Drug Class
Excluded Medications
Preferred Alternatives
RESPIRATORY (continued) Idiopathic Pulmonary Fibrosis Agents
pirfenidone 267mg capsules or tablets, pirfenidone 801mg tablets, OFEV DUPIXENT, FASENRA, NUCALA, TEZSPIRE, XOLAIR LAMA/LABAs: ANORO ELLIPTA, STIOLTO RESPIMAT LAMAs: tiotropium inhaler, INCRUSE ELLIPTA, SPIRIVA RESPIMAT LABAs: formoterol inhalation solution, STRIVERDI RESPIMAT ICS/LABAs: budesonide/formoterol, fluticasone/salmeterol inhalation powder, ADVAIR HFA, BREO ELLIPTA, DULERA
PIRFENIDONE 534MG TABLETS
Immunological Agents for Asthma
CINQAIR
Inhaled Phosphodiesterase (PDE)-3 & PDE-4 Inhibitors
OHTUVAYRE
Leukotriene Pathway Inhibitors
zileuton er, ZYFLO
montelukast, zafirlukast STRIVERDI RESPIMAT
Long-Acting Beta Agonist Inhalers SEREVENT DISKUS
Long-Acting Muscarinic Antagonist Inhalers Long-Acting Muscarinic Antagonist/ Long-Acting Beta-Agonist Combination Inhalers
tiotropium powder inhaler, INCRUSE ELLIPTA, SPIRIVA RESPIMAT
TUDORZA PRESSAIR
BEVESPI AEROSPHERE, DUAKLIR PRESSAIR, UMECLIDINIUM/VILANTEROL ALVESCO, ARMONAIR DIGIHALER, ARNUITY ELLIPTA, FLOVENT DISKUS, FLOVENT HFA, FLUTICASONE PROPIONATE DISKUS, FLUTICASONE PROPIONATE HFA, PULMICORT FLEXHALER AIRDUO RESPICLICK, FLUTICASONE/SALMETEROL DPI, FLUTICASONE/SALMETEROL HFA, FLUTICASONE/VILANTEROL ALBUTEROL SULFATE HFA (by Prasco), LEVALBUTEROL HFA, PROAIR DIGIHALER, PROAIR RESPICLICK, VENTOLIN HFA, XOPENEX HFA
ANORO ELLIPTA, STIOLTO RESPIMAT
Pulmonary Anti-Inflammatory Inhalers
ASMANEX HFA, ASMANEX TWISTHALER, QVAR REDIHALER
budesonide/formoterol, fluticasone/salmeterol inhalation powder, ADVAIR HFA, BREO ELLIPTA, DULERA
Pulmonary Anti-Inflammatory/ Beta-Agonist Combination Inhalers
albuterol sulfate hfa (all manufacturers covered except Prasco)
Short-Acting Beta 2 -Agonist Inhalers
MISCELLANEOUS AGENTS Allergen Immunotherapy
Coverage may be approved for the treatment of Peanut Allergy under certain conditions.
PALFORZIA
ENTADFI TEZRULY
finasteride 5mg plus tadalafil 5mg
Benign Prostatic Hyperplasia Agents
terazosin
DYSPORT, MYOBLOC Migraine - AIMOVIG, AJOVY, EMGALITY, QULIPTA Hyperhidrosis - Over-the-Counter aluminum chloride containing products
BOTOX
Botulinum Toxin Products
DAXXIFY, XEOMIN
DYSPORT, MYOBLOC ENSPRYNG, EPYSQLI
Complement Inhibitors
BKEMV, PIASKY, SOLIRIS, ULTOMIRIS
budesonide suspension made into a slurry or suspension and swallowed (not inhaled)
Eosinophilic Esophagitis Agents
EOHILIA
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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