Drug Class
Excluded Medications
Preferred Alternatives
testosterone cypionate, testosterone enanthate, XYOSTED
AVEED, AZMIRO
ENDOCRINE (continued) Testosterone Products
KYZATREX, NATESTO, TLANDO, UNDECATREX ADTHYZA 16.25MG, 32.5MG, 65MG, 97.5MG, 130MG LEVOTHYROXINE CAPSULES, THYQUIDITY, TIROSINT, TIROSINT-SOL
testosterone gel, testosterone solution levothyroxine tablets, thyroid pork, ARMOUR THYROID
Thyroid Replacement Therapy
levothyroxine tablets
Miscellaneous Endocrine Agents
CORTROPHIN GEL
No alternatives recommended
GASTROINTESTINAL Antidiarrheal Agents Antiemetics (Injectable)
opium tincture, MYTESI
diphenoxylate/atropine, loperamide
CINVANTI, FOCINVEZ
fosaprepitant injection
granisetron, ondansetron, aprepitant, VARUBI TABLETS
AKYNZEO CAPSULES
ANTIVERT, MECLIZINE 50MG TABLETS
meclizine 25mg tablets granisetron, ondansetron doxylamine/pyridoxine hcl aprepitant, VARUBI TABLETS
ANZEMET BONJESTA
Antiemetics (Oral)
EMEND POWDER PACKETS
ONDANSETRON ODT 16MG TABLETS
ondansetron odt 4mg or 8mg tablets
magnesium sulfate/potassium sulfate/sodium sulfate solution, peg 3350/ascorbic acid powder packets
Bowel Evacuants
CLENPIQ, PLENVU, SUFLAVE, SUTAB
Constipation Agents Corticosteroids (Rectal Formulations)
RELISTOR TABLETS
lubiprostone, MOVANTIK, SYMPROIC
CORTIFOAM
budesonide foam, hydrocortisone enema
Gallstone Dissolution Agents
RELTONE
ursodiol
Gastroparesis Agents
GIMOTI
No alternatives recommended hydrocortisone ac suppositories, pramoxine/hydrocortisone cream pramoxine/hydrocortisone cream
HYDROCORTISONE/PRAMOXINE 25-18MG SUPPOSITORIES
Hemorrhoidal Preparations
PROCTOFOAM-HC
balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA 250MG CAPSULES
Inflammatory Bowel Agents
DIPENTUM
Irritable Bowel Syndrome & Chronic Constipation Agents
IBSRELA
lubiprostone, prucalopride, LINZESS, TRULANCE
Pancreatic Enzymes
PERTZYE
CREON, PANCREAZE, ZENPEP
esomeprazole magnesium capsules, lansoprazole capsules, omeprazole capsules, pantoprazole tablets, rabeprazole tablets esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, rabeprazole
dexlansoprazole, DEXILANT
Proton Pump Inhibitors
KONVOMEP, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE
Miscellaneous Gastrointestinal Agents
DARTISLA ODT
glycopyrrolate tablets
HEMATOLOGICAL Antiplatelet Agents
aspirin plus omeprazole, esomeprazole magnesium, lansoprazole, pantoprazole or rabeprazole
YOSPRALA DR
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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