4Q2022 Precision Formulary Exclusion List - Magellan Rx Management

4Q2023 Precision Formulary Exclusion List

Therapeutic Category

Excluded Medications

Preferred Alternatives

ALLERGIC REACTIONS

Anaphylaxis Treatment

Auvi-Q (0.15mg, 0.3mg)

epinephrine injection (0.15mg, 0.3mg)

Adlarity patch

donepezil, rivastigmine patch, galantamine

ALZHEIMER¡¯S AGENTS

Alzheimer¡¯s Disease

ANALGESICS

Non-Steroidal AntiInflammatory Agents

Opioid Analgesics

Skeletal Muscle Relaxants

Qmiiz ODT

meloxicam

Relafen, Relafen DS

nabumetone

Oral

Other

Ketorolac Nasal Spray, Sprix Nasal Spray diclofenac, ibuprofen, meloxicam

Topical

Flector, Licart, Pennsaid, Voltaren gel

diclofenac gel/solution/patch

Combinations

Apadaz,

benzhydrocodone/acetaminophen

hydrocodone/acetaminophen,

oxycodone/acetaminophen

Seglentis

tramadol, celecoxib

Arymo ER, Embeda, Exalgo ER,

Hysingla ER, Kadian ER, MS Contin,

Nucynta ER, oxycodone ER,

oxycodone powder, Oxycontin,

Zohydro ER

hydromorphone HCl ER, morphine sulfate

ER, oxymorphone HCl ER, Xtampza ER

Oral LongActing

Conzip, Tramadol ER 100mg, 200mg,

tramadol ER tablets

300mg cap

Oral ShortActing

Opioid Analgesics Transmucosal Fentanyl

Analgesics

Diclofenac Cap 35mg, Zorvolex

celecoxib, diflunisal, etodolac,

flurbiprofen, ibuprofen, indomethacin,

ketoprofen, ketorolac, meclofenamate,

meloxicam, nabumetone, naproxen,

oxaprozin, piroxicam, sulindac, tolmetin,

diclofenac powder packet

Nucynta

Examples: codeine sulfate,

hydromorphone HCl, morphine sulfate,

oxycodone HCl, oxymorphone HCl

Qdolo, tramadol cup

tramadol

Roxybond

oxycodone IR

fentanyl citrate buccal tab, Fentora, Lazanda, Subsys

fentanyl citrate lozenge

Norgesic Forte, Norgesic tablet, Orphengesic Forte

orphenadrine tab, aspirin

baclofen solution, Fleqsuvy/baclofen suspension,

Lyvispah granule packet, Ozobax

baclofen

** This list is not inclusive of all formulary strategies. Please check the formulary listing for specific drug coverage. All therapeutic classes do not allow

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grandfathering, unless specifically mentioned.

Grandfathering allowed; no duration limit. All other therapeutic classes do not allow Grandfathering, no exceptions.

All medications require a Prior Authorization. Use of a non-preferred medication requires clinical failure or intolerance of one or more preferred medications

prior to beginning therapy.

Grandfathering varies depending on which formulary the plan is enrolled in. The number and type of preferred alternative(s) will depend on the indication.

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Therapeutic Category

Excluded Medications

Preferred Alternatives

ANTIANXIETY AGENTS

Loreev XR

clonazepam, diazepam, lorazepam,

oxazepam, temazepam

Doryx, Doxycycline Hyclate DR 80mg, Minolira,

minocycline ER 105mg, 135 mg tablet

doxycycline, minocycline

Lymepak

doxycycline

Xifaxan 200 mg tablet

Please talk to your doctor about clinically

appropriate options.

Cleocin vaginal suppositories and cream, Nuvessa gel

clindamycin vaginal cream, metronidazole

vaginal gel

Elepsia XR

levetiracetam

Eprontia

topiramate sprinkle

Lamictal ODT Kit

lamotrigine ODT

Oxtellar XR

oxcarbazepine IR

Zonisade

Zonisamide capsule

bupropion 450mg XL, Forfivo XL

bupropion XL

Auvelity ER, citalopram 30 mg capsule

bupropion, citalopram tablet,

desvenlafaxine ER, duloxetine,

escitalopram, fluoxetine, mirtazapine,

paroxetine ER/IR, sertraline

tablet/solution, venlafaxine ER/IR

sertraline cap

sertraline tab

venlafaxine ER 112.5 mg

venlafaxine ER 37.5 mg, 75 mg, 150 mg,

225 mg

Brexafemme, Vivjoa

fluconazole tab

Emgality 120 mg/mL

amitriptyline, atenolol, divalproex sodium,

nadolol, propranolol, timolol, topiramate,

venlafaxine, Aimovig, Ajovy

Reyvow

Nurtec ODT, Ubrelvy

Ergotamine Derivative

(alpha)

Trudhesa

dihydroergotamine

Non-Steroidal AntiInflammatory Agents

Elyxyb

eletriptan, frovatriptan, rizatriptan,

sumatriptan, zolmitriptan

Serotonin Receptor

Agonists

Onzetra Xsail, Tosymra, Zembrace Symtouch

rizatriptan ODT, sumatriptan injection,

sumatriptan nasal spray, zolmitriptan ODT

Dhivy

carbidopa/levodopa IR,

carbidopa/levodopa ODT

Antianxiety Agents

ANTIBACTERIALS

Oral Antibiotics

Vaginal Anti-infectives

ANTICONVULSANTS

Seizure Disorders

ANTIDEPRESSANTS

Antidepressants

ANTIFUNGALS, ORAL

Oral Antifungals

ANTIMIGRAINES

CGRP Antagonists and

Ditans

ANTIPARKINSON AGENTS

Parkinson¡¯s Disease

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Therapeutic Category

Excluded Medications

Preferred Alternatives

ANTIPSYCHOTICS

Atypical/Second

Generation Antipsychotics

Lybalvi

Secuado

aripiprazole, asenapine, clozapine,

olanzapine, quetiapine, quetiapine ER,

paliperidone ER, risperidone, ziprasidone

AUTONOMIC & CENTRAL NERVOUS SYSTEM

Attention Deficit Disorder

Adhansia XR

dexmethylphenidate ER, methylphenidate

ER, Vyvanse

Adzenys XR-ODT, Adzenys ER Susp, Cotempla XRODT, Daytrana, Dyanavel XR, Mydayis, Quillichew ER,

Quillivant XR, Xelstrym, Zenzedi

amphetamine-dextroamphetamine IR/ER,

dexmethylphenidate IR/ER,

dextroamphetamine IR/SR,

methylphenidate IR/ER, Azstarys,

Jornay PM, Vyvanse

Qelbree

atomoxetine, clonidine ER, guanfacine ER

rosuvastatin-ezetimibe, Roszet

atorvastatin, ezetimibe, rosuvastatin,

simvastatin

Livalo, Zypitamag

atorvastatin, lovastatin, pravastatin,

rosuvastatin, simvastatin

Soaanz

bumetanide, furosemide, torsemide

Conjupri, levamlodipine, Katerzia

amlodipine

Inderal LA, Inderal XL, Innopran XL

propranolol ER

Kapspargo

metoprolol ER

CARDIOVASCULAR

Cholesterol-Lowering

Agents

Edema

Hypertension

Valsartan solution

candesartan, losartan, valsartan tablets

Hypertension with

Osteoarthritis

Consensi

amlodipine, celecoxib

Angina

Aspruzyo

ranolazine ER

Phexxi

Please talk to your doctor about clinically

appropriate options. Alternative hormonal

or non-hormonal contraceptives.

Lo Loestrin Fe

Examples: junel FE, larin FE, microgestin FE,

tarina FE

Nextstellis

drospirenone/ethinyl estradiol, loryna,

nikki, Natazia

Slynd

Examples: Camila, Incassia, Nora-be,

Norethindrone, Norlyda

Twirla

levonorgestrel/ethinyl estradiol combined

generic oral contraceptive, Xulane, zafemy

Alkindi Sprinkle, cortisone

hydrocortisone

Hemady

dexamethasone

Rayos

prednisone

CONTRACEPTIVES

Gel

Oral

Patch

CORTICOSTEROIDS

Oral Steroids

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Therapeutic Category

Excluded Medications

Preferred Alternatives

DERMATOLOGICAL AGENTS

Avita, Differin

adapalene, tretinoin cream/gel, Retin-A

micro gel 0.06% and 0.08%

Clindagel, Veltin

adapalene, adapalene/benzoyl peroxide,

clindamycin gel/lotion/solution,

clindamycin/benzoyl peroxide, dapsone,

erythromycin/benzoyl peroxide, tretinoin

cream, Amzeeq, Epiduo Forte, Onexton,

Twyneo

Arazlo, Fabior, Tazorac cream 0.1% and 0.05%, gel

0.1%, 0.05%, tazarotene foam 0.1%

tazarotene cream

Winlevi

adapalene, clindamycin, dapsone,

tazarotene cream, tretinoin cream

Topical Anesthetics

ZTlido

lidocaine patch

Topical Antifungals

Jublia

ciclopirox, tavaborole, terbinafine

Epsolay cream

azelaic acid gel, Finacea foam, Soolantra

Noritate cream

azelaic acid gel, metronidazole

cream/gel/lotion, ivermectin 1% cream,

Finacea foam, Soolantra

ALA Scalp lotion

hydrocortisone

Apexicon E cream

fluocinonide, betamethasone

Capex shampoo

fluocinolone acetonide scalp oil, DermaSmoothe/FS

Cordran tape

flurandrenolide

Halobetasol foam, Lexette

betamethasone, clobetasol, halobetasol

cream/ointment

Halog

betamethasone, mometasone,

triamcinolone

Impeklo lotion

augmented betamethasone dipropionate,

clobetasol

Impoyz cream

clobetasol

Pandel cream

flurandrenolide, hydrocortisone valerate,

triamcinolone acetonide

Trianex Ointment 0.05%

hydrocortisone valerate, triamcinolone

acetonide

Ultravate lotion

clobetasol propionate, fluocinonide,

halobetasol propionate

Verdeso foam

betamethasone, fluocinolone

calcipotriene foam 0.005%, Sorilux

calcipotriene

Duobrii lotion

clobetasol, fluocinonide, halobetasol,

tazarotene

Zoryve

betamethasone, calcitriol, calcipotriene,

coal tar, clobetasol, pimecrolimus,

tacrolimus, tazarotene, Vtama, Wynzora

Topical Acne Treatment

Topical Anti-Infectives

Topical Corticosteroids

DERMATOLOGICAL AGENTS

Topical Plaque Psoriasis

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Therapeutic Category

Excluded Medications

Preferred Alternatives

DIABETES

Examples: Abbott (FreeStyle, Precision), Arkray

Blood Glucose Meters, Test

(Glucocard), Lifescan (Onetouch), Trividia, (TRUEtest,

Strips and Control Solutions

TRUEtrack), Roche (Accu-Chek)

Ascencia (Contour, Contour Next)

Continuous Glucose

Monitoring (CGM)

Freestyle Libre

Dexcom

metformin 625mg tablet

Metformin 500 mg, 750 mg, 850 mg, 1000 mg

Blood Sugar Regulators

Miscellaneous

metformin HCl 24hr ER osmotic release, metformin HCl

metformin ER

24hr ER modified release

Dipeptidyl Peptidase-4

(DPP4) Inhibitors &

Combinations

alogliptin, alogliptin with metformin, alogliptin with

pioglitazone, Kazano, Kombiglyze XR, Nesina,

Onglyza, Oseni

Janumet, Janumet XR, Januvia,

Jentadueto, Jentadueto XR, Tradjenta

Basal insulins

Basaglar, generic insulin glargine, insulin degludec,

insulin glargine-YFGN, Levemir, Semglee, Semglee

(YFGN), Tresiba

Lantus, Toujeo

Glucagon-Like Peptide-1

(GLP1) Agonists

Adlyxin

Bydureon, Bydureon BCise, Byetta, Ozempic,

Rybelsus, Trulicity, Victoza, Mounjaro

Insulins

Novolin, Novolin Relion

Humulin

Rapid-acting Insulins

Admelog, Apidra, Fiasp, Insulin Aspart, Insulin Lispro

Pen, Novolog, Novolog Relion

Humalog, Lyumjev, Insulin Lispro vial

Sodium-glucose Cotransporter (SGLT2)

Inhibitors

Invokamet, Invokamet XR, Invokana, Qtern,

Segluromet, Steglatro, Steglujan

Farxiga, Jardiance, Synjardy, Synjardy XR,

Xigduo XR, Glyxambi, Trijardy XR

Aveed, Jatenzo, Natesto, Testopel, Tlando

testosterone, Androderm, Xyosted

Anti-Diarrheal Agents

Motofen

diphenoxylate/atropine, loperamide

Antiemetics

Sancuso patch

granisetron solution/tablet, ondansetron

ODT

Anti-Inflammatory

Anti-Ulcer Agents

Duexis, ibuprofen-famotidine

famotidine PLUS ibuprofen, omeprazole

PLUS naproxen

Irritable Bowel Syndrome

with Constipation/ Chronic

Idiopathic Constipation

(IBS-C/CIC)

Amitiza, Ibsrela, Trulance

Linzess

Opioid-Induced

Constipation (OIC)

Amitiza, Movantik, Relistor

Symproic

Inflammatory Bowel

Disease

Dipentum

balsalazide, mesalamine DR cap 400mg,

Apriso

Ortikos

budesonide ER

Laxatives

Osmoprep, Plenvu

Gavilyte, PEG 3350, Clenpiq, Suprep

Pancreatic Enzymes

Pancreaze, Pertzye, Viokace

Creon, Zenpep

Peptic Ulcers

Dartisla ODT

glycopyrrolate

Proton Pump Inhibitors

omeprazole with sodium bicarbonate (cap, powder

pak), rabeprazole sprinkle cap

esomeprazole magnesium delayed release,

lansoprazole, omeprazole, pantoprazole

ENDOCRINE (OTHER)

Testosterone Replacement

GASTROINTESTINAL

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