Hometown Health | Nevada Health Insurance



Formulary Drug ExclusionsCertain medications have been excluded from your plan’s formulary. The full list of drug exclusions can be found below.? If you choose to use an excluded drug, you may be required to pay 100% of the cost.? If you are currently using one of the drugs excluded from coverage, ask your doctor to choose one of the generic or brand formulary alternatives.4171950180340PREFERRED DRUGS00PREFERRED DRUGS-85725177800DRUG CATEGORY*DRUG CLASS00DRUG CATEGORY*DRUG CLASS2047875182880EXCLUDED DRUGS00EXCLUDED DRUGSAllergiesAntihistamines- 1st genKARBINAL ERcarbinoxamine, cyproheptadine Antihistamines – 2nd genCLARINEXXYZALcetirizineADHDStimulantsDESOXYN, DYANAVEL XR, EVEKEO, QUILLICHEW ERamphetamine-dextroamphetamine, amphetamine-dextroamphetamine er, methylphenidate ER, QUILLIVANT XRAsthmaLeukotriene ModifierZYFLO, ZYFLO CRmontelukastBirth ControlContraceptive, OrallevonorgestrelLevonorgestrel-ethinyl estradiolBleeding DisordersDirect Factor XA InhibitorsSAVAYSAELIQUIS, XARELTOThrombopoietin Receptor AgonistsNPLATEPROMACTACardiovascular Event PreventionAspirinDURLAZAaspirin (OTC – not a covered benefit)Cosmetics (Hair, Skin, Nail)Cosmetic AgentsBOTOX COSMETIC, LATISSE, minoxidil topicalNot a covered benefitCough and ColdNarcotic Antitussive-Antihistamine CombinationTUZISTRA XRhydrocodone/homatropine,promethazine/codeineNarcotic Antitussive-Expectorant CombinationOBREDON, HYCOFENIXhydrocodone/homatropine,promethazine/codeineDepressionAntidepressant (SNRI-type)IRENKAduloxetineDiabetes BiguanidesGLUMETZAmetformin erInsulinsAFREZZAHUMULIN R, NOVOLIN R2047875-101600EXCLUDED DRUGS00EXCLUDED DRUGS-85725-98425DRUG CATEGORY*DRUG CLASS00DRUG CATEGORY*DRUG CLASS2036445-92710PREFERRED DRUGS00PREFERRED DRUGSGastrointestinal DisordersIrritable Bowel Disorder - DiarrheaVIBERZI, XIFAXAN dicyclomine, hyoscyamineGERD and/or Ulcer TherapyProton Pump InhibitorsACIPHEX, DEXILANT, NEXIUM, ZEGERIDomeprazole, pantoprazole, rabeprazoleAnticholinergicsLIBRAXchlordiazepoxide/clidiniumHigh CholesterolLipotropicsVASCEPAatorvastatin, fenofibrateHigh Blood PressureAntihypertensives, ACE InhibitorsEPANEDenalaprilAntihypertensives, ACE Inh/CCBPRESTALIAamlodipine/benazeprilBeta-Adrenergic Blocking AgentsINNOPRAN XL, INDERAL XLpropranololDUTOPROLmetoprolol/hydrochlorothiazideInfectionAntibiotic, VaginalMETROGELmetronidazoleNUVESSAmetronidazoleVANDAZOLEmetronidazoleAntivirals, GeneralSITAVIGacyclovir, valacyclovirAntifungals, TopicalJUBLIAciclopiroxPenicillinsMOXATAGamoxicillin, amoxicillin-clavulanateTetracyclinesACTICLATE, ARESTIN, ORACEA, SOLODYNdoxycycline, minocycline Menopause SymptomsEstrogen Agonist-AntagonistOSPHENAPREMARIN, VAGIFEMMovement DisordersMovement Disorder AgentHORIZANTpramipexoleAnti-Parkinsonism DrugsRYTARYcarbidopa/levodopa EROpiate WithdrawalNarcotic AntagonistsEVZIO, NARCANNot a covered benefit-85725-91440DRUG CATEGORY*DRUG CLASS00DRUG CATEGORY*DRUG CLASS2047875-90170EXCLUDED DRUGS00EXCLUDED DRUGS2036445-93980PREFERRED DRUGS00PREFERRED DRUGSPain +/- InflammationAnalgesic, NarcoticsXARTEMIS XR, HYSINGLA ER, TREZIXhydrocodone/acetaminophen,oxycodone/acetaminophen,ZOHYDRO ERBELBUCA, BUTRANSfentanyl patch, morphine sulfate erAnti-Migraine PreparationZECUITYsumatripan (oral, nasal)Glucocorticoid, SteroidRAYOSprednisoneNSAID, Anti-InflammatoryNAPRELAN, PENNSAID, TIVORBEX, VIVLODEX, VOLTAREN GEL, ZIPSORdiclofenac, FLECTOR, ibuprofen indomethacin, meloxicam, naproxenNSAID, COX Inhibitor Type & Proton Pump Inhibitor VIMOVOnaproxen & omeprazole, naproxen & pantoprazoleNSAID & H2 Receptor AntagonistDUEXISibuprofen & famotidine,naproxen & ranitidinePostherpetic Neuralgia GRALISEgabapentinPotassium DeficiencyHyperkalemia AgentsVELTASSAkionex, sodium polystyrene sulfonateSexual DisorderDrugs to Treat ImpotencyCIALIS, LEVITRA, MUSE, VIAGRANot a covered benefitHypoactive Sexual Desire DisorderADDYINot a covered benefitSkin DisorderAcne Agents, Topical AntibioticsCLINDACIN KIT, CLINDAGEL, EVOCLINclindamycin gel, lotionAcne Agents, Topical CombosACANYA, BENZACLIN PUMP, BENZAMYCINPAK, ONEXTONbenzoyl peroxide/clindamycin gel, benzoyl peroxide/erythromycin gelAcne Agents, Topical RetinoidsTRETIN-X, RETIN-A MICRO 0.08%tretinoin cream, gel, tretinoin microsphere gel 0.04%, 0.1%Anti-Infective & Anti-Inflammatory TopicalALOCORTIN-Ahydrocortisone/iodoquinol creamAnti-Inflammatory Steroidal, TopicalCLOBEX, CLODANclobetasolAntineoplastic & Premalignant Lesion AgentsCARAC, EFUDEX, FLUOROPLEXfluorouracil2047875-100330EXCLUDED DRUGS00EXCLUDED DRUGS-85725-106680DRUG CATEGORY*DRUG CLASS00DRUG CATEGORY*DRUG CLASS2036445-103505PREFERRED DRUGS00PREFERRED DRUGSSkin DisorderAntipruritic & Anestheticlidocaine lotionlidocaine creamBeta-Adrenergic BlockersHEMANGEOLpropranololImmunomodulatorsZYCLARAimiquimodRosacea Agents, TopicalMIRVASO, NORITATE, SOOLANTRAmetronidazole, FINACEASleepHypnotics, Melatonin MT1/MT2 Receptor AgonistHETLIOZROZEREMTestosterone ReplacementAndrogenic AgentsNATESTOANDRODERM, ANDROGELTransplant Rejection ProphylaxisImmunosuppressiveENVARSUS XRtacrolimusUrinary Tract DisordersKidney Stone AgentsPROCYSBICYSTAGONWeight LossAnorexic AgentsBELVIQNot a covered benefit*This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. ~This is not an all-inclusive list of available drug options. This list is subject to change. Brand drugs are represented by CAPS, generic drugs in lowercase.In addition to the drugs listed above, certain classes of medication are not covered under your pharmacy benefit. These medication classes include: non-FDA approved drugs, over the counter (OTC) medications, drugs to treat impotency or sexual disorders, fertility agents, weight loss drugs, hemantinics, reusable needles, disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents, diagnostic agents, cosmetic medications, and compounded medications.Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. There may be additional plan restrictions. Please consult your plan for further information. ................
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