2026 National Preferred Formulary Exclusions
The excluded medications shown below are not covered on the Express Scripts drug list. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drug prices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card. If there is a clinical reason, identified by your doctor, that requires you to continue taking your current medication, your doctor can request a coverage review by visiting the Express Scripts online portal at esrx.com/PA. Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans. Drug Class Excluded Medications Preferred Alternatives
vancomycin capsules, vancomycin 50mg/ml oral solution
FIRVANQ, VANCOMYCIN 25MG/ML SOLUTION
ANTIINFECTIVES Antibiotic Agents (Oral)
FULVICIN P/G griseofulvin ultra 125mg or 250mg tablets LIKMEZ, METRONIDAZOLE 125MG TABLETS metronidazole 250mg or 500mg tablets SIVEXTRO linezolid tablets or suspension
nitrofurantoin macro, nitrofurantoin mono/macro, sulfamethoxazole/trimethoprim, trimethoprim
fosfomycin
Antibiotic Agents for Urinary Tract Infections
NITROFURANTOIN 50MG/5ML SUSPENSION nitrofurantoin 25mg/5ml suspension
Antifungal Agents (Oral)
TOLSURA
itraconazole
Antivirals
penciclovir cream, DENAVIR, XERESE
acyclovir oral or cream, famciclovir, valacyclovir
Chagas Disease Agents
LAMPIT
BENZNIDAZOLE
KISUNLA, LEQEMBI
No alternatives recommended
AUTONOMIC & CENTRAL NERVOUS SYSTEM Alzheimer’s Agents Amyotrophic Lateral Sclerosis (ALS) Agents
donepezil, galantamine tablets, galantamine er, rivastigmine
ZUNVEYL
QALSODY
No alternatives recommended
EPRONTIA, TOPIRAMATE 50MG SPRINKLE CAPSULES
topiramate 25mg sprinkle capsules
FINTEPLA GABARONE LIBERVANT MOTPOLY XR
DIACOMIT, EPIDIOLEX
gabapentin
diazepam rectal gel, NAYZILAM, VALTOCO
Anticonvulsants
lacosamide
PRIMIDONE 125MG TABLETS
primidone 50mg or 250mg tablets
VIGAFYDE ZONISADE
vigabatrin powder packets
zonisamide
ONZETRA XSAIL
sumatriptan nasal spray, zolmitriptan nasal spray etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen or oxaprozin plus almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan
sumatriptan/naproxen sodium, SYMBRAVO, TREXIMET
Antimigraine Agents
TRUDHESA
dihydroergotamine nasal spray
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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