Express Scripts 2020 National Preferred Formulary Exclusions
2021 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)
Anticonvulsants
Antimigraine Agents
Antiparkinsonism Agents
Antipsychotics (Oral) Antispasmodic Agents Central Nervous System Stimulants
Duchenne Muscular Dystrophy (DMD) Agents Lambert-Eaton Myasthenic Syndrome Agents Long-Acting Opioid Oral Analgesics Multiple Sclerosis (Beta Interferons)
Narcotic Analgesics & Combinations
Excluded Medications
FIRVANQ TOLSURA SITAVIG LAMPIT LUCEMYRA
APTIOM FINTEPLA TOPIRAMATE ER CAPSULES VYEPTI GOCOVRI ER ONGENTYS XADAGO, ZELAPAR CAPLYTA OZOBAX
AMPHETAMINE ER SUSPENSION
EMFLAZA EXONDYS 51, VILTEPSO, VYONDYS 53 FIRDAPSE MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, XTAMPZA ER EXTAVIA APADAZ, BENZHYDROCODONE/ACETAMINOPHEN NUCYNTA PRIMLEV
Preferred Alternatives
vancomycin capsules, vancomycin oral solution
itraconazole acyclovir oral or cream, famciclovir, valacyclovir BENZNIDAZOLE
clonidine
carbamazepine, oxcarbazepine, pregabalin, topiramate, VIMPAT DIACOMIT, EPIDIOLEX topiramate tablets, QUDEXY XR AIMOVIG, AJOVY, EMGALITY amantadine capsules, amantadine tablets, amantadine oral solution entacapone rasagiline, selegiline aripiprazole, asenapine, olanzapine, quetiapine er, quetiapine fumarate, risperidone, ziprasidone, LATUDA baclofen, tizanidine dexmethylphenidate er, dextroamphetamine er, dextroamphetamine/amphetamine er, methylphenidate cd, methylphenidate er, methylphenidate la, DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR, VYVANSE prednisone solution, prednisone tablets No alternatives recommended RUZURGI hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, OXYCONTIN AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE hydrocodone/acetaminophen hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen oxycodone/acetaminophen
~ Medications will be excluded beginning 04/01/2021
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 1
Continued
CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)
Drug Class
AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued) Narcotic Antagonists
Neuropathic Agents Sedative-Hypnotic Agents Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants Tardive Dyskinesia Therapy
Transmucosal Fentanyl Analgesics
Miscellaneous Antidepressants
CARDIOVASCULAR ACE Inhibitors
Excluded Medications
BUNAVAIL EVZIO, NALOXONE AUTO-INJECTOR LYRICA CR DORAL, QUAZEPAM PEXEVA~, VIIBRYD~
DRIZALMA SPRINKLE INGREZZA 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 DERMATOLOGICAL Agents for Hyperhidrosis Oral Agents for Acne Rosacea Agents (Oral) Topical Acne Combinations Topical Acne/Antibiotic Combinations Topical Agents for Actinic Keratosis
~ Medications will be excluded beginning 04/01/2021
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
PRADAXA, SAVAYSA BYSTOLIC~ DUTOPROL INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE KATERZIA ALTOPREV, EZALLOR SPRINKLE PRALUENT DRYSOL~ DORYX DR 80 MG, DOXYCYCLINE HYCLATE DR 80 MG MINOCYCLINE ER CAPSULES, XIMINO DOXYCYCLINE 40 MG CAPSULES EPIDUO FORTE VELTIN CARAC, FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA
Page 2
Preferred Alternatives
buprenorphine/naloxone, ZUBSOLV naloxone syringes, NARCAN NASAL SPRAY gabapentin, pregabalin estazolam, lorazepam citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA
AUSTEDO
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 atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO REPATHA
Over-the-Counter aluminum chloride containing products
doxycycline hyclate, doxycycline monohydrate minocycline er tablets doxycycline hyclate, doxycycline monohydrate adapalene/benzoyl peroxide clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream
Continued
CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)
Drug Class
DERMATOLOGICAL (continued) Topical Antibiotics for Acne Topical Antifungals
Topical Corticosteroids
Vitamin D Analogs (Topical) Miscellaneous Topical Dermatological Agents
Excluded Medications
CLINDAGEL, CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE) ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL
CLOCORTOLONE
VERDESO FOAM
CALCIPOTRIENE FOAM ALCORTIN A LIDOCAINE/TETRACAINE
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
ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations
ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, KOMBIGLYZE XR
ALOGLIPTIN/PIOGLITAZONE
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations
QTERN
Glucagon-Like Peptide-1 Agonists
ADLYXIN, VICTOZA
Insulins
ADMELOG, AFREZZA~, APIDRA, FIASP, INSULIN ASPART, INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG
NOVOLIN, RELION NOVOLIN
SEMGLEE
EAR/NOSE Nasal Steroids
BECONASE AQ, OMNARIS, ZETONNA
Otic Fluoroquinolone Antibiotics
CIPROFLOXACIN/FLUOCINOLONE OTIC
ENDOCRINE (OTHER) Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty)
FENSOLVI
Growth Hormones
HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON
Somatostatin Analogs
MYCAPSSA, SANDOSTATIN LAR DEPOT SIGNIFOR LAR
Testosterone Products Miscellaneous Endocrine Drugs
AVEED KORLYM
Preferred Alternatives
clindamycin phosphate gel, erythromycin gel, AMZEEQ
ciclopirox, econazole, ketoconazole, naftifine, oxiconazole betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment calcipotriene, calcitriol hydrocortisone, mupirocin lidocaine cream, lidocaine/prilocaine cream 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
HUMULIN LANTUS, LEVEMIR, TOUJEO, TRESIBA
budesonide, flunisolide, fluticasone, mometasone, QNASL
ciprofloxacin/dexamethasone otic, OTOVEL
LUPRON DEPOT-PED, TRIPTODUR
GENOTROPIN, NORDITROPIN FLEXPRO
SOMATULINE DEPOT For Acromegaly: SOMATULINE DEPOT For Cushing's Disease: SIGNIFOR testosterone cypionate, testosterone enanthate ketoconazole, LYSODREN, SIGNIFOR
~ Medications will be excluded beginning 04/01/2021
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 3
Continued
CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)
Drug Class
GASTROINTESTINAL Antidiarrheal Agents
Antiemetics (Oral)
Bowel Evacuants Corticosteroids (Rectal Formulations) 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 VIII Recombinant Products
Granulocyte Colony Stimulating Factors
Iron Replacement Agents
Sickle Cell Disease Agents
Thrombocytopenia Agents
HEPATITIS Hepatitis C
Excluded Medications
MYTESI
AKYNZEO CAPSULES EMEND POWDER PACKETS CLENPIQ~, GOLYTELY PACKETS~, OSMOPREP, PLENVU~, SUPREP~ CORTIFOAM GIMOTI HELIDAC, PYLERA PROCTOFOAM-HC
DIPENTUM
AMITIZA PERTZYE ACIPHEX SPRINKLE, ESOMEPRAZOLE STRONTIUM, NEXIUM PACKETS, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE
ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR
ARANESP, EPOGEN, MIRCERA
NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE
GRANIX, NEUPOGEN NEULASTA, UDENYCA MONOFERRIC OXBRYTA SIKLOS MULPLETA TAVALISSE LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI COMPLERA
HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.
~ Medications will be excluded beginning 04/01/2021
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
DELSTRIGO
PIFELTRO PREZCOBIX RUKOBIA ER STRIBILD
Page 4
Preferred Alternatives
diphenoxylate/atropine, loperamide
granisetron, ondansetron, aprepitant, VARUBI TABLETS aprepitant, VARUBI TABLETS
peg-electrolyte solution
hydrocortisone enema, UCERIS FOAM 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 ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT NIVESTYM, ZARXIO FULPHILA, ZIEXTENZO sodium ferric gluconate complex, VENOFER hydroxyurea, ADAKVEO, DROXIA DROXIA DOPTELET DOPTELET, PROMACTA, NPLATE
EPCLUSA, HARVONI, VOSEVI, ZEPATIER
ODEFSEY efavirenz/emtricitabine/tenofovir disoproxil fumarate, efavirenz/lamivudine/tenofovir disoproxil fumarate, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ efavirenz, EDURANT atazanavir, ritonavir, KALETRA TABLETS, PREZISTA Coverage may be approved for the treatment of human immunodeficiency virus-1 infection in heavily treatmentexperienced patients with multidrug-resistant infection. BIKTARVY, GENVOYA
Continued
CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)
Drug Class
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 Gels Vaginal Progesterones ONCOLOGY Acute Myeloid Leukemia (AML) Agents Bevacizumab-Containing Agents Breast Cancer Agents Chronic Lymphocytic Leukemia (CLL) Agents Multiple Myeloma Agents Myelodysplastic Syndrome Agents Myelofibrosis Agents Prostate Cancer Agents Rituximab-Containing Agents
Excluded Medications
Preferred Alternatives
COLCHICINE CAPSULES
colchicine tablets, MITIGARE
DICLOFENAC 35 MG CAPSULES, INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY, TIVORBEX, ZIPSOR, ZORVOLEX
diclofenac, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam
FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES
fenoprofen calcium tablets, diclofenac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen
RELAFEN DS
nabumetone, diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, piroxicam
DICLOFENAC EPOLAMINE PATCHES, PENNSAID
diclofenac sodium topical, FLECTOR PATCHES, LICART PATCHES
CLIMARA PRO ANNOVERA~, BALCOLTRA~, LO LOESTRIN FE~, NATAZIA~, TWIRLA PHEXXI SLYND~ FEMRING INTRAROSA, OSPHENA~ PREMPHASE~, PREMPRO~ PREMARIN TABLETS~ CHORIONIC GONADOTROPIN, PREGNYL FOLLISTIM AQ PREGENNA, TRINAZ ELESTRIN, ESTROGEL CRINONE 4% CRINONE 8%
COMBIPATCH
generic oral and ring contraceptives, xulane patches
Barrier methods of contraception, such as condoms, diaphragms, spermicides or sponges. generic progestin-only oral contraceptives estradiol cream, estradiol patches, estradiol tablets, yuvafem, ESTRING, PREMARIN CREAM estradiol cream, yuvafem, ESTRING, PREMARIN CREAM amabelz, estradiol/norethindrone acetate, fyavolv, jinteli, mimvey, norethindrone/ethinyl estradiol estradiol tablets NOVAREL, OVIDREL GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT generic prenatal vitamins DIVIGEL medroxyprogesterone, megestrol, norethindrone, progesterone ENDOMETRIN
ONUREG AVASTIN KISQALI, KISQALI FEMARA CO-PACK, PIQRAY CALQUENCE BLENREP, XPOVIO INQOVI INREBIC TRELSTAR RITUXAN, RITUXAN HYCELA, TRUXIMA
azacitidine, decitabine
MVASI, ZIRABEV IBRANCE, VERZENIO IMBRUVICA, VENCLEXTA DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID, THALOMID, VELCADE decitabine JAKAFI ELIGARD, FIRMAGON RUXIENCE
~ Medications will be excluded beginning 04/01/2021
? 2021 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 5
Continued
CRP2011_006458.1 334293 DL44109Q-OE-21 (01/15/2021)
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