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.
2023 Magellan Rx Management, LLC. All rights reserved_MRX1069_1023
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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
2023 Magellan Rx Management, LLC. All rights reserved_MRX1069_1023
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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
2023 Magellan Rx Management, LLC. All rights reserved_MRX1069_1023
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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
2023 Magellan Rx Management, LLC. All rights reserved_MRX1069_1023
4
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
2023 Magellan Rx Management, LLC. All rights reserved_MRX1069_1023
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