Drug Class
Excluded Medications
Preferred Alternatives
COMBOGESIC
ibuprofen plus acetaminophen
COXANTO, DICLOFENAC 35MG CAPSULES, DOLOBID, FENOPROFEN 200MG CAPSULES, FENOPRON, KETOROLAC NASAL SPRAY, OXAPROZIN 300MG CAPSULES, RELAFEN DS, SPRIX, ZORVOLEX
MUSCULOSKELETAL & RHEUMATOLOGY (continued) Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
generic oral nonsteroidal anti-inflammatory drugs
ELYXYB
celecoxib
MELOXICAM SUSPENSION
ibuprofen suspension, naproxen suspension
Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
DICLOFENAC EPOLAMINE PATCHES
FLECTOR, LICART
OBSTETRICAL & GYNECOLOGICAL Combination Patches
CLIMARA PRO
COMBIPATCH
FEMLYV, LO LOESTRIN FE, NATAZIA, NEXTSTELLIS, TWIRLA, TYBLUME
generic oral, patch and ring contraceptives
Contraceptives
Barrier methods of contraception, such as condoms, diaphragms or spermicides.
PHEXXI
SLYND
generic progestin-only oral contraceptives estradiol cream, estradiol vaginal inserts, PREMARIN CREAM
ESTRING, IMVEXXY, INTRAROSA, OSPHENA
Estrogen & Estrogen Modifiers for Vaginal Symptoms
estradiol cream, estradiol patches, estradiol tablets, estradiol vaginal inserts, PREMARIN CREAM
FEMRING
Estrogen/Progestin Combinations (Oral)
estradiol/norethindrone acetate, ethinyl estradiol/norethindrone acetate
BIJUVA, PREMPHASE, PREMPRO
Estrogens (Oral)
MENEST, PREMARIN TABLETS
estradiol tablets
CHORIONIC GONADOTROPIN 10,000 UNITS, NOVAREL
Human Chorionic Gonadotropin
OVIDREL, PREGNYL
GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT generic prenatal vitamins
Ovulatory Stimulants (Follitropins)
FOLLISTIM AQ
Prenatal Vitamins
CITRANATAL, NATAL PNV, PREGENNA, TRINAZ
Topical Estrogen Agents
ELESTRIN
estradiol gel, gel pump or patches
medroxyprogesterone, megestrol, norethindrone, progesterone paroxetine hcl, paroxetine hcl ext-release Coverage may be approved for the treatment of Acute Myeloid Leukemia under certain conditions.
Vaginal Progesterones
CRINONE 4%
Miscellaneous Gynecological Agents paroxetine mesylate
ONUREG
ONCOLOGY Acute Myeloid Leukemia (AML) Agents
REZLIDHIA VANFLYTA GRAFAPEX
TIBSOVO RYDAPT
Alkylating Agents
busulfan, cyclophosphamide, etoposide, fludarabine Coverage may be approved for the treatment of Diffuse Large B-cell Lymphoma under certain conditions.
B-Cell Lymphoma Agents
COLUMVI
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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