(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
© 2026 Evernorth Health Services. All rights reserved. All trademarks are the property of their respective owners. CRP1584203A 204612 NP Excl (08/01/2026)
Made with FlippingBook - professional solution for displaying marketing and sales documents online