(continued)
DRUG CLASS
EXCLUDED MEDICATIONS
PREFERRED ALTERNATIVES
Anxiolytic Agents
BUCAPSOL, BUSPIRONE 2.5MG AND 12.5MG buspirone 5mg, 7.5mg, 10mg, 15mg, 30mg LOREEV XR lorazepam tablets
Central Nervous System Stimulants
ARYNTA, DYANAVEL XR, XELSTRYM
amphetamine er odt, dextroamphetamine er, dextroamphetamine/amphetamine, lisdexamfetamine dexmethylphenidate er, methylphenidate cd, methylphenidate er capsules or tablets (except 45mg, 63mg), methylphenidate la, AZSTARYS
METHYLPHENIDATE ER 45MG AND 63MG, QUILLICHEW ER, QUILLIVANT XR, RELEXXII ER
ONYDA XR
clonidine er tablets atomoxetine capsules
Central Nervous System Non-Stimulants Duchenne Muscular Dystrophy (DMD) Agents
ATOMOXETINE SOLUTION, ATONCY
AGAMREE
prednisolone solution/syrup, prednisolone tablets, prednisone solution, prednisone tablets
AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53
No alternatives recommended
DUVYZAT, ELEVIDYS
Coverage may be approved for the treatment of Duchenne Muscular Dystrophy under certain conditions. tetrabenazine, INGREZZA, INGREZZA SPRINKLE KESIMPTA, OCREVUS, OCREVUS ZUNOVO dimethyl fumarate, fingolimod, teriflunomide, BAFIERTAM, MAYZENT, VUMERITY, ZEPOSIA (for Multiple Sclerosis only) tramadol 50mg and 100mg, tramadol er tablets hydromorphone, morphine sulfate, oxycodone capsules, oxycodone uncoated tablets, oxymorphone hydrocodone/acetaminophen, morphine sulfate, oxycodone uncoated tablets, tramadol 50mg and 100mg, tramadol/acetaminophen hydrocodone bitartrate er, hydromorphone er, morphine sulfate er, oxymorphone hcl er
Movement Disorders Therapy Multiple Sclerosis Agents
AUSTEDO, AUSTEDO XR
BRIUMVI
GILENYA, PONVORY, TASCENSO ODT
Narcotic Analgesics and Combinations
CONZIP, TRAMADOL 25MG AND 75MG, TRAMADOL ER CAPSULES, TRAMADOL SOLUTION
levorphanol
NUCYNTA
NUCYNTA ER, OXYCODONE ER, OXYCONTIN, TAPENTADOL ER, XTAMPZA ER
OXYCODONE COATED TABLETS, ROXYBOND oxycodone uncoated tablets PRIMLEV, PROLATE SOLUTION oxycodone/acetaminophen
Narcotic Antagonists
ZIMHI, ZURNAI
naloxone nasal or syringes, KLOXXADO
Niemann-Pick Disease Type C Agents Orphenadrine-Containing Analgesics
MIPLYFFA
AQNEURSA
orphenadrine/aspirin/caffeine, NORGESIC, NORGESIC FORTE
orphenadrine citrate er
Rett Syndrome Agents
DAYBUE, DAYBUE STIX
Coverage may be approved for the treatment of Rett Syndrome under certain conditions.
Sedative-Hypnotic Agents
DORAL, QUAZEPAM
estazolam, lorazepam
ZOLPIDEM 7.5MG CAPSULES ESCITALOPRAM CAPSULES
eszopiclone, zaleplon, zolpidem tablets
Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants
citalopram, escitalopram tablets, fluoxetine, fluvoxamine, paroxetine hcl, sertraline, vilazodone desvenlafaxine er, duloxetine dr (20mg, 30mg, 40mg, 60mg), venlafaxine hcl er, FETZIMA
DRIZALMA SPRINKLE, VENLAFAXINE BESYLATE ER
Tricyclic Antidepressants
protriptyline
desipramine, nortriptyline
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