Drug Class
Excluded Medications
Preferred Alternatives
DIABETES (continued) Glucose-Elevating Drugs
GLUCAGEN HYPOKIT, GLUCAGON EMERGENCY KIT (by Fresenius), ZEGALOGUE
glucagon emergency kit (by Amphastar), BAQSIMI, GVOKE
Insulin (Basal) & Glucagon-Like Peptide-1 (GLP-1) Agonist Combinations
XULTOPHY
SOLIQUA
U-100: HUMALOG (CARTRIDGE, KWIKPEN, JUNIOR KWIKPEN), HUMALOG TEMPO, INSULIN LISPRO, LYUMJEV KWIKPEN & VIAL, LYUMJEV TEMPO U-200: HUMALOG KWIKPEN, LYUMJEV KWIKPEN
U-100: ADMELOG, APIDRA, FIASP, HUMALOG VIAL, INSULIN ASPART, NOVOLOG, RELION NOVOLOG Inhalation: AFREZZA
U-100: BASAGLAR, BASAGLAR TEMPO, INSULIN DEGLUDEC, INSULIN GLARGINE, LANTUS, LEVEMIR, REZVOGLAR
U-100: INSULIN GLARGINE-YFGN, SEMGLEE (YFGN), TRESIBA
Insulins
U-200: TRESIBA U-300: TOUJEO
U-200: INSULIN DEGLUDEC U-300: INSULIN GLARGINE
INSULIN ASPART PROTAMINE, NOVOLOG MIX, RELION NOVOLOG MIX NOVOLIN, NOVOLIN MIX, RELION NOVOLIN, RELION NOVOLIN MIX BRENZAVVY, DAPAGLIFLOZIN, INVOKANA, STEGLATRO DAPAGLIFLOZIN/METFORMIN ER, INVOKAMET, INVOKAMET XR, SEGLUROMET
HUMALOG MIX, INSULIN LISPRO PROTAMINE MIX
HUMULIN, HUMULIN MIX
FARXIGA, JARDIANCE
Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors & Combinations
SYNJARDY, SYNJARDY XR, XIGDUO XR
GLIMEPIRIDE 3MG TABLETS GLIPIZIDE 2.5MG TABLETS
glimepiride 1mg, 2mg or 4mg tablets
Sulfonylurea Agents
glipizide 5mg tablets
EAR/NOSE Nasal Antihistamines & Combination Products
azelastine/fluticasone, DYMISTA
azelastine nasal plus fluticasone nasal
Nasal Steroids
BECONASE AQ, OMNARIS, QNASL, ZETONNA flunisolide, fluticasone, mometasone, XHANCE
CETRAXAL
ciprofloxacin otic, ofloxacin otic
Otic Antibiotics & Combination Products
CIPRO HC, CIPROFLOXACIN/FLUOCINOLONE OTIC
ciprofloxacin/dexamethasone otic
ketoconazole tablets, mifepristone 300mg, SIGNIFOR
ISTURISA
ENDOCRINE Cushing’s Agents
RECORLEV
ketoconazole tablets
Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty)
LUPRON DEPOT-PED
FENSOLVI, SUPPRELIN LA, TRIPTODUR
HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ NUSPIN, SAIZEN, SAIZENPREP, ZOMACTON
GENOTROPIN, OMNITROPE
Growth Hormones
SKYTROFA, SOGROYA
GENOTROPIN, OMNITROPE, NGENLA
LANREOTIDE, SANDOSTATIN LAR DEPOT
SOMATULINE DEPOT
Somatostatin Analogs
For Acromegaly: SOMATULINE DEPOT For Cushing’s Disease: SIGNIFOR
SIGNIFOR LAR
(continued)
© 2025 Evernorth Health Services. All rights reserved. All trademarks are the property of their respective owners.
CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
Page 10
Made with FlippingBook. PDF to flipbook with ease