, loperamide

CINVANTI, FOCINVEZ

fosaprepitant injection

Antiemetics (Oral)

AKYNZEO CAPSULES, GRANISOL

granisetron, ondansetron solution or tablets, aprepitant, VARUBI

ANTIVERT BONJESTA

meclizine

doxylamine/pyridoxine hcl

DRONABINOL SOLUTION EMEND POWDER PACKETS

dronabinol capsules aprepitant, VARUBI

NEREUS

promethazine tablets, scopolamine patches

ONDANSETRON ODT 16MG TABLETS DICYCLOMINE 40 MG TABLETS sucralfate suspension, CARAFATE

ondansetron odt 4mg or 8mg dicyclomine 20 mg tablets

Antispasmodics Anti-Ulcer Agents

sucralfate tablets

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Bowel Evacuants

CLENPIQ, PLENVU, SUFLAVE, SUTAB

magnesium sulfate/potassium sulfate/sodium sulfate solution, peg 3350/ascorbic acid powder packets

Constipation Agents

RELISTOR TABLETS

lubiprostone, MOVANTIK, SYMPROIC budesonide foam, hydrocortisone enema

Corticosteroids (Rectal Formulations)

CORTIFOAM

Gallstone Dissolution Agents

RELTONE

ursodiol

Gastroparesis Agents

GIMOTI

No alternatives recommended

Hemorrhoidal Preparations

HYDROCORTISONE/PRAMOXINE 25-18MG SUPPOSITORIES

hydrocortisone ac suppositories, pramoxine/ hydrocortisone cream

MICORT HC

hydrocortisone 2.5% rectal cream pramoxine/hydrocortisone cream

PROCTOFOAM-HC

Inflammatory Bowel Agents

DIPENTUM

balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA 250MG CAPSULES lubiprostone, prucalopride, LINZESS, TRULANCE

Irritable Bowel Syndrome and Chronic Constipation Agents

IBSRELA

Pancreatic Enzymes Proton Pump Inhibitors

PERTZYE

CREON, PANCREAZE, ZENPEP

dexlansoprazole dr, DEXILANT

esomeprazole magnesium dr capsules, lansoprazole dr capsules, omeprazole dr capsules, pantoprazole dr tablets, rabeprazole dr tablets esomeprazole magnesium dr, lansoprazole dr, omeprazole dr, pantoprazole dr, rabeprazole dr tablets

KONVOMEP, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE

Miscellaneous Gastrointestinal Agents

DARTISLA ODT YOSPRALA DR

glycopyrrolate tablets

HEMATOLOGICAL Antiplatelet Agents

aspirin plus omeprazole dr, esomeprazole magnesium dr, lansoprazole dr, pantoprazole dr or rabeprazole dr tablets

Erythropoiesis-Stimulating Agents

ARANESP, EPOGEN, MIRCERA

PROCRIT, RETACRIT

Factor Deficiency Agents and Related Products

IXINITY, RIXUBIS NOVOSEVEN RT

BENEFIX

SEVENFACT

NUWIQ, RECOMBINATE

ADVATE, ADYNOVATE, AFSTYLA, ALTUVIIIO, ELOCTATE, ESPEROCT, JIVI, KOVALTRY, NOVOEIGHT, XYNTHA, XYNTHA SOLOFUSE

REBINYN

ALPROLIX, IDELVION FULPHILA, ZIEXTENZO

Granulocyte Colony Stimulating Factors

FYLNETRA, NEULASTA, NYVEPRIA, ROLVEDON, RYZNEUTA, STIMUFEND, UDENYCA

FILKRI, GRANIX, NEUPOGEN, NYPOZI, RELEUKO, ZARXIO

NIVESTYM

Hematopoietic and Thrombopoietic Agents

APHEXDA

plerixafor

Hemophilia Agents

QFITLIA

For Hemophilia A with inhibitors: ALHEMO, HEMLIBRA For Hemophilia A without inhibitors: ALHEMO, HEMLIBRA, HYMPAVZI For Hemophilia B with inhibitors: ALHEMO For Hemophilia B without inhibitors: ALHEMO, HYMPAVZI

Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors

VAFSEO

PROCRIT, RETACRIT

Iron Replacement Agents

MONOFERRIC

iron sucrose, sodium ferric gluconate complex

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Sickle Cell Disease Agents Thrombocytopenia Agents

SIKLOS, XROMI

hydroxyurea, DROXIA

ALVAIZ

eltrombopag, DOPTELET, NPLATE

MULPLETA WAYRILZ AQVESME

DOPTELET

eltrombopag, DOPTELET, NPLATE, TAVALISSE Coverage may be approved for the treatment of Alpha-Thalassemia, Transfusion-dependent Beta-Thalassemia or Non-Transfusion-dependent Beta-Thalassemia under certain conditions. Coverage may be approved for the treatment of Myelodysplastic Syndrome with Transfusion- Dependent Anemia under certain conditions. EPCLUSA, HARVONI, LEDIPASVIR/SOFOSBUVIR, SOFOSBUVIR/VELPATASVIR, VOSEVI EPCLUSA, SOFOSBUVIR/VELPATASVIR, VOSEVI atazanavir, darunavir, fosamprenavir, lopinavir/ ritonavir, ritonavir, PREZISTA Coverage may be approved for the treatment of Human Immunodeficiency Virus-1 Infection in heavily treatment-experienced patients with multidrug-resistant infection.

Miscellaneous Hematology Agents

RYTELO

HEPATITIS Hepatitis C

MAVYRET

SOVALDI

HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.

PREZCOBIX

RUKOBIA ER

STRIBILD

BIKTARVY, GENVOYA colchicine, MITIGARE

MUSCULOSKELETAL AND RHEUMATOLOGY Gout Therapy Muscle Relaxants and Antispasmodic Agents

GLOPERBA

ATMEKSI, METHOCARBAMOL 1,000MG TABLETS methocarbamol 500mg tablets

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

COMBOGESIC

ibuprofen plus acetaminophen

COXANTO, DICLOFENAC 35MG CAPSULES, DOLOBID, FENOPROFEN 200MG CAPSULES, FENOPRON, OXAPROZIN 300MG CAPSULES, RELAFEN DS, SPRIX, ZORVOLEX

generic oral nonsteroidal anti-inflammatory drugs

ELYXYB, VYSCOXA

celecoxib

MELOXICAM SUSPENSION, ZYBIC DICLOFENAC EPOLAMINE PATCHES

ibuprofen suspension, naproxen suspension

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

FLECTOR, LICART

OBSTETRICAL AND GYNECOLOGICAL Combination Patches

CLIMARA PRO

COMBIPATCH

Contraceptives

AVERI, FEMLYV, LO LOESTRIN FE, NATAZIA, NEXTSTELLIS, TWIRLA, TYBLUME

generic oral, patch and ring contraceptives

PHEXX

Barrier methods of contraception, such as condoms, diaphragms or spermicides.

SLYND

generic progestin-only oral contraceptives

Estrogen and Estrogen Modifiers for Vaginal Symptoms

ESTRING, IMVEXXY, INTRAROSA, OSPHENA estradiol cream, estradiol vaginal inserts, PREMARIN CREAM FEMRING

estradiol cream, estradiol patches, estradiol tablets, estradiol vaginal inserts, PREMARIN CREAM estradiol/norethindrone acetate, ethinyl estradiol/ norethindrone acetate conjugated estrogen tablets, estradiol tablets

Estrogen/Progestin Combinations (Oral)

BIJUVA, PREMPHASE, PREMPRO

Estrogens (Oral)

MENEST

Human Chorionic Gonadotropin

CHORIONIC GONADOTROPIN 10,000 UNITS, NOVAREL

OVIDREL, PREGNYL

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Ovulatory Stimulants (Follitropins)

FOLLISTIM AQ

GONAL-F, GONAL-F RFF REDI-JECT

Prenatal Vitamins

CITRANATAL, NATAL PNV, PREGENNA, TRINAZ generic prenatal vitamins

Topical Estrogen Agents Vaginal Progesterones

ELESTRIN

estradiol gel, gel pump or patches

CRINONE 4%

medroxyprogesterone, megestrol, norethindrone, progesterone

Miscellaneous Gynecological Agents ONCOLOGY Acute Myeloid Leukemia (AML) Agents

paroxetine mesylate

paroxetine hcl, paroxetine hcl er

ONUREG

Coverage may be approved for the treatment of Acute Myeloid Leukemia under certain conditions.

REZLIDHIA VANFLYTA GRAFAPEX COLUMVI

TIBSOVO RYDAPT

Alkylating Agents

busulfan, cyclophosphamide, etoposide, fludarabine Coverage may be approved for the treatment of Diffuse Large B-cell Lymphoma under certain conditions. Coverage may be approved for the treatment of Follicular Lymphoma or Diffuse Large B-cell Lymphoma under certain conditions.

B-Cell Lymphoma Agents

EPKINLY, LUNSUMIO VELO

Bendamustine Agents

VIVIMUSTA

bendamustine, BENDEKA

Bevacizumab-Containing Agents

ALYMSYS, AVASTIN, JOBEVNE, VEGZELMA

ZIRABEV

Bispecific Human Epidermal Growth Factor Receptor 2 (HER2)-Directed Antibody

ZIIHERA

PERJETA plus HERCESSI or OGIVRI

Bortezomib Agents

BORUZU

bortezomib

Bruton Tyrosine Kinase Inhibitors

BRUKINSA, JAYPIRCA

For Mantle Cell Lymphoma: CALQUENCE For Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma: CALQUENCE, IMBRUVICA For BRUKINSA only: Coverage may be approved for treatment of Waldenström’s Macroglobulinemia under certain conditions. acitretin, bexarotene capsules, isotretinoin, romidepsin, ADCETRIS, POTELIGEO, ZOLINZA

Cutaneous T-Cell Lymphoma Agents

LYMPHIR

Docetaxel Agents

BEIZRAY/ALBUMIN, DOCIVYX

docetaxel fluorouracil gemcitabine

Fluorouracil Injectable Products

FAVLYXA AVGEMSI LIFYORLI

Gemcitabine Agents

Glucocorticoid Receptor Antagonists

Coverage may be approved for the treatment of Platinum Resistant Epithelial Ovarian, Fallopian Tube or Primary Peritoneal Cancer under certain conditions.

Interferons

BESREMI INLEXZO ITOVEBI

hydroxyurea

Intravesical Agents Kinase Inhibitors

gemcitabine, mitomycin, valrubicin

Coverage may be approved for the treatment of Breast Cancer under certain conditions.

Leucovorin Agents

VYKOURA

leucovorin injection melphalan injection

Melphalan Injectable Agents Multiple Myeloma Agents

IVRA

BLENREP, XPOVIO

bortezomib, lenalidomide, pomalidomide, DARZALEX, KYPROLIS, NINLARO, THALOMID

Myelodysplastic Syndrome Agents

INQOVI

decitabine

Myelofibrosis Agents

INREBIC, OJJAARA

JAKAFI, JAKAFI XR

(continued)

DRUG CLASS

EXCLUDED MEDICATIONS

PREFERRED ALTERNATIVES

Non-Small Cell Lung Cancer Agents

HERNEXEOS, HYRNUO

Coverage may be approved for the treatment of HER2 (ERBB2) activating mutation non-small cell lung cancer. Coverage may be approved for the treatment of KRAS G12C-mutated non-small cell lung cancer.

KRAZATI

TEPMETKO

TABRECTA LYNPARZA

PARP Inhibitors

RUBRACA, ZEJULA

Pemetrexed Agents

AXTLE

pemetrexed disodium

Programmed Death Ligand-1 Blocking Antibodies

UNLOXCYT

KEYTRUDA, KEYTRUDA QLEX, LIBTAYO abiraterone plus LYNPARZA, TALZENNA plus XTANDI ELIGARD, FIRMAGON, LUPRON DEPOT, LUTRATE DEPOT

Prostate Cancer Agents

AKEEGA

CAMCEVI, LEUPROLIDE DEPOT, TRELSTAR, VABRINTY

Renal Cell Cancer Agents Rituximab-Containing Agents Thiotepa Injectable Agents Trabectedin Injectable Products Trastuzumab-Containing Agents

FOTIVDA

CABOMETYX, INLYTA, LENVIMA

RIABNI, RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE

TEPYLUTE

thiotepa

EVDI

YONDELIS

HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, KANJINTI, ONTRUZANT, TRAZIMERA

HERCESSI, OGIVRI

Tyrosine Kinase Inhibitors

PHYRAGO QINLOCK

dasanitib

imatinib, nilotinib, pazopanib, sorafenib, sunitinib, IMKELDI, STIVARGA

Tyrosine Kinase Inhibitors - Nilotinib Products

NILOTINIB TARTRATE

nilotinib hcl, DANZITEN

OPHTHALMIC Antiglaucoma Agents (Beta-Adrenergic Blockers)

BETIMOL, TIMOPTIC OCUDOSE

timolol maleate drops, betaxolol drops, carteolol drops, levobunolol drops

Antiglaucoma Agents (Ophthalmic Prostaglandins)

tafluprost drops, travoprost drops, DURYSTA, IDOSE TR, IYUZEH, OMLONTI, TRAVATAN Z, VYZULTA, ZIOPTAN, ZOLYMBUS

bimatoprost drops, latanoprost drops

Blepharoptosis Agents

UPNEEQ IZERVAY

No alternatives recommended

Ophthalmic Agents (Complement Protein C5 Inhibitors)

Coverage may be approved for the treatment of Geographic Atrophy under certain conditions.

Ophthalmic Agents (Vascular Endothelial Growth Inhibitors)

EYLEA, EYLEA HD, VABYSMO

PAVBLU CIMERLI

BYOOVIZ, LUCENTIS

SUSVIMO

No alternatives recommended

Ophthalmic Agents (Other)

ATROPINE (PRESERVATIVE FREE) 1% EYE SINGLE USE DROPPERETTE

atropine 1% drops

CYSTADROPS

CYSTARAN

VERKAZIA

azelastine drops, bepotastine drops, cromolyn drops, epinsatine drops, olopatadine drops azelastine drops, bepotastine drops, cromolyn drops, epinastine drops, olopatadine drops dexamethasone drops, difluprednate drops, fluorometholone drops, loteprednol 0.5% drops, prednisolone drops

Ophthalmic Anti-Allergic

ZERVIATE

Ophthalmic Anti-Inflammatory

BYQLOVI, CLOBETASOL DROPS, FLAREX, FML FORTE, LOTEMAX OINTMENT, LOTEMAX SM, MAXIDEX, PRED MILD

Ophthalmic Combinations

TOBRADEX ST

tobramycin/dexamethasone drops

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

ACUVAIL, ILEVRO, NEVANAC

bromfenac drops, diclofenac drops, ketorolac drops

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