PDF 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 (Oral) Antispasmodic Agents Central Nervous System Non-Stimulants Central Nervous System Stimulants

Duchenne Muscular Dystrophy (DMD) Agents Lambert-Eaton Myasthenic Syndrome Agents Multiple Sclerosis (Beta Interferons)

Narcotic Analgesics & Combinations

Excluded Medications

FIRVANQ BREXAFEMME TOLSURA SITAVIG LAMPIT LUCEMYRA ADUHELM APTIOM FINTEPLA ONZETRA XSAIL, ZOLMITRIPTAN NASAL SPRAY VYEPTI APOKYN GOCOVRI ER ONGENTYS XADAGO, ZELAPAR CAPLYTA OZOBAX QELBREE ER

AMPHETAMINE ER SUSPENSION

AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53 EMFLAZA FIRDAPSE EXTAVIA APADAZ, BENZHYDROCODONE/ACETAMINOPHEN MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, XTAMPZA ER NUCYNTA PRIMLEV, PROLATE SOLUTION QDOLO

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 aripiprazole, asenapine, olanzapine, quetiapine er, quetiapine fumarate, risperidone, ziprasidone, LATUDA baclofen, tizanidine 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 RUZURGI AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE hydrocodone/acetaminophen hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, OXYCONTIN hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen oxycodone/acetaminophen tramadol tablets

? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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CRP2011_006458.1 334293 EXCL-NPF-OE-22 (10/19/2021)

Drug Class

AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Narcotic Antagonists Sedative-Hypnotic Agents Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants

Transmucosal Fentanyl Analgesics

Miscellaneous Antidepressants

CARDIOVASCULAR ACE Inhibitors

Excluded Medications

BUNAVAIL DORAL, QUAZEPAM PEXEVA, VIIBRYD

DRIZALMA SPRINKLE FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS SPRAVATO EPANED QBRELIS EDARBI

Angiotensin Receptor Blockers (ARBs) and Combinations

EDARBYCLOR

Anticoagulants

Beta Blockers & Combinations

Calcium Channel Blockers 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 BYSTOLIC DUTOPROL INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE CONJUPRI KATERZIA ALTOPREV, EZALLOR SPRINKLE 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

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Page 2

Preferred Alternatives

buprenorphine/naloxone, ZUBSOLV

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 enalapril lisinopril candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan ELIQUIS, XARELTO atenolol, carvedilol, metoprolol succinate metoprolol tartrate/hydrochlorothiazide, metoprolol succinate er plus hydrochlorothiazide propranolol er metoprolol succinate amlodipine, felodipine er, nifedipine er, nisoldipine amlodipine atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO 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)

CRP2011_006458.1 334293 EXCL-NPF-OE-22 (10/19/2021)

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 desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment calcipotriene, calcitriol hydrocortisone, 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, 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

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CRP2011_006458.1 334293 EXCL-NPF-OE-22 (10/19/2021)

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

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CRP2011_006458.1 334293 EXCL-NPF-OE-22 (10/19/2021)

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, 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

MVASI, ZIRABEV IBRANCE, VERZENIO DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE decitabine JAKAFI TABRECTA ELIGARD, FIRMAGON everolimus, sunitinib malate, CABOMETYX, INLYTA, LENVIMA, NEXAVAR, VOTRIENT

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.

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CRP2011_006458.1 334293 EXCL-NPF-OE-22 (10/19/2021)

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