Express Scripts 2020 National Preferred Formulary Exclusions
2022 National Preferred Formulary Exclusions
The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.
Take action to avoid paying full price. 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. 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.
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
ANTIINFECTIVES Antibiotic Agents - Vancomycins (Oral) Antifungal Agents (Oral) Antivirals (Oral) Chagas Disease Agents AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Alzheimer's Agents Anticonvulsants
Antimigraine Agents
Antiparkinsonism Agents
Antipsychotics (Injectable) Antispasmodic Agents Anxiolytic Agents Central Nervous System Non-Stimulants Central Nervous System Stimulants
Duchenne Muscular Dystrophy (DMD) Agents Multiple Sclerosis (Beta Interferons)
Narcotic Analgesics & Combinations
Narcotic Antagonists
Excluded Medications
FIRVANQ BREXAFEMME TOLSURA SITAVIG LAMPIT LUCEMYRA ADUHELM APTIOM FINTEPLA ONZETRA XSAIL, ZOLMITRIPTAN NASAL SPRAY 2.5 MG VYEPTI APOKYN GOCOVRI ER ONGENTYS XADAGO, ZELAPAR INVEGA HAFYERA OZOBAX LOREEV XR QELBREE ER
AMPHETAMINE ER SUSPENSION
AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53 EMFLAZA EXTAVIA APADAZ, BENZHYDROCODONE/ACETAMINOPHEN NUCYNTA ER, OXYCODONE ER, XTAMPZA ER
NUCYNTA PRIMLEV, PROLATE SOLUTION QDOLO BUNAVAIL
Preferred Alternatives
vancomycin capsules, vancomycin oral solution
fluconazole itraconazole acyclovir oral or cream, famciclovir, valacyclovir BENZNIDAZOLE
clonidine
No alternatives recommended carbamazepine, oxcarbazepine, pregabalin, topiramate, VIMPAT DIACOMIT, EPIDIOLEX sumatriptan nasal spray, ZOMIG NASAL AIMOVIG, AJOVY, EMGALITY KYNMOBI amantadine capsules, amantadine tablets, amantadine oral solution entacapone rasagiline, selegiline ABILIFY MAINTENA, ARISTADA, RISPERDAL CONSTA baclofen, tizanidine lorazepam tablets atomoxetine, clonidine er, guanfacine er dexmethylphenidate er, dextroamphetamine er, dextroamphetamine/amphetamine er, methylphenidate cd, methylphenidate er, methylphenidate la, DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE No alternatives recommended prednisone solution, prednisone tablets AVONEX, BETASERON, PLEGRIDY, REBIF hydrocodone/acetaminophen hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, OXYCONTIN hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen oxycodone/acetaminophen tramadol tablets buprenorphine/naloxone, ZUBSOLV
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 1
(continued)
CRP2111_0012558.1 DL2111_0012558C 334293 EXCL-NPF-OE-22 (12/10/2021)
Drug Class
AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Sedative-Hypnotic Agents Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants
Transmucosal Fentanyl Analgesics
Miscellaneous Antidepressants
CARDIOVASCULAR ACE Inhibitors
Excluded Medications
DORAL, QUAZEPAM PEXEVA, VIIBRYD DRIZALMA SPRINKLE FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS SPRAVATO QBRELIS EDARBI
Angiotensin Receptor Blockers (ARBs) and Combinations
EDARBYCLOR
Anticoagulants
Beta Blockers & Combinations
Calcium Channel Blockers Diuretics HMG & Cholesterol Inhibitor Combinations PCSK9 Inhibitors Miscellaneous Cardiovascular Agents DERMATOLOGICAL Agents for Hyperhidrosis Oral Agents for Acne Rosacea Agents (Oral) Rosacea Agents (Topical)
Topical Agents for Acne
PRADAXA, SAVAYSA DUTOPROL INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE CONJUPRI KATERZIA THALITONE ALTOPREV, EZALLOR SPRINKLE ROSUVASTATIN/EZETIMIBE PRALUENT CORLANOR
DRYSOL DORYX DR 80 MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80 MG MINOCYCLINE ER CAPSULES, XIMINO DOXYCYCLINE 40 MG CAPSULES ZILXI CLENIA PLUS CLINDAGEL, CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE) EPIDUO FORTE TAZAROTENE FOAM VELTIN
WINLEVI
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 2
Preferred Alternatives
estazolam, lorazepam
citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA
fentanyl citrate lozenges
olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline
lisinopril
candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan ELIQUIS, XARELTO metoprolol tartrate/hydrochlorothiazide, metoprolol succinate er plus hydrochlorothiazide propranolol er metoprolol succinate amlodipine, felodipine er, nifedipine er, nisoldipine amlodipine chlorthalidone atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO ezetimibe plus atorvastatin or rosuvastatin REPATHA atenolol, bisoprolol, carvedilol, metoprolol succinate, metoprolol tartrate, propranolol
Over-the-Counter aluminum chloride containing products
doxycycline hyclate, doxycycline monohydrate
minocycline er tablets doxycycline hyclate, doxycycline monohydrate azelaic acid, metronidazole, sodium sulfacetamide/sulfur, FINACEA sodium sulfacetamide/sulfur
clindamycin phosphate gel, erythromycin gel
adapalene/benzoyl peroxide tazarotene cream, TAZORAC GEL clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON clindamycin phosphate gel, clindamycin/tretinoin, erythromycin gel, tretinoin, ONEXTON
(continued)
CRP2111_0012558.1 DL2111_0012558C 334293 EXCL-NPF-OE-22 (12/10/2021)
Drug Class
DERMATOLOGICAL (continued) Topical Agents for Actinic Keratosis Topical Antifungals
Excluded Medications
CARAC, FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, KLISYRI, ZYCLARA ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL
CLOCORTOLONE
Topical Corticosteroids
IMPEKLO
Vitamin D Analogs (Topical) Miscellaneous Topical Dermatological Agents
VERDESO FOAM
CALCIPOTRIENE FOAM, SORILUX ALCORTIN A LIDOCAINE/TETRACAINE, PLIAGLIS TRI-LUMA
DIABETES Blood Glucose Meters & Test Strips
ASCENSIA (CONTOUR) ROCHE (ACCU-CHEK) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations Glucagon-Like Peptide-1 Agonists
Insulins
Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors & Combinations EAR/NOSE Nasal Steroids Otic Fluoroquinolone Antibiotics ENDOCRINE Cushing's Agents Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty) Growth Hormones
Somatostatin Analogs
ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, KOMBIGLYZE XR ALOGLIPTIN/PIOGLITAZONE
QTERN
ADLYXIN, VICTOZA ADMELOG, AFREZZA, APIDRA, FIASP, INSULIN ASPART, INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG, RELION NOVOLOG INSULIN GLARGINE-YFGN, LANTUS NOVOLIN, RELION NOVOLIN INVOKAMET, INVOKAMET XR INVOKANA
BECONASE AQ, OMNARIS, QNASL, ZETONNA
CIPRO HC, CIPROFLOXACIN/FLUOCINOLONE OTIC, OTOVEL
ISTURISA
FENSOLVI
HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON BYNFEZIA MYCAPSSA, SANDOSTATIN LAR DEPOT
SIGNIFOR LAR
Testosterone Products
AVEED
Preferred Alternatives
diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream ciclopirox, econazole, ketoconazole, naftifine, oxiconazole betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide betamethasone dipropionate, clobetasol, desonide, desoximetasone, diflorasone, fluocinonide, halcinonide, halobetasol, mometasone, triamcinolone alclometasone, betamethasone valerate, desonide, fluocinolone, flurandrenolide, hydrocortisone butyrate, triamcinolone calcipotriene, calcitriol generic topical corticosteroids plus mupirocin lidocaine cream, lidocaine/prilocaine cream fluocinolone acetonide, hydroquinone, tretinoin FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, VERIO FLEX ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS JANUVIA
JANUMET, JANUMET XR
pioglitazone plus JANUVIA
GLYXAMBI, STEGLUJAN
BYDUREON BCISE, BYETTA, OZEMPIC, TRULICITY
HUMALOG, LYUMJEV
LEVEMIR, SEMGLEE (YFGN), TOUJEO, TRESIBA HUMULIN SEGLUROMET, SYNJARDY, SYNJARDY XR, XIGDUO XR FARXIGA, JARDIANCE, STEGLATRO
flunisolide, fluticasone, mometasone
ciprofloxacin/dexamethasone otic
SIGNIFOR
LUPRON DEPOT-PED, TRIPTODUR
GENOTROPIN, NORDITROPIN FLEXPRO
octreotide SOMATULINE DEPOT For Acromegaly: SOMATULINE DEPOT For Cushing's Disease: SIGNIFOR testosterone cypionate, testosterone enanthate
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 3
(continued)
CRP2111_0012558.1 DL2111_0012558C 334293 EXCL-NPF-OE-22 (12/10/2021)
Drug Class
ENDOCRINE (continued) Thyroid Replacement Therapy Miscellaneous Endocrine Agents GASTROINTESTINAL Antidiarrheal Agents
Antiemetics (Oral)
Bowel Evacuants Corticosteroids (Rectal Formulations) Gallstone Dissolution Agents Gastroparesis Agents Helicobacter Pylori Agents Hemorrhoidal Preparations Inflammatory Bowel Agents Irritable Bowel Syndrome & Chronic Constipation Agents Pancreatic Enzymes
Proton Pump Inhibitors
HEMATOLOGICAL Antiplatelet Agents Erythropoiesis-Stimulating Agents
Factor Deficiency Agents & Related Products
Granulocyte Colony Stimulating Factors
Iron Replacement Agents
Sickle Cell Disease Agents
Thrombocytopenia Agents HEPATITIS Hepatitis C
HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.
Excluded Medications
Preferred Alternatives
LEVOTHYROXINE CAPSULES, THYQUIDITY, TIROSINT, TIROSINT-SOL
KORLYM
levothyroxine tablets ketoconazole, LYSODREN, SIGNIFOR
MYTESI
diphenoxylate/atropine, loperamide
AKYNZEO CAPSULES ANTIVERT EMEND POWDER PACKETS CLENPIQ, GOLYTELY PACKETS, OSMOPREP, PLENVU, SUPREP, SUTAB CORTIFOAM RELTONE GIMOTI HELIDAC, PYLERA PROCTOFOAM-HC
DIPENTUM
AMITIZA, LUBIPROSTONE PERTZYE ACIPHEX SPRINKLE, DEXILANT, ESOMEPRAZOLE STRONTIUM, NEXIUM PACKETS, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE
ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR
ARANESP, EPOGEN, MIRCERA NOVOSEVEN RT
NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE
GRANIX, NEUPOGEN NEULASTA, NYVEPRIA, UDENYCA MONOFERRIC OXBRYTA SIKLOS MULPLETA LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI
CABENUVA
COMPLERA
DELSTRIGO
PIFELTRO PREZCOBIX
granisetron, ondansetron, aprepitant, VARUBI TABLETS meclizine aprepitant, VARUBI TABLETS
peg-electrolyte solution (high and low volume generics)
hydrocortisone enema, UCERIS FOAM ursodiol No alternatives recommended lansoprazole/amoxicillin/clarithromycin, TALICIA pramoxine/hydrocortisone balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA LINZESS, TRULANCE CREON, PANCREAZE, ZENPEP
esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, rabeprazole
aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole PROCRIT, RETACRIT SEVENFACT ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT NIVESTYM, ZARXIO FULPHILA, ZIEXTENZO sodium ferric gluconate complex, VENOFER hydroxyurea, ADAKVEO, DROXIA DROXIA DOPTELET
EPCLUSA, HARVONI, VOSEVI, ZEPATIER
atazanavir plus lamivudine, darunavir plus lamivudine, lopinavir/ritonavir plus lamivudine, DOVATO, JULUCA, TIVICAY plus lamivudine, TIVICAY plus EDURANT ODEFSEY efavirenz/emtricitabine/tenofovir disoproxil fumarate, efavirenz/lamivudine/tenofovir disoproxil fumarate, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ efavirenz, EDURANT atazanavir, lopinavir/ritonavir, ritonavir, PREZISTA
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 4
(continued)
CRP2111_0012558.1 DL2111_0012558C 334293 EXCL-NPF-OE-22 (12/10/2021)
Drug Class
HIV Antiretrovirals (continued) Note: Current patients established on therapy are allowed to continue therapy. MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) OBSTETRICAL & GYNECOLOGICAL Combination Patches
Contraceptives
Estrogen & Estrogen Modifiers for Vaginal Symptoms
Estrogen/Progestin Combinations (Oral) Estrogens (Oral) Human Chorionic Gonadotropin Ovulatory Stimulants (Follitropins) Prenatal Vitamins Topical Estrogen Agents Vaginal Progesterones ONCOLOGY Acute Myeloid Leukemia (AML) Agents Bevacizumab-Containing Agents Breast Cancer Agents Multiple Myeloma Agents Myelodysplastic Syndrome Agents Myelofibrosis Agents Non-Small Cell Lung Cancer Agents Prostate Cancer Agents Renal Cell Cancer Agents
Excluded Medications
Preferred Alternatives
RUKOBIA ER STRIBILD
Coverage may be approved for the treatment of human immunodeficiency virus-1 infection in heavily treatmentexperienced patients with multidrug-resistant infection.
BIKTARVY, GENVOYA
COLCHICINE CAPSULES
colchicine tablets, MITIGARE
DICLOFENAC 35 MG CAPSULES, DICLOFENAC POTASSIUM 25 MG TABLETS, INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES
RELAFEN DS
TIVORBEX
ZIPSOR, ZORVOLEX
DICLOFENAC EPOLAMINE PATCHES, PENNSAID
diclofenac, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam
fenoprofen calcium tablets, etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone
nabumetone, etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, oxaprozin
etodolac, flurbiprofen, ibuprofen, indomethacin, ketoprofen, meloxicam, nabumetone
diclofenac potassium, etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone
diclofenac sodium topical, FLECTOR PATCHES, LICART PATCHES
CLIMARA PRO
COMBIPATCH
ANNOVERA, BALCOLTRA, LO LOESTRIN FE, NATAZIA, NEXTSTELLIS, TWIRLA, TYBLUME
PHEXXI
SLYND ESTRING, IMVEXXY, INTRAROSA, OSPHENA
FEMRING
BIJUVA, PREMPHASE, PREMPRO
MENEST, PREMARIN TABLETS PREGNYL FOLLISTIM AQ PREGENNA, TRINAZ DIVIGEL, ELESTRIN, ESTROGEL, EVAMIST CRINONE 4% CRINONE 8%
generic oral, patch and ring contraceptives
Barrier methods of contraception, such as condoms, diaphragms, spermicides or sponges. generic progestin-only oral contraceptives estradiol cream, estradiol vaginal inserts, PREMARIN CREAM estradiol cream, estradiol patches, estradiol tablets, estradiol vaginal inserts, PREMARIN CREAM estradiol/norethindrone acetate, ethinyl estradiol/norethindrone acetate estradiol tablets NOVAREL, OVIDREL GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT generic prenatal vitamins estradiol patches medroxyprogesterone, megestrol, norethindrone, progesterone ENDOMETRIN
ONUREG
azacitidine, decitabine
AVASTIN KISQALI, KISQALI FEMARA CO-PACK, PIQRAY
BLENREP, XPOVIO
INQOVI INREBIC TEPMETKO TRELSTAR FOTIVDA
ZIRABEV IBRANCE, VERZENIO DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE decitabine JAKAFI TABRECTA ELIGARD, FIRMAGON CABOMETYX, INLYTA, LENVIMA
Please note that product placement is subject to change throughout the year based upon changes in market dynamics.
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 5
(continued)
CRP2111_0012558.1 DL2111_0012558C 334293 EXCL-NPF-OE-22 (12/10/2021)
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