Express Scripts 2020 National Preferred Formulary Exclusions

2024 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the Express Scripts drug list. 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. If there is a clinical reason, identified by your doctor, that requires you to continue taking your current medication, your doctor can request a coverage review by visiting the Express Scripts online portal at PA.

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 (Oral) Antibiotic Agents for Urinary Tract Infections Antifungal Agents (Oral) Antivirals (Oral) Chagas Disease Agents AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Alzheimer's Agents Amyotrophic Lateral Sclerosis (ALS) Agents

Anticonvulsants

Antimigraine Agents

Antiparkinsonism Agents

Antipsychotics (Injectable) Antipsychotics (Oral) Antispasmodic Agents Anxiolytic Agents Cataplexy Treatment

Excluded Medications

Preferred Alternatives

FIRVANQ, VANCOMYCIN 25 MG/ML SOLUTION SIVEXTRO NITROFURANTOIN 50 MG/5 ML SUSPENSION TOLSURA

SITAVIG, XERESE

LAMPIT

vancomycin capsules, vancomycin 50 mg/ml oral solution linezolid nitrofurantoin 25 mg/5 ml suspension itraconazole acyclovir oral or cream, famciclovir, penciclovir cream, valacyclovir BENZNIDAZOLE

LUCEMYRA

clonidine

ADUHELM, LEQEMBI QALSODY, RELYVRIO EPRONTIA FINTEPLA MOTPOLY XR PRIMIDONE 125 MG TABLETS ZONISADE ONZETRA XSAIL, ZOLMITRIPTAN NASAL SPRAY 2.5 MG VYEPTI ZAVZPRET

APOKYN

DHIVY

GOCOVRI ER, OSMOLEX ER

ONGENTYS XADAGO, ZELAPAR

INVEGA HAFYERA, RYKINDO ER, UZEDY ER

LYBALVI

QUETIAPINE 150 MG TABLETS BACLOFEN SOLUTION, LYVISPAH, OZOBAX, OZOBAX DS LOREEV XR SODIUM OXYBATE (by Amneal), XYREM

No alternatives recommended No alternatives recommended topiramate sprinkle capsules DIACOMIT, EPIDIOLEX lacosamide primidone 50 mg or 250 mg tablets zonisamide sumatriptan nasal spray, ZOMIG NASAL 2.5 MG AIMOVIG, AJOVY, EMGALITY NURTEC ODT, UBRELVY Coverage may be approved for the treatment of Parkinson's Disease under certain conditions. carbidopa/levodopa amantadine capsules, amantadine oral solution, amantadine tablets entacapone rasagiline, selegiline ABILIFY ASIMTUFII, ABILIFY MAINTENA, ARISTADA, RISPERDAL CONSTA aripiprazole, asenapine, lurasidone, olanzapine, paliperidone er, quetiapine, quetiapine er, ziprasidone quetiapine 50 mg or 100 mg, quetiapine er baclofen suspension, baclofen tablets lorazepam tablets LUMRYZ ER, SODIUM OXYBATE (by Hikma), XYWAV

? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 1

(continued)

CRP2412_16637C 334293 EXCL-NPF-OE-24 (12/20/2023)

Drug Class

Excluded Medications

AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Central Nervous System Stimulants

DYANAVEL XR, XELSTRYM

METHYLPHENIDATE ER 45 MG, 63 MG & 72 MG, QUILLICHEW ER, QUILLIVANT XR, RELEXXII ER

Duchenne Muscular Dystrophy (DMD) Agents

AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53 EMFLAZA

Friedreich's Ataxia Agents

SKYCLARYS

Multiple Sclerosis Agents

BRIUMVI EXTAVIA GILENYA, TASCENSO ODT

APADAZ, BENZHYDROCODONE/ACETAMINOPHEN

CONZIP, QDOLO, TRAMADOL 100 MG TABLETS, TRAMADOL ER CAPSULES, TRAMADOL SOLUTION

NUCYNTA

Narcotic Analgesics & Combinations

NUCYNTA ER, OXYCODONE ER, XTAMPZA ER

OXAYDO, ROXYBOND

PRIMLEV, PROLATE SOLUTION

SEGLENTIS

Narcotic Antagonists

ZIMHI

Rett Syndrome Agents

DAYBUE

Sedative-Hypnotic Agents

DORAL, QUAZEPAM ZOLPIDEM 7.5 MG CAPSULES, ZOLPIMIST

Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants

CITALOPRAM CAPSULES, PEXEVA, SERTRALINE CAPSULES

Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants DRIZALMA SPRINKLE, VENLAFAXINE BESYLATE ER

Transmucosal Fentanyl Analgesics

FENTANYL CITRATE BUCCAL TABLETS, FENTORA, SUBSYS

APLENZIN, BUPROPION XL 450 MG, FORFIVO XL

Miscellaneous Antidepressants

AUVELITY ER

SPRAVATO

CARDIOVASCULAR ACE Inhibitors

Alpha-Adrenergic Agonists

QBRELIS CLONIDINE ER 0.17 MG, NEXICLON XR

EDARBI

Angiotensin Receptor Blockers (ARBs) and Combinations

EDARBYCLOR

Anticoagulants

VALSARTAN SOLUTION PRADAXA, SAVAYSA

Preferred Alternatives

dextroamphetamine er, dextroamphetamine/amphetamine er, lisdexamfetamine

dexmethylphenidate er, methylphenidate cd, methylphenidate er, methylphenidate la

No alternatives recommended

prednisone solution, prednisone tablets

Coverage may be approved for the treatment of Friedreich's Ataxia under certain conditions. KESIMPTA, OCREVUS AVONEX, BETASERON, PLEGRIDY, REBIF fingolimod, teriflunomide, BAFIERTAM, MAYZENT, PONVORY, VUMERITY hydrocodone/acetaminophen

tramadol tablets, tramadol er tablets

hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen

hydrocodone bitartrate er, hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, OXYCONTIN oxycodone

oxycodone/acetaminophen

tramadol tablets plus celecoxib

naloxone syringes

No alternatives recommended

estazolam, lorazepam

eszopiclone, zaleplon, zolpidem tablets

citalopram tablets, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline tablets desvenlafaxine er, duloxetine, venlafaxine hcl er, FETZIMA

fentanyl citrate lozenges

bupropion xl 150 mg or 300 mg bupropion, citalopram, duloxetine, paroxetine, sertraline, venlafaxine, FETZIMA olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline

lisinopril

clonidine patches, clonidine tablets

candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan

valsartan tablets dabigatran, ELIQUIS, XARELTO

? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 2

(continued)

CRP2412_16637C 334293 EXCL-NPF-OE-24 (12/20/2023)

Drug Class

CARDIOVASCULAR (continued) Beta Blockers & Combinations Calcium Channel Blockers Diuretics Fenofibrates HMG & Cholesterol Inhibitor Combinations PCSK9 & siRNA Inhibitors Pulmonary Arterial Hypertension (PAH) Agents Sodium Glucose Co-Transporter-1 and 2 Inhibitors

Miscellaneous Cardiovascular Agents

DERMATOLOGICAL Agents for Hyperhidrosis Oral Agents for Acne

Rosacea Agents (Oral) Rosacea Agents (Topical)

Topical Agents for Acne

Topical Agents for Actinic Keratosis Topical Antifungals Topical Corticosteroids

? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Excluded Medications

Preferred Alternatives

HEMANGEOL INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE CONJUPRI, LEVAMLODIPINE KATERZIA, NORLIQVA FUROSCIX, SOAANZ THALITONE ANTARA, FENOFIBRATE CAPSULES (30 MG, 50 MG, 90 MG, 150 MG), LIPOFEN

ALTOPREV, ATORVALIQ, EZALLOR SPRINKLE

ROSUVASTATIN/EZETIMIBE LEQVIO, PRALUENT

LIQREV, TADLIQ

INPEFA ASPRUZYO SPRINKLE ER

CORLANOR

LOCODO NORPACE CR

propranolol solution propranolol er metoprolol succinate amlodipine, felodipine er, nifedipine er, nisoldipine amlodipine tablets bumetanide, furosemide, torsemide chlorthalidone fenofibrate capsules (43 mg, 67 mg, 130 mg, 134 mg, 200 mg), fenofibrate tablets, fenofibric acid atorvastatin, fluvastatin er, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin tablets ezetimibe plus atorvastatin or rosuvastatin REPATHA sildenafil oral suspension, sildenafil 20 mg tablets, tadalafil 20 mg tablets FARXIGA, JARDIANCE ranolazine er atenolol, bisoprolol, carvedilol, metoprolol succinate, metoprolol tartrate, propranolol colchicine amiodarone, quinidine sulfate, sotalol

DRYSOL, QBREXZA

Over-the-Counter aluminum chloride containing products

ABSORICA LD

isotretinoin capsules

DORYX DR 80 MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80 MG

doxycycline hyclate, doxycycline monohydrate

MINOCYCLINE BIPHASIC TABLETS, MINOCYCLINE ER CAPSULES, XIMINO

minocycline 24 hour er tablets

DOXYCYCLINE 40 MG CAPSULES, ORACEA

Oral: doxycycline hyclate, doxycycline monohydrate Topical: azelaic acid, ivermectin, metronidazole

NORITATE

metronidazole

ZILXI

azelaic acid, ivermectin, metronidazole, sodium sulfacetamide/sulfur, FINACEA FOAM

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

FABIOR, TAZAROTENE FOAM

tazarotene cream, tretinoin

VELTIN

clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide

WINLEVI

azelaic acid, clindamycin phosphate gel, clindamycin/tretinoin, dapsone, erythromycin gel, tretinoin

CARAC, FLUOROURACIL 0.5% CREAM, KLISYRI, ZYCLARA

diclofenac 3% gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream

ECOZA, ERTACZO, LULICONAZOLE, LUZU, OXISTAT LOTION, SULCONAZOLE, XOLEGEL

ciclopirox, clotrimazole, econazole, ketoconazole, naftifine, oxiconazole

MICONAZOLE/ZINC OXIDE/PETROLATUM, VUSION

clotrimazole, ketoconazole, miconazole, nystatin

CLOCORTOLONE PUMP, HALOBETASOL 0.05% FOAM, IMPOYZ, LEXETTE, SERNIVO, ULTRAVATE, VERDESO FOAM

generic topical corticosteroids

Page 3

(continued)

CRP2412_16637C 334293 EXCL-NPF-OE-24 (12/20/2023)

Drug Class

DERMATOLOGICAL (continued) Vitamin D Analogs (Topical)

Miscellaneous Topical Dermatological Agents

DIABETES Biguanidine Agents Blood Glucose Meters & Test Strips

Diabetic Pen Needles & Syringes

Excluded Medications

CALCIPOTRIENE FOAM, SORILUX

ALCORTIN A

CONDYLOX, VEREGEN

LIDOCAINE/TETRACAINE, PLIAGLIS

TAZORAC 0.05% CREAM

TRI-LUMA

YCANTH

METFORMIN 625 MG TABLETS

ASCENSIA (CONTOUR) ONETOUCH SOLUTIONS STARTER KIT ROCHE (ACCU-CHEK) TEMPO (WELCOME KIT, REFILL KIT, SMART BUTTON) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

PEN NEEDLES & SYRINGES BY: ARKRAY HOME AIDE DIAGNOSTICS HTL-STREFA NOVO NORDISK OWEN MUMFORD PRODIGY DIABETES CARE SIMPLE DIAGNOSTICS TRIVIDIA (NIPRO DIAGNOSTICS) ULTIMED ALL OTHER DIABETIC PEN NEEDLES & SYRINGES THAT ARE NOT LISTED AS PREFERRED

Diabetic Supply Kits

BIGFOOT UNITY PROGRAM KIT

ALOGLIPTIN, NESINA, TRADJENTA

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations

ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO

ALOGLIPTIN/PIOGLITAZONE

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations

QTERN, STEGLUJAN

Glucagon-Like Peptide-1 Agonists

VICTOZA

Glucose-Elevating Drugs

GLUCAGEN HYPOKIT, GLUCAGON EMERGENCY KIT (by Fresenius), ZEGALOGUE

Insulin (Basal) and Glucagon-Like Peptide-1 (GLP-1) Agonist Combinations

XULTOPHY

ADMELOG, AFREZZA, APIDRA, FIASP, INSULIN ASPART, NOVOLOG, RELION NOVOLOG

Insulins

INSULIN DEGLUDEC, INSULIN GLARGINE (by Winthrop), INSULIN GLARGINE-YFGN, LANTUS, LEVEMIR, REZVOGLAR

INSULIN ASPART PROTAMINE, NOVOLOG MIX, RELION NOVOLOG MIX

NOVOLIN, NOVOLIN MIX, RELION NOVOLIN, RELION NOVOLIN MIX

Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors & Combinations

BRENZAVVY, INVOKANA INVOKAMET, INVOKAMET XR

Preferred Alternatives

calcipotriene, calcitriol generic topical corticosteroids plus mupirocin imiquimod 5% cream, podofilox solution lidocaine cream, lidocaine/prilocaine cream tazarotene 0.1% cream fluocinolone acetonide, hydroquinone, tretinoin No alternatives recommended metformin 500 mg or 850 mg tablets FREESTYLE KITS/METERS (FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE) FREESTYLE TEST STRIPS (FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE) ONETOUCH KITS/METERS (ULTRA2, VERIO FLEX) ONETOUCH TEST STRIPS (ULTRA, VERIO) PRECISION XTRA METERS, TEST STRIPS

BD DIABETES PEN NEEDLES BD DIABETES SYRINGES

DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR saxagliptin, JANUVIA saxagliptin/metformin, JANUMET, JANUMET XR pioglitazone plus JANUVIA GLYXAMBI BYDUREON BCISE, BYETTA, OZEMPIC, TRULICITY glucagon emergency kit (by Amphastar), BAQSIMI, GVOKE

SOLIQUA HUMALOG, HUMALOG TEMPO, INSULIN LISPRO, LYUMJEV, LYUMJEV TEMPO

SEMGLEE (YFGN), TOUJEO, TRESIBA

HUMALOG MIX, INSULIN LISPRO PROTAMINE MIX

HUMULIN, HUMULIN MIX FARXIGA, JARDIANCE, STEGLATRO SEGLUROMET, SYNJARDY, SYNJARDY XR, XIGDUO XR

? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 4

(continued)

CRP2412_16637C 334293 EXCL-NPF-OE-24 (12/20/2023)

Drug Class

DIABETES (continued) Sulfonylurea Agents EAR/NOSE Nasal Steroids Otic Antibiotics & Combination Products

ENDOCRINE Cushing's Agents Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty) Growth Hormones

Somatostatin Analogs

Testosterone Products

Thyroid Replacement Therapy Miscellaneous Endocrine Agents GASTROINTESTINAL Antidiarrheal Agents

Antiemetics (Oral)

Bowel Evacuants Corticosteroids (Rectal Formulations) Fecal Microbiota Agents Gallstone Dissolution Agents Gastroparesis Agents Helicobacter Pylori Agents

Hemorrhoidal Preparations

Inflammatory Bowel Agents Irritable Bowel Syndrome & Chronic Constipation Agents Pancreatic Enzymes

Excluded Medications

Preferred Alternatives

GLIPIZIDE 2.5 MG TABLETS

glipizide 5 mg tablets

BECONASE AQ, OMNARIS, QNASL, ZETONNA

flunisolide, fluticasone, mometasone

CETRAXAL CIPRO HC, CIPROFLOXACIN/FLUOCINOLONE OTIC ISTURISA KORLYM RECORLEV

ciprofloxacin otic, ofloxacin otic ciprofloxacin/dexamethasone otic SIGNIFOR ketoconazole, LYSODREN, SIGNIFOR ketoconazole, LYSODREN

LUPRON DEPOT-PED, SUPPRELIN LA

FENSOLVI, TRIPTODUR

HUMATROPE, NORDITROPIN FLEXPRO, NUTROPIN AQ NUSPIN, SAIZEN, SAIZENPREP, ZOMACTON

GENOTROPIN, OMNITROPE

SKYTROFA, SOGROYA

GENOTROPIN, OMNITROPE, NGENLA

LANREOTIDE, SANDOSTATIN LAR DEPOT

SOMATULINE DEPOT

SIGNIFOR LAR

For Acromegaly: SOMATULINE DEPOT For Cushing's Disease: SIGNIFOR

AVEED

testosterone cypionate, testosterone enanthate

KYZATREX, NATESTO, TLANDO

testosterone gel, testosterone solution, ANDRODERM PATCHES

ADTHYZA

levothyroxine tablets, ARMOUR THYROID

LEVOTHYROXINE CAPSULES, THYQUIDITY, TIROSINT, TIROSINT-SOL

levothyroxine tablets

CORTROPHIN GEL

No alternatives recommended

MYTESI

diphenoxylate/atropine, loperamide

AKYNZEO CAPSULES ANTIVERT, MECLIZINE 50 MG TABLETS ANZEMET BONJESTA EMEND POWDER PACKETS

CLENPIQ, OSMOPREP, PLENVU, SUFLAVE, SUTAB

CORTIFOAM

REBYOTA

RELTONE GIMOTI

VOQUEZNA

HYDROCORTISONE/PRAMOXINE 25-18 MG SUPPOSITORIES PROCTOFOAM-HC

DIPENTUM

IBSRELA, MOTEGRITY, ZELNORM PERTZYE

granisetron, ondansetron, aprepitant, VARUBI TABLETS meclizine 25 mg tablets granisetron, ondansetron

doxylamine/pyridoxine hcl

aprepitant, VARUBI TABLETS magnesium sulfate/potassium sulfate/sodium sulfate solution, peg 3350/ascorbic acid powder packets hydrocortisone enema, UCERIS FOAM Coverage may be approved for the prevention of recurrent Clostridioides difficile infection under certain conditions.

ursodiol

No alternatives recommended

bismuth/metronidazole/tetracycline, lansoprazole/amoxicillin/clarithromycin, TALICIA hydrocortisone ac suppositories, pramoxine/hydrocortisone cream

pramoxine/hydrocortisone cream

balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA 250 MG CAPSULES lubiprostone, LINZESS, TRULANCE CREON, PANCREAZE, ZENPEP

? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

Page 5

(continued)

CRP2412_16637C 334293 EXCL-NPF-OE-24 (12/20/2023)

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download