(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
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