(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
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