Excluded Medications/Products at a Glance (continued)
EPSOLAY ERTACZO ESBRIET*^ ESTRACE CREAM^ ESTRING
FUROSCIX FYLNETRA* GABARONE GAMMAKED* GANIRELIX ACETATE*^
INSULIN ASPART, INSULIN ASPART PROTAMINE INSULIN DEGLUDEC INSULIN GLARGINE U-100, INSULIN GLARGINE U-300 INTRAROSA INTUNIV^ INVEGA HAFYERA INVEGA SUSTENNA INVEGA TRINZA INVOKAMET, INVOKAMET XR, INVOKANA IXINITY* IYUZEH IZERVAY* JADENU*^, JADENU SPRINKLE*^ JAYPIRCA* JENTADUETO, JENTADUETO XR JYLAMVO KANJINTI* KAPSPARGO SPRINKLE KARBINAL ER SUSPENSION KATERZIA KAZANO KEPPRA^, KEPPRA XR^ KETOROLAC NASAL SPRAY INZIRQO ISTALOL^ ISTURISA* ITOVEBI* IVRA
LEVOTHYROXINE CAPSULES LEXAPRO^ LIALDA^ LIBERVANT LIBRAX^ LIDOCAINE/TETRACAINE LIDODERM^ LIFESCAN (ONETOUCH SOLUTIONS STARTER, ULTRA, ULTRA2, VERIO, VERIO FLEX) LIKMEZ LIPITOR^ LIPOFEN LIQREV* LIVALO^ LO LOESTRIN FE LOCOID^, LOCOID LIPOCREAM^ LODOCO LOESTRIN^, LOESTRIN FE^ LOREEV XR LOTREL^ LOTRONEX^ LOVAZA^ LUMIGAN LUNESTA^ LUPRON DEPOT-PED* LUZU LYRICA^, LYRICA CR^ LYVISPAH MAVYRET* MAXALT^, MAXALT MLT^ MAXIDEX MECLIZINE 50MG TABLETS MELOXICAM SUSPENSION MENEST MESTINON^ METAXALONE 640MG TABLETS METFORMIN 625MG TABLETS LOVENOX*^ LUCEMYRA^ LUCENTIS* LULICONAZOLE
ESTROGEL^ EUFLEXXA*
GEL-ONE* GELSYN-3* GENVISC 850*
EVEKEO^ EVENITY* EVERSENSE 365: SENSOR, TRANSMITTER EXFORGE^, EXFORGE HCT^ EXJADE*^ EXONDYS 51* FABIOR FANAPT FEMLYV FEMRING FENOFIBRATE CAPSULES (30MG, 50MG, 90MG, 150MG) FENOPROFEN 200MG CAPSULES FENOPRON FENTANYL CITRATE BUCCAL TABLETS FENTORA FERAHEME^ FERRIC CITRATE FIASP FINTEPLA* FIRAZYR*^ FIRVANQ FLAREX FLEQSUVY^ FLOVENT DISKUS, FLOVENT HFA FLUOROURACIL 0.5% CREAM flurandrenolide FLUTICASONE PROPIONATE DISKUS, FLUTICASONE PROPIONATE HFA FLUTICASONE/SALMETEROL DPI FLUTICASONE/ SALMETEROL HFA FLUTICASONE/VILANTEROL FML FORTE FOCALIN^, FOCALIN XR^ FOCINVEZ FOLLISTIM AQ* FORFIVO XL EYLEA*, EYLEA HD* EZALLOR SPRINKLE FORTEO^ fosfomycin FOSRENOL CHEWABLE TABLETS^ FOSRENOL POWDER PACKETS FOTIVDA* FULVICIN P/G
GILENYA 0.25MG*, GILENYA 0.5MG*^ GIMOTI* GLEEVEC*^
GLIMEPIRIDE 3MG TABLETS GLIPIZIDE 2.5MG TABLETS GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (by Fresenius) GLUMETZA^ GOCOVRI ER* GRAFAPEX GRANIX* HADLIMA* halcinonide HEMADY HEMICLOR HERCEPTIN*, HERCEPTIN HYLECTA* HERZUMA* HOME AIDE DIAGNOSTICS PEN NEEDLES & SYRINGES HTL-STREFA PEN NEEDLES & SYRINGES HULIO* HUMALOG VIAL HUMATROPE* HUMIRA* HYALGAN* HYDROCORTISONE/PRAMOXINE 25-18MG SUPPOSITORIES HYMOVIS* HYQVIA* HYRIMOZ* IBSRELA ibuprofen/famotidine IDACIO* IDOSE TR* IMAAVY* IMITREX^ IMPOYZ IMVEXXY INDERAL LA^ INDERAL XL, INNOPRAN XL INDOCIN SUPPOSITORIES^, INDOCIN SUSPENSION^ INFLECTRA*
KEVEYIS*^ KINERET* KISUNLA* KLISYRI KLONOPIN^ KOMBIGLYZE XR^ KONVOMEP KORLYM*^
KRAZATI* KUVAN*^ KYZATREX
LABETALOL 400MG TABLETS LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ LAMPIT LANREOTIDE* LANTUS LATUDA^ LEDIPASVIR/SOFOSBUVIR* LEQEMBI* LEQVIO* LETAIRIS*^
METHOCARBAMOL 1,000MG TABLETS METHYLPHENIDATE ER 45MG, 63MG & 72MG METRONIDAZOLE 125MG TABLETS
MICARDIS^, MICARDIS HCT^ MICONAZOLE/ZINC OXIDE/ PETROLATUM MINASTRIN 24 FE^ MINIVELLE^ MINOCYCLINE BIPHASIC TABLETS MINOCYCLINE ER CAPSULES
LEUPROLIDE DEPOT* LEVALBUTEROL HFA LEVAMLODIPINE LEVEMIR levorphanol
INPEFA INQOVI* INREBIC*
MIPLYFFA* MIRCERA*
(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 20
Made with FlippingBook. PDF to flipbook with ease