Drug Class
Excluded Medications
Preferred Alternatives
OPHTHALMIC (continued) Antiglaucoma Agents (Ophthalmic Prostaglandins)
tafluprost drops, travoprost drops, DURYSTA, IDOSE TR, IYUZEH, LUMIGAN, TRAVATAN Z, VYZULTA, XELPROS, ZIOPTAN
bimatoprost drops, latanoprost drops
Blepharoptosis Agents
UPNEEQ
No alternatives recommended
Ophthalmic Agents (Complement Protein C5 Inhibitors)
Coverage may be approved for the treatment of Geographic Atrophy under certain conditions.
IZERVAY
EYLEA, EYLEA HD, VABYSMO
PAVBLU
Ophthalmic Agents (Vascular Endothelial Growth Inhibitors)
LUCENTIS SUSVIMO
BYOOVIZ, CIMERLI
No alternatives recommended
ATROPINE (PRESERVATIVE FREE) 1% EYE SINGLE USE DROPPERETTE
atropine 1% drops
CYSTADROPS QLOSI, VUITY
CYSTARAN
Ophthalmic Agents (Other)
No alternatives recommended
azelastine drops, bepotastine drops, cromolyn drops, epinsatine drops, olopatadine drops azelastine drops, bepotastine drops, cromolyn drops, epinastine drops, olopatadine drops dexamethasone drops, difluprednate drops, fluorometholone drops, loteprednol 0.5% drops, prednisolone drops
VERKAZIA
Ophthalmic Anti-Allergic
ALOMIDE, ALREX, ZERVIATE
CLOBETASOL DROPS, FLAREX, FML FORTE, MAXIDEX, PRED MILD
Ophthalmic Anti-Inflammatory
Ophthalmic Combinations
TOBRADEX ST, ZYLET
tobramycin/dexamethasone drops
Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
ACUVAIL, NEVANAC
bromfenac drops, diclofenac drops, ketorolac drops
ciprofloxacin drops, gatifloxacin drops, levofloxacin drops, moxifloxacin drops, ofloxacin drops
Ophthalmic Quinolone Antibiotics BESIVANCE, CILOXAN OINTMENT
DUROLANE, EUFLEXXA, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS, SUPARTZ FX, SYNOJOYNT, SYNVISC, SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3
OSTEOARTHRITIS Hyaluronic Acid Derivatives
MONOVISC, ORTHOVISC
RENAL Nephropathic Cystinosis Agents
PROCYSBI
CYSTAGON
OXYBUTYNIN 2.5MG
oxybutynin solution or syrup, oxybutynin 5mg tablets
Overactive Bladder Agents
oxybutynin solution or syrup, MYRBETRIQ ER SUSPENSION
VESICARE LS
FERRIC CITRATE, FOSRENOL POWDER PACKETS, VELPHORO, XPHOZAH URIMAR-T CAPSULES, URNEVA
calcium acetate, lanthanum, sevelamer carbonate, sevelamer hcl
Phosphate Binders
Miscellaneous Urologicals
uro mp, uro sp
carbinoxamine liquid and 4mg tablets; cetirizine solution and syrup; desloratidine tablets; hydroxyzine solution, syrup and tablets; levocetirizine solution and tablets epinephrine auto-injector (by Mylan, Teva), AUVI-Q, EPIPEN, EPIPEN JR
RESPIRATORY Antihistamines (Oral)
clemastine, CARBINOXAMINE ER 4MG/5ML SUSPENSION, KARBINAL ER SUSPENSION
EPINEPHRINE AUTO-INJECTOR (by Amneal Pharma, Avkare)
Epinephrine Auto-Injector Systems
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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