Excluded Medications/Products at a Glance (continued)
sumatriptan/naproxen sodium SUPARTZ FX*
TRANSDERM-SCOP^ TRAVATAN Z travoprost drops TRAZIMERA* TRELSTAR TREXALL
VANCOMYCIN 25MG/ML SOLUTION VANFLYTA* VANOS^
XIMINO XOLEGEL XOPENEX HFA XPHOZAH XPOVIO* XROMI XTAMPZA ER XULTOPHY XYREM* YASMIN^ YOSPRALA DR YUFLYMA* YUSIMRY* ZARXIO* ZAVESCA*^ ZAVZPRET ZEGALOGUE ZEGERID^
SUPREP^ SUSVIMO* SUTAB SYMBICORT^ SYMBRAVO
VEGZELMA* VELPHORO VELTIN^ VENLAFAXINE BESYLATE ER VENTOLIN HFA
TREXIMET TRI-LUMA triamterene TRIBENZOR^ TRICOR^ TRIENTINE 500MG CAPSULES TRILEPTAL^ TRILURON* TRINAZ TRIVIDIA (NIPRO DIAGNOSTICS) PEN NEEDLES & SYRINGES TRIVISC*
SYNOJOYNT* SYNTHROID^ SYNVISC*, SYNVISC-ONE* TACLONEX^ TADLIQ* tafluprost drops TARGRETIN CAPSULES*^ TASCENSO ODT*
VERDESO VEREGEN VERKAZIA VESICARE^ VESICARE LS VIAGRA^ VICTOZA^ VIGAFYDE* VIIBRYD^ VILTEPSO* VIMOVO VIMPAT^ VISCO-3* VIVELLE-DOT^ VIVIMUSTA* VIVLODEX^ VPRIV* VUITY VUSION VYALEV* VYEPTI* VYONDYS 53* VYTORIN^ VYVANSE^~
TASIGNA*^ TAYTULLA^ TAZAROTENE FOAM TAZORAC^ TECFIDERA*^ TEKTURNA^ telmisartan/amlodipine TEPMETKO* TEPYLUTE
TRUDHESA TRUVADA*^ TRUXIMA* TRYVIO TUDORZA PRESSAIR TWIRLA
ZEJULA* ZELAPAR ZELSUVMI ZEPBOUND VIALS ZERVIATE ZETIA^
TESTIM^ TEZRULY THALITONE THIOLA*^
TWYNEO TYBLUME TYKERB*^ UDENYCA*
ZETONNA ZIIHERA* ZILBRYSQ* zileuton er ZILXI ZIMHI
THIOLA EC*^ THYQUIDITY TIKOSYN^ TIMOPTIC OCUDOSE TIROSINT, TIROSINT-SOL TLANDO TOBI SOLUTION*^ TOBRADEX ST TOFIDENCE IV* TOLSURA TOPAMAX^ TOPICORT SPRAY^ TOPIRAMATE 50MG SPRINKLE CAPSULES TOPROL XL^ TOVIAZ^ TRADJENTA TRAMADOL 25MG & 75MG TABLETS TRAMADOL ER CAPSULES TRAMADOL SOLUTION
ULORIC^ ULTIMED PEN NEEDLES & SYRINGES ULTOMIRIS* ULTRAVATE UMECLIDINIUM/VILANTEROL UNDECATREX UPLIZNA* UPNEEQ URIMAR-T CAPSULES URNEVA UROXATRAL^ USTEKINUMAB IV*, USTEKINUMAB SC* USTEKINUMAB-AEKN SC* VABYSMO* VAFSEO VAGIFEM^ VALIUM^ VALSARTAN SOLUTION VALTREX^
ZIOPTAN ZIPSOR^ ZITUVIMET, ZITUVIMET XR ZITUVIO ZMA CLEAR ZOCOR^ ZOLOFT^ ZOLPIDEM 7.5MG CAPSULES ZOMACTON* ZOMIG TABLETS^ ZONEGRAN^
VYZULTA WAINUA* WELCHOL^
WELLBUTRIN SR^, WELLBUTRIN XL^ WEZLANA IV*, WEZLANA SC*
WINLEVI XADAGO XALATAN^ XANAX^, XANAX XR^ XATMEP XELPROS
ZONISADE ZORVOLEX ZOVIRAX OINTMENT^
ZUNVEYL ZYCLARA ZYFLO ZYLET ZYTIGA*^
XELSTRYM XENAZINE*^
XEOMIN* XERESE
* Specialty Drug ^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded. # Continuation of Therapy applies through June 30, 2026; Excluded for all utilizers effective July 1, 2026. ~ Pending generic availability
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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