Express Scripts 2019 National Preferred Formulary Exclusions

[Pages:5]2019 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. Log on to covered to compare drug prices. 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

AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Anticonvulsants

Antiparkinsonism Agents

Beta Interferons for Multiple Sclerosis

Duchenne Muscular Dystrophy (DMD) Agents

Long-Acting Opioid Oral Analgesics

Narcotic Analgesics & Combinations Narcotic Antagonists Neuropathic Agents Tardive Dyskinesia Therapy Transmucosal Fentanyl Analgesics

Miscellaneous Antidepressants CARDIOVASCULAR Anticoagulants

Beta Blockers & Combinations

Calcium Channel Blockers HMG & Cholesterol Inhibitor Combinations

PCSK9 Inhibitors DERMATOLOGICAL Oral Agents for Acne Oral Agents for Rosacea Topical Acne/Antibiotic Combinations

Excluded Medications

LUCEMYRA TOPIRAMATE ER CAPSULES GOCOVRI ER, OSMOLEX ER XADAGO EXTAVIA EMFLAZA EXONDYS 51 EMBEDA, OXYCODONE ER APADAZ, BENZHYDROCODONE/ACETAMINOPHEN BUTRANS EVZIO LYRICA CR INGREZZA ABSTRAL, FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA SPRAVATO

PRADAXA, SAVAYSA KAPSPARGO SPRINKLE DUTOPROL, METOPROLOL SUCCINATE/HCTZ ER KATERZIA ALTOPREV, EZALLOR SPRINKLE, ZYPITAMAG PRALUENT (NDCs starting with 72733), REPATHA (NDCs starting with 72511) MINOLIRA DOXYCYCLINE 40 MG CAPSULES AKTIPAK, VELTIN

Preferred Alternatives

clonidine

topiramate tablets, QUDEXY XR amantadine capsules, amantadine tablets, amantadine oral solution rasagiline, selegiline AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE prednisone solution, prednisone tablets No alternatives recommended hydromorphone ER, morphine sulfate ER, oxymorphone ER, HYSINGLA ER, NUCYNTA ER, OXYCONTIN hydrocodone/acetaminophen buprenorphine patch, BELBUCA naloxone syringes, NARCAN NASAL SPRAY gabapentin, pregabalin, GRALISE AUSTEDO

fentanyl citrate lozenges

olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline

ELIQUIS, XARELTO

metoprolol succinate metoprolol tartrate/hydrochlorothiazide, metoprolol succinate ER plus hydrochlorothiazide amlodipine atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin, LIVALO PRALUENT (NDCs starting with 00024), REPATHA (NDCs starting with 55513)

minocycline ER

ORACEA clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON

? 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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204612 DL44109Q-SD-19 (11/15/2019)

Drug Class

DERMATOLOGICAL (continued) Topical Agents for Actinic Keratosis Topical Antifungals

Topical Corticosteroids

Miscellaneous Topical Dermatological Agents

DIABETES Blood Glucose Meters & Test Strips

Dipeptidyl Peptidase-4 Inhibitors & Combinations

Glucagon-Like Peptide-1 Agonists Insulins

EAR/NOSE Nasal Steroids Otic Fluoroquinolone Antibiotics ENDOCRINE (OTHER) Combination Patches Estrogen and Estrogen Modifiers for Vaginal Symptoms

Growth Hormones Somatostatin Analogs Topical Estrogen Gels GASTROINTESTINAL Corticosteroids (Rectal Formulations) Inflammatory Bowel Agents Irritable Bowel Agents Pancreatic Enzymes Proton Pump Inhibitors HEMATOLOGICAL Antiplatelet Agents Erythropoiesis-Stimulating Agents

Excluded Medications

Preferred Alternatives

FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA LULICONAZOLE CLOCORTOLONE

TOPICORT SPRAY, VERDESO FOAM ALCORTIN A LIDOCAINE/TETRACAINE

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

ciclopirox, econazole, ketoconazole, naftifine, oxiconazole

betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide

desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment

hydrocortisone, mupirocin

lidocaine cream, lidocaine/prilocaine cream

ABBOTT (FREESTYLE, PRECISION), BAYER (BREEZE, CONTOUR), NATIONAL MEDICAL (ADVOCATE), OMNIS HEALTH (EMBRACE, VICTORY), ROCHE (ACCU-CHEK), TRIVIDIA (TRUETEST, TRUETRACK), UNISTRIP ALL OTHER METERS & STRIPS THAT ARE NOT LIFESCAN BRAND

LIFESCAN (ONETOUCH)

ALOGLIPTIN, NESINA, ONGLYZA

JANUVIA, TRADJENTA

ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR

JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

ALOGLIPTIN/PIOGLITAZONE

pioglitazone plus JANUVIA or TRADJENTA

ADLYXIN, VICTOZA

BYDUREON, BYETTA, OZEMPIC, TRULICITY

NOVOLIN

HUMULIN

ADMELOG, APIDRA, FIASP, INSULIN LISPRO, NOVOLOG

HUMALOG

BECONASE AQ, OMNARIS, ZETONNA

budesonide, flunisolide, fluticasone, mometasone, QNASL

CETRAXAL

ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEX, OTOVEL

CLIMARA PRO

COMBIPATCH

FEMRING

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON SANDOSTATIN LAR DEPOT, SIGNIFOR LAR ESTROGEL

estradiol patches, estradiol tablets, yuvafem, ESTRING, PREMARIN CREAM, PREMARIN TABLETS

GENOTROPIN, NORDITROPIN FLEXPRO

SOMATULINE DEPOT DIVIGEL

CORTIFOAM

hydrocortisone enema, UCERIS FOAM

DIPENTUM

ZELNORM PANCREAZE, PERTZYE ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, PROTONIX SUSPENSION, RABEPRAZOLE DR SPRINKLE

ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR

ARANESP, EPOGEN, MIRCERA

balsalazide disodium, mesalamine delayed release, sulfasalazine, APRISO, PENTASA

AMITIZA, LINZESS, TRULANCE

CREON, ZENPEP

esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM PACKETS

aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole

PROCRIT, RETACRIT

? 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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204612 DL44109Q-SD-19 (11/15/2019)

Drug Class

HEMATOLOGICAL (continued) Factor VIII Recombinant Products Granulocyte Colony Stimulating Factors HEPATITIS Hepatitis C

HIV Antiretrovirals

MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) OBSTETRICAL & GYNECOLOGICAL Human Chorionic Gonadotropin Ovulatory Stimulants (Follitropins) Vaginal Progesterones ONCOLOGY Breast Cancer Agents Multiple Myeloma Agents Myelofibrosis Agents OPHTHALMIC Antiglaucoma Drugs (Beta-Adrenergic Blockers) Antiglaucoma Drugs (Ophthalmic Prostaglandins) Ophthalmic Anti-Allergic

Ophthalmic Anti-Inflammatory Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) OSTEOARTHRITIS Hyaluronic Acid Derivatives RENAL DISEASE Phosphate Binders

Excluded Medications

RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE NEUPOGEN, NIVESTYM LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI ATRIPLA, DELSTRIGO, SYMTUZA COMPLERA PIFELTRO PREZCOBIX STRIBILD COLCHICINE ZURAMPIC FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES

RELAFEN DS

ZORVOLEX DICLOFENAC EPOLAMINE PATCH CHORIONIC GONADOTROPIN, PREGNYL FOLLISTIM AQ ENDOMETRIN KISQALI, KISQALI FEMARA CO-PACK, PIQRAY

XPOVIO INREBIC TIMOPTIC OCUDOSE XELPROS, ZIOPTAN ALOCRIL, ALOMIDE

FML FORTE, FML S.O.P., MAXIDEX, PRED MILD

ACUVAIL, NEVANAC DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRIVISC, VISCO-3 FOSRENOL POWDER PACKETS

Preferred Alternatives

ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT GRANIX, ZARXIO

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, TRIUMEQ ODEFSEY efavirenz, EDURANT atazanavir, ritonavir, KALETRA TABLETS, PREZISTA BIKTARVY, GENVOYA COLCRYS, MITIGARE allopurinol, probenecid fenoprofen calcium tablets, diclofenac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen nabumetone, diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, piroxicam diclofenac, etodolac, ibuprofen, meloxicam, nabumetone, naproxen, piroxicam FLECTOR PATCH

NOVAREL, OVIDREL

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT CRINONE 8% GEL

IBRANCE, VERZENIO

DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE JAKAFI betaxolol drops, levobunolol drops, timolol drops, ALPHAGAN P 0.1%, COMBIGAN bimatoprost drops, latanoprost drops, LUMIGAN, TRAVATAN Z azelastine drops, cromolyn drops, olopatadine drops, ALREX, BEPREVE, PAZEO dexamethasone drops, fluorometholone drops, prednisolone drops, INVELTYS, LOTEMAX bromfenac drops, diclofenac drops, ketorolac drops, ILEVRO, PROLENSA

EUFLEXXA, MONOVISC, ORTHOVISC

lanthanum, sevelamer carbonate, sevelamer hcl, PHOSLYRA, VELPHORO

? 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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204612 DL44109Q-SD-19 (11/15/2019)

Drug Class

RESPIRATORY Epinephrine Auto-Injector Systems Immunological Agents for Asthma Long-Acting Beta Agonist Nebulized Long-Acting Muscarinic Antagonist Inhalers Long-Acting Muscarinic Antagonist/ Long-Acting Beta-Agonist Combination Inhalers

Pulmonary Anti-Inflammatory Inhalers

Short-Acting Beta -Agonist Inhalers 2

WEIGHT LOSS Weight Loss Agents

MISCELLANEOUS AGENTS

Antifungal Agents Anti-infectives

Bone Modifiers

Hereditary Angioedema Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis Potassium Binders

Excluded Medications

Preferred Alternatives

AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX)

epinephrine auto-injector (by Mylan), EPIPEN, EPIPEN JR

CINQAIR

FASENRA, NUCALA, DUPIXENT

BROVANA

PERFOROMIST

SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, TUDORZA PRESSAIR INCRUSE ELLIPTA

STIOLTO RESPIMAT

ANORO ELLIPTA, BEVESPI AEROSPHERE

ALVESCO

ALBUTEROL SULFATE HFA, LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA

ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR REDIHALER

PROAIR HFA/RESPICLICK, VENTOLIN HFA

QSYMIA SIKLOS NOCTIVA TOLSURA DOXYCYCLINE HYCLATE DR 80 MG EVENITY PROLIA BERINERT ONPATTRO VELTASSA

benzphetamine, diethylpropion, phentermine

DROXIA desmopressin tablets itraconazole doxycycline hyclate dr alendronate, ibandronate, risedronate, zoledronic acid, FORTEO, TYMLOS alendronate, ibandronate, risedronate RUCONEST

No alternatives recommended

LOKELMA

Drug Class

Indication Based Management Nonpreferred Medications

Preferred Alternatives

INFLAMMATORY CONDITIONS

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred medications is required prior to initiating therapy with a Nonpreferred medication. A formulary exception may be granted for patients already established on therapy with a Nonpreferred medication.

ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, RINVOQ ER, SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), SKYRIZI, STELARA SC, TREMFYA, XELJANZ, XELJANZ XR

Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

? 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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Excluded Medications/Products at a Glance

ABBOTT (FREESTYLE, PRECISION) ABILIFY^ ABSTRAL ACIPHEX^ ACIPHEX SPRINKLE ACUVAIL ADCIRCA^ ADDERALL^ ADLYXIN ADMELOG AKTIPAK ALBUTEROL SULFATE HFA ALCORTIN A ALOCRIL ALOGLIPTIN ALOGLIPTIN/METFORMIN ALOGLIPTIN/PIOGLITAZONE ALOMIDE ALTOPREV ALVESCO AMPYRA^ ANDROGEL 1%^ ANUSOL-HC^ APADAZ APIDRA ARANESP ARIMIDEX^ ASACOL HD^ ASPIRIN/OMEPRAZOLE DR ATACAND^, ATACAND HCT^ ATRIPLA AUVI-Q AVALIDE^, AVAPRO^ AVODART^ AZOR^ BARACLUDE TABLETS^ BAYER (BREEZE, CONTOUR) BECONASE AQ BENICAR^, BENICAR HCT^ BENZHYDROCODONE/ACETAMINOPHEN BERINERT BRISDELLE^ BROVANA BUPAP^ BUTRANS CELEBREX^ CELEXA^ CETRAXAL CHORIONIC GONADOTROPIN CINQAIR CLIMARA PRO CLOCORTOLONE COLCHICINE COMPLERA COREG^ CORTIFOAM COSOPT^ COZAAR^, HYZAAR^ CRESTOR^ CYMBALTA^ CYTOMEL^ DELSTRIGO DELZICOL^ DETROL^, DETROL LA^ DICLOFENAC EPOLAMINE PATCH DIOVAN^, DIOVAN HCT^ DIPENTUM DOXYCYCLINE 40 MG CAPSULES

DOXYCYCLINE HYC DR 80 MG DUROLANE DUTOPROL EFFEXOR XR^ EMBEDA EMFLAZA ENDOMETRIN EPINEPHRINE AUTO-INJECTOR (BY IMPAX) EPOGEN ESTROGEL EVENITY EVZIO EXFORGE^, EXFORGE HCT^ EXONDYS 51 EXTAVIA EZALLOR SPRINKLE FEMRING FENOPROFEN CAPSULES FENORTHO FENTANYL CITRATE BUCCAL TABLETS FENTORA FIASP FLUOROURACIL 0.5% CREAM FML FORTE, FML S.O.P. FOLLISTIM AQ FOSRENOL CHEWABLE TABLETS^ FOSRENOL POWDER PACKETS GANIRELIX ACETATE^ GEL-ONE GELSYN-3 GENVISC 850 GLEEVEC^ GLUCOPHAGE^, GLUCOPHAGE XR^ GLUMETZA^ GOCOVRI ER HUMATROPE HYALGAN HYMOVIS IMIQUIMOD 3.75% CREAM PUMP IMITREX^ INDERAL LA^ INGREZZA INREBIC INSULIN LISPRO INTUNIV^ ISTALOL^ KAPSPARGO SPRINKLE KATERZIA KAZANO KEPPRA^, KEPPRA XR^ KISQALI, KISQALI FEMARA CO-PACK KOMBIGLYZE XR LAMICTAL^, LAMICTAL ODT^, LAMICTAL XR^ LAZANDA LEDIPASVIR/SOFOSBUVIR LEVALBUTEROL HFA LEXAPRO^ LIBRAX^ LIDOCAINE/TETRACAINE LIDODERM^ LIPITOR^ LOESTRIN^, LOESTRIN FE^ LOTREL^ LOVENOX^ LUCEMYRA LULICONAZOLE LUNESTA^ LYRICA CR

MAVYRET

SINGULAIR^

MAXALT^, MAXALT MLT^

SODIUM HYALURONATE

MAXIDEX

SOFOSBUVIR/VELPATASVIR

METOPROLOL SUCCINATE/HCTZ ER

SOVALDI

MICARDIS^, MICARDIS HCT^

SPIRIVA HANDIHALER, SPIRIVA RESPIMAT

MINASTRIN 24 FE^

SPRAVATO

MINOLIRA

STIOLTO RESPIMAT

MIRCERA

STRATTERA^

NALFON CAPSULES

STRIBILD

NAMENDA XR^

SUPARTZ FX

NASONEX^

SYMTUZA

NATIONAL MEDICAL (ADVOCATE)

SYNVISC, SYNVISC-ONE

NESINA

TESTIM^

NEUPOGEN

TIKOSYN^

NEURONTIN^

TIMOPTIC OCUDOSE

NEVANAC

TOBI SOLUTION^

NIVESTYM

TOLSURA

NOCTIVA

TOPAMAX^

NORCO^

TOPICORT SPRAY

NORVASC^

TOPIRAMATE ER CAPSULES

NOVOLIN

TRIBENZOR^

NOVOLOG

TRICOR^

NUTROPIN AQ NUSPIN

TRILEPTAL^

NUVIGIL^

TRIVIDIA (TRUETEST, TRUETRACK)

OMNARIS

TRIVISC

OMNIS HEALTH (EMBRACE, VICTORY)

TUDORZA PRESSAIR

OMNITROPE

UNISTRIP

ONGLYZA

UROXATRAL^

ONPATTRO

VAGIFEM^

ORTHO TRI-CYCLEN^, ORTHO TRI-CYCLEN LO^ VALIUM^

OSMOLEX ER

VALTREX^

OXYCODONE ER

VELTASSA

PANCREAZE

VELTIN

PATADAY^

VERDESO FOAM

PERTZYE

VIAGRA^

PIFELTRO

VICTOZA

PIQRAY

VISCO-3

PLAQUENIL^

VIVELLE-DOT^

PLAVIX^

VYTORIN^

PRADAXA

WELLBUTRIN SR^

PRALUENT (NDCs starting with 72733)

XADAGO

PRAVACHOL^

XALATAN^

PRED MILD

XANAX^, XANAX XR^

PREGNYL

XELPROS

PREVACID^, PREVACID SOLUTAB^

XENAZINE^

PREZCOBIX

XOPENEX HFA

PRILOSEC SUSPENSION

XPOVIO

PRISTIQ^

XYNTHA, XYNTHA SOLOFUSE

PROLIA

YASMIN^

PROTONIX^

YOSPRALA DR

PROTONIX SUSPENSION

ZAVESCA^

PROVENTIL HFA

ZEGERID^

PROVIGIL^

ZELNORM

PROZAC^

ZETIA^

PULMICORT RESPULES^

ZETONNA

QSYMIA

ZIOPTAN

RABEPRAZOLE DR SPRINKLE

ZOCOR^

RECOMBINATE

ZOLOFT^

RELAFEN DS

ZOMACTON

RENAGEL^

ZOMIG TABLETS^, ZOMIG ZMT^

REPATHA (NDCs starting with 72511)

ZONEGRAN^

ROCHE (ACCU-CHEK)

ZORVOLEX

SAIZEN, SAIZENPREP

ZURAMPIC

SANDOSTATIN LAR DEPOT

ZYCLARA

SAVAYSA

ZYFLO CR^

SEROQUEL^, SEROQUEL XR^

ZYPITAMAG

SIGNIFOR LAR

ZYTIGA 250 MG^

SIKLOS

^ Multisource brand exclusion ? The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the same active ingredients as their corresponding brand-name medications, although they may have a different appearance. As new generic medications become available, additional multisource brand products may become excluded.

? 2019 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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204612 DL44109Q-SD-19 (11/15/2019)

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