Drug Class
Excluded Medications
Preferred Alternatives
VYEPTI
AIMOVIG, AJOVY, EMGALITY
AUTONOMIC & CENTRAL NERVOUS SYSTEM Antimigraine Agents (continued)
eletriptan, naratriptan, rizatriptan, sumatriptan, NURTEC ODT, UBRELVY Coverage may be approved for the treatment of Parkinson’s Disease under certain conditions.
ZAVZPRET
APOKYN
DHIVY
carbidopa/levodopa
GOCOVRI ER
amantadine
Antiparkinsonism Agents
cabergoline, entacapone, pramipexole, rasagiline, ropinirole
NOURIANZ
ONAPGO, VYALEV XADAGO, ZELAPAR
carbidopa/levodopa er rasagiline, selegiline
risperidone er, ABILIFY ASIMTUFII, ABILIFY MAINTENA, ARISTADA, ARISTADA INITIO, ERZOFRI, RYKINDO ER, UZEDY ER aripiprazole, asenapine, lurasidone, olanzapine, paliperidone er, quetiapine tablets (except 150mg), risperidone, ziprasidone
INVEGA HAFYERA, INVEGA SUSTENNA, INVEGA TRINZA
Antipsychotics (Injectable)
COBENFY, FANAPT
Antipsychotics (Oral)
OPIPZA
aripiprazole odt or oral solution quetiapine 50mg or 100mg tablets baclofen solution, suspension or tablets metaxalone 400mg or 800mg tablets
QUETIAPINE 150MG TABLETS LYVISPAH, OZOBAX, OZOBAX DS METAXALONE 640MG TABLETS
Antispasmodic Agents
BUCAPSOL LOREEV XR
buspirone
Anxiolytic Agents
lorazepam tablets
LUMRYZ ER, SODIUM OXYBATE (by Hikma), XYWAV dextroamphetamine er, dextroamphetamine/ amphetamine er, lisdexamfetamine dexmethylphenidate er, methylphenidate cd, methylphenidate er, methylphenidate la, AZSTARYS
Cataplexy Treatment
SODIUM OXYBATE (by Amneal), XYREM
DYANAVEL XR, XELSTRYM
Central Nervous System Stimulants
METHYLPHENIDATE ER 45MG, 63MG & 72MG, QUILLICHEW ER, QUILLIVANT XR, RELEXXII ER
ONYDA XR
clonidine er tablets
prednisolone solution/syrup, prednisolone tablets, prednisone solution, prednisone tablets
AGAMREE
AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53
Duchenne Muscular Dystrophy (DMD) Agents
No alternatives recommended
Coverage may be approved for the treatment of Duchenne Muscular Dystrophy under certain conditions.
DUVYZAT
Movement Disorders Therapy
AUSTEDO, AUSTEDO XR
INGREZZA, INGREZZA SPRINKLE
BRIUMVI
KESIMPTA, OCREVUS, OCREVUS ZUNOVO dimethyl fumarate, fingolimod, teriflunomide, BAFIERTAM, MAYZENT, VUMERITY, ZEPOSIA (for Multiple Sclerosis only)
Multiple Sclerosis Agents
GILENYA, PONVORY, TASCENSO ODT
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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