(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Short-Acting Beta2-Agonist Inhalers
ALBUTEROL SULFATE HFA (by Prasco), LEVALBUTEROL HFA, PROAIR RESPICLICK, VENTOLIN HFA, XOPENEX HFA
albuterol sulfate hfa (all manufacturers covered except Prasco)
MISCELLANEOUS AGENTS Allergen Immunotherapy
PALFORZIA
Coverage may be approved for the treatment of Peanut Allergy under certain conditions. Coverage may be approved for the treatment of Barth Syndrome under certain conditions.
Barth Syndrome Agents
FORZINITY
Benign Prostatic Hyperplasia Agents
ENTADFI TEZRULY
finasteride 5mg plus tadalafil 5mg
terazosin
Botulinum Toxin Products
BOTOX
DYSPORT, MYOBLOC Migraine — AIMOVIG, AJOVY, EMGALITY, QULIPTA Hyperhidrosis — Over-the-Counter aluminum chloride containing products
DAXXIFY, XEOMIN
DYSPORT, MYOBLOC
Cardiomyopathy and Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis
AMVUTTRA
HTTR-C: VYNDAMAX Coverage may be approved for treatment of Polyneuropathy of Hereditary Transthyretin- Mediated Amyloidosis (hATTR) under certain conditions.
ATTRUBY
VYNDAMAX
ONPATTRO, WAINUA
Coverage may be approved for treatment of Polyneuropathy of Hereditary Transthyretin- Mediated Amyloidosis (hATTR) under certain conditions.
Complement Inhibitors
BKEMV, PIASKY, SOLIRIS, ULTOMIRIS
ENSPRYNG, EPYSQLI
Eosinophilic Esophagitis Agents
EOHILIA
budesonide suspension made into a slurry or suspension and swallowed (not inhaled) avanafil, sildenafil, tadalafil, vardenafil duloxetine dr (20mg, 30mg, 40mg, 60mg), milnacipran, pregabalin
Erectile Dysfunction Fibromyalgia Agents
VYBRIQUE
TONMYA
Folic Acid Products
FOLIC ACID ORAL SOLUTION, QUIOFIC
folic acid tablets
Gaucher Disease Agents
ELELYSO, VPRIV
CEREZYME
Glucocorticoids
ALKINDI SPRINKLE, KHINDIVI
hydrocortisone tablets dexamethasone tablets CINRYZE, RUCONEST
DEXLYT, HEMADY
Hereditary Angioedema
BERINERT DAWNZERA
ANDEMBRY, HAEGARDA, TAKHZYRO
EKTERLY AVLAYAH
icatibant
Hunter Syndrome Agents
Coverage may be approved for the treatment of Mucopolysaccharidosis Type II (Hunter syndrome) under certain conditions.
Hypoactive Sexual Desire Disorder Agents
ADDYI
VYLESSI
Immune Globulins
CUTAQUIG
SC: GAMMAGARD LIQUID, GAMMAGARD LIQUID ERC, GAMUNEX-C, XEMBIFY IV: GAMMAGARD LIQUID, GAMMAGARD LIQUID ERC, GAMMAGARD S-D, GAMUNEX-C SC: GAMMAGARD LIQUID, GAMMAGARD LIQUID ERC, GAMUNEX-C, XEMBIFY
GAMMAKED, GAMMAPLEX, PANZYGA, QIVIGY, YIMMUGO
© 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