Drug Class
Excluded Medications
Preferred Alternatives
DORYX DR 80MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80MG MINOCYCLINE BIPHASIC TABLETS, MINOCYCLINE ER CAPSULES, XIMINO
doxycycline hyclate, doxycycline monohydrate
DERMATOLOGICAL Oral Agents for Acne (continued)
minocycline 24 hour er tablets
Oral: minocycline Topical: azelaic acid, ivermectin, metronidazole azelaic acid, ivermectin topical, metronidazole topical, sodium sulfacetamide/sulfur, FINACEA FOAM
Rosacea Agents (Oral)
EMROSI
EPSOLAY, ZILXI
Rosacea Agents (Topical)
NORITATE
metronidazole topical
adapalene, adapalene/benzoyl peroxide, benzoyl peroxide gel, clindamycin topical, clindamycin/ benzoyl peroxide, tretinoin, tretinoin micro
CABTREO, TWYNEO
CLENIA PLUS, SULFACETAMIDE/SULFUR 8%-4% CLEANSER, SULFACETAMIDE/SULFUR 9%-4.25% SUSPENSION, ZMA CLEAR
sulfacetamide/sulfur 9%-4% cleanser, sulfacetamide/sulfur 8%-4% suspension
Topical Agents for Acne
azelaic acid, dapsone 5% (tube) or 7.5% gel (pump), clindamycin topical, erythromycin topical, FINACEA FOAM
DAPSONE 7.5% GEL (TUBE)
FABIOR, TAZAROTENE FOAM
tazarotene cream or gel, tretinoin
azelaic acid, clindamycin phosphate gel, clindamycin/tretinoin, dapsone, erythromycin gel, tretinoin diclofenac 3% gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod
WINLEVI
CARAC, FLUOROURACIL 0.5% CREAM, KLISYRI, ZYCLARA
Topical Agents for Actinic Keratosis
ciclopirox 8% topical solution, tavaborole topical solution
ciclopirox 8% treatment kit
MICONAZOLE/ZINC OXIDE/PETROLATUM, VUSION naftifine, oxiconazole, ECOZA, ERTACZO, LULICONAZOLE, LUZU, NAFTIN, OXISTAT LOTION, SULCONAZOLE, XOLEGEL clocortolone, diflorasone, diflorasone/emollient, flurandrenolide, halcinonide, CLOBETASOL 0.025%, IMPOYZ, SERNIVO, ULTRAVATE, VERDESO
clotrimazole, ketoconazole, miconazole, nystatin
Topical Antifungals
ciclopirox, clotrimazole, econazole, ketoconazole
generic topical corticosteroids except those listed in the exclusion column
Topical Corticosteroids
Vitamin D Analogs (Topical)
CALCIPOTRIENE FOAM, SORILUX
calcipotriene cream, ointment or solution
generic topical corticosteroids except those listed in the exclusion column for Topical Corticosteroids plus mupirocin
ALCORTIN A
crotamiton
permethrin
Miscellaneous Topical Dermatological Agents
alclometasone cream and ointment; desonide cream and ointment; fluocinolone body oil, cream, ointment and solution; hydrocortisone 1% cream and ointment, 2.5% cream, lotion, ointment and solution; hydrocortisone valerate cream and ointment
doxepin cream
LIDOCAINE/TETRACAINE, PLIAGLIS
lidocaine cream, lidocaine/prilocaine cream
(continued)
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CRP1386903A 204612 EXCL-NPF-26 (08/08/2025)
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