(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
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