EXPRESS SCRIPTS PHARMACY BENEFIT SERVICES 2027 National Preferred Formulary Exclusions
The excluded medications shown below are not covered on the National Preferred Formulary prescription drug list (PDL). If you’re currently using one of the excluded medications, please ask your physician to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare medication prices. Not all the medications listed are covered by all prescription plans; check your benefit materials for the specific medications covered and the copays for your plan. For specific questions about your coverage, please call the number on your prescription ID card. If there is a clinical reason, identified by your physician, that requires you to continue taking your current medication, your physician can request a coverage review by visiting the Express Scripts online portal at esrx.com/PA. Express Scripts Pharmacy Benefit Services manages your prescription plan for your employer, plan sponsor, health plan or benefit fund.
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
ANTIINFECTIVES Antibiotic Agents (Oral)
FIRVANQ, VANCOMYCIN 25MG/ML SOLUTION vancomycin capsules, vancomycin 50mg/ml solution LIKMEZ, METRONIDAZOLE 125MG TABLETS metronidazole 250mg or 500mg tablets SIVEXTRO linezolid tablets or suspension
Antibiotic Agents for Urinary Tract Infections
fosfomycin, BLUJEPA, ORLYNVAH, PIVYA
amoxicillin/clavulanate, cefadroxil, ciprofloxacin, levofloxacin, nitrofurantoin macrocrystal, nitrofurantoin mono/macro, sulfamethoxazole/ trimethoprim, trimethoprim
NITROFURANTOIN 50MG/5ML SUSPENSION nitrofurantoin 25mg/5ml suspension
Antifungal Agents (Oral)
TOLSURA
itraconazole
Antivirals
penciclovir cream, DENAVIR, XERESE
acyclovir oral or cream, famciclovir, valacyclovir
Chagas Disease Agents
LAMPIT
BENZNIDAZOLE
AUTONOMIC AND CENTRAL NERVOUS SYSTEM Alzheimer’s Agents
KISUNLA, LEQEMBI, LEQEMBI IQLIK
Coverage may be approved for the treatment of Alzheimer’s under certain conditions.
ZUNVEYL
donepezil, galantamine tablets, galantamine er, rivastigmine
Amyotrophic Lateral Sclerosis (ALS) Agents
QALSODY
Coverage may be approved for the treatment of Amyotrophic Lateral Sclerosis (ALS) under certain conditions.
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