Drug Class
Excluded Medications
Preferred Alternatives
CARDIOVASCULAR Angiotensin Receptor Blockers (ARBs) & Combinations (continued)
telmisartan/amlodipine
amlodipine/olmesartan, amlodipine/valsartan
VALSARTAN SOLUTION
valsartan tablets
Anticoagulants
PRADAXA, SAVAYSA
dabigatran, ELIQUIS, XARELTO
BISOPROLOL FUMARATE 2.5MG TABLETS
bisoprolol 5mg or 10mg
INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE LABETALOL 400MG TABLETS CONJUPRI, LEVAMLODIPINE
propranolol er
Beta Blockers & Combinations
metoprolol succinate
labetalol 100mg, 200mg or 300mg tablets amlodipine, felodipine er, nifedipine er, nisoldipine
Calcium Channel Blockers
KATERZIA, NORLIQVA FUROSCIX, SOAANZ HEMICLOR, THALITONE
amlodipine
bumetanide, furosemide, torsemide
chlorthalidone
Diuretics
INZIRQO
hydrochlorothiazide capsules or tablets amiloride hcl, eplerenone, spironolactone
triamterene, DYRENIUM
Generic Anti-Hypertensive Agents (Categories include: ACE Inhibitors, Alpha-Adrenergic Blockers, Angiotensin Receptor Blockers [ARBs], Beta Blockers, Calcium Channel Blockers, Central Alpha-Adrenergic Agonists, Direct Renin Inhibitors, Direct Vasodilators and Diuretics) fenofibrate capsules (43mg, 67mg, 130mg, 134mg, 200mg), fenofibrate tablets, fenofibric acid atorvastatin, fluvastatin er, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin ezetimibe plus atorvastatin or rosuvastatin
Endothelin Receptor Antagonists
TRYVIO
FENOFIBRATE CAPSULES (30MG, 50MG, 90MG, 150MG), LIPOFEN
Fenofibrates
ALTOPREV, ATORVALIQ, EZALLOR SPRINKLE
HMG & Cholesterol Inhibitor Combinations
ROSUVASTATIN/EZETIMIBE
PCSK9 & siRNA Inhibitors
LEQVIO, PRALUENT
REPATHA
Pulmonary Arterial Hypertension (PAH) Agents Sodium Glucose Co-Transporter-1 & 2 Inhibitors
sildenafil oral suspension, sildenafil 20mg tablets, tadalafil 20mg tablets
LIQREV, TADLIQ
INPEFA
FARXIGA, JARDIANCE
ASPRUZYO SPRINKLE ER
ranolazine er
ivabradine tablets, atenolol, bisoprolol 5mg or 10mg, carvedilol, metoprolol succinate, metoprolol tartrate, propranolol
CORLANOR SOLUTION, CORLANOR TABLETS
Miscellaneous Cardiovascular Agents
LODOCO
colchicine
NORPACE CR
amiodarone, quinidine sulfate, sotalol Over-the-Counter aluminum chloride containing products
DERMATOLOGICAL Agents for Hyperhidrosis
DRYSOL, QBREXZA, SOFDRA
Coverage may be approved for the treatment of molluscum contagiosum.
Molluscum Contagiosum Agents
ZELSUVMI
Oral Agents for Acne
ABSORICA LD
isotretinoin capsules
(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 7
Made with FlippingBook. PDF to flipbook with ease