Common Drugs Not Covered and Their Covered Alternatives

Common Drugs Not Covered and Their Covered Alternatives

About this list: This is a list of the most common single-source brand (drugs that do not have a generic equivalent or exact copy) and generic drugs that will not be covered. Multi-source brand name drugs (drugs that have a generic equivalent or exact copy) are not included on this list, but most will not be covered as well.

If your drug is on this list:

This means it won't be covered. Talk to your doctor about switching to a covered drug to treat your health problems. Your doctor may also ask for a drug to be covered if you have a medically necessary need for it. We will review your doctor's request, but coverage may not be possible for all drugs. If you want to take a drug that is not covered, you may have to pay its full cost.

Key: BRAND medications are listed in UPPERCASE and generics in lowercase. *These drugs may be covered in other strengths and/or dosage forms.

Drugs Not Covered

Covered Drugs that Treat the Same Health Problems

ABSTRAL

fentanyl lozenge on a handle

ACCU-CHECK TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

ACCUTREND GLUCOSE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

acyclovir cream

acyclovir capsule/tablet/suspension, famciclovir, valacyclovir

ADAPALENE

adapalene cream/pump, tretinoin, tretinoin microsphere

adapalene-benzoyl peroxide gel adapalene cream/pump, clindamycin-benzoyl peroxide 1-5% gel, neuac gel

ADHANSIA XR

metadate er, methylphenidate hcl er, methylphenidate la

ADLYXIN

OZEMPIC, TRULICITY, VICTOZA, BYETTA, BYDUREON BCISE, RYBELSUS

ADMELOG

NOVOLOG, FIASP, NOVOLIN R

ADMELOG SOLOSTAR

NOVOLOG, FIASP, NOVOLIN R

ADVANCED GLUCOSE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

ADVOCATE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

ADZENYS ER

dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er

ADZENYS XR-ODT

dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er

AFREZZA

NOVOLOG, FIASP, NOVOLIN R

AGAMATRIX AMP TEST STRIPS CONTOUR NEXT, TRUE METRIX, TRUETRACK

AIRDUO

salmeterol-fluticasone, wixela inhub, ADVAIR HFA, BREO, DULERA, SYMBICORT

AKLIEF

tretinoin, adapalene, tazarotene

AKTIPAK

erythromycin-benzoyl peroxide, clindamycin-benzoyl peroxide 1-5% gel, clindamycin (topical)

ALBUTEROL SULFATE HFA

albuterol sulfate hfa, PROAIR RESPICLICK

ALDACTAZIDE

spironolactone-hctz

ALOGLIPTIN-METFORMIN

JANUMET/XR, JENTADUETO/XR

ALOGLIPTIN-PIOGLITAZONE JANUVIA OR TRADJENTA PLUS pioglitazone

ALTABAX

mupirocin, XEPI

ALTOPREV

lovastatin, atorvastatin, pravastatin, rosuvastatin

aminocaproic acid

tranexamic acid

AMPHETAMINE 1.25 MG/ML dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er SUSPENSION

amphetamine sulfate tablet dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er

AMZEEQ

clindamycin (topical), erythromycin (topical)

ANALPRAM HC

hydrocortisone-pramoxine 2.5-1% cream, pramcort, hydrocortisone 1% cream

ANDRODERM

generic testosterone

ANNOVERA

generic contraceptive

APOKYN

KYNMOBI, entacapone, rasagiline, selegiline

ARAZLO

tazarotene, tretinoin, adapalene

ARMONAIR

ARNUITY ELLIPTA, FLOVENT, QVAR

04HQ1504 R11/20 CLOSED NC ALTS Page 1 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

Covered Drugs that Treat the Same Health Problems

ARYMO ER

morphine sulfate er (tablet, sustained action), tramadol hcl er tablet, OXYCONTIN

ASSURE 4 TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

ASSURE PLATINUM TEST STRIPS CONTOUR NEXT, TRUE METRIX, TRUETRACK

ASSURE PRISM MULTI TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

ASTAGRAF XL

tacrolimus, cyclosporine

AURYXIA

calcium acetate, sevelamer carbonate, VELPHORO

AUSTEDO

tetrabenazine, INGREZZA

AUVI-Q

generic epinephrine auto-injector

AVITA

tretinoin, tretinoin microsphere, adapalene cream/pump

AZASAN

azathioprine

azelastine-fluticasone

flunisolide spray, fluticasone spray PLUS azelastine spray

AZELEX

clindamycin-benzoyl peroxide, neuac gel, erythromycin-benzoyl peroxide

AZSTARYS

dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er

baclofen 5mg tab*

baclofen 10mg or 20mg, carisoprodol 350mg, cyclobenzaprine 5mg or 10mg

BALCOTRA

generic contraceptive

BELSOMRA

zolpidem, zaleplon, eszopiclone

BENZAMYCINPAK

erythromycin-benzoyl peroxide, clindamycin-benzoyl peroxide 1-5% gel, clindamycin (topical)

benzonatate 150mg*

benzonatate 100mg or 200mg

BG-STAR TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

BIJUVA

estradiol-norethindrone, norethindrone acetate-ethinyl estradiol

BINOSTO

alendronate, ibandronate

BREZTRI AEROSPHERE

TRELEGY, BREO ELLIPTA, ANORO ELLIPTA

BRIVIACT

levetiracetam, lamotrigine, carbamazepine

BROMSITE

ketorolac, diclofenac

BRYHALI

halobetasol propionate, clobetasol, betamethasone dipropionate

BUDESONIDE-FORMOTEROL SYMBICORT, salmeterol-fluticasone, wixela inhub, ADVAIR HFA FUMARATE

BUNAVAIL

buprenorphine-naloxone film, ZUBSOLV SL TAB

buprenorphine hcl sl tablet buprenorphine-naloxone film, ZUBSOLV SL TAB

buprenorphine-naloxone sl tablet*

buprenorphine-naloxone film, ZUBSOLV SL TAB

BUPROPION XL

bupropion

BYVALSON

nebivolol PLUS valsartan

CALCIPOTRIENE

calcipotriene, calcitrene, calcitriol

calcipotriene-betamethasone calcipotriene-betamethasone ointment, calcipotriene, calcitrene suspension

CAMBIA

sumatriptan succinate, rizatriptan/odt, naratriptan

CAPCOF

promethazine vc w/ codeine, promethazine-phenyleph-codeine, hydrocod-cpm-pseudoephedrine

CAPEX SHAMPOO

fluocinolone solution, clobetasol shampoo

CAPLYTA

aripiprazole, quetiapine fumarate/ER, olanzapine

CARDIZEM LA

diltiazem er capsule (generics for dilt-xr, tiazac, and cartia xt)

CARDURA XL

doxazosin, tamsulosin, terazosin

CAREONE BLOOD GLUCOSE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

CARESENS N TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

CARETOUCH TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

CAROSPIR

spironolactone, eplerenone

CEQUA

XIIDRA

04HQ1504 R11/20 CLOSED NC ALTS Page 2 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

CESAMET CETRAXAL CETYLEV CIPROFLOXACIN HCL- FLUOCINOLONE CLARINEX SYRUP CLARINEX-D 12 HOUR CLENPIQ CLEVER CHOICE TEST STRIPS clindamycin phos-benzoyl peroxide 1.2-2.5% gel* CLINPRO 5000 CLOCORTOLONE PIVALATE CLODERM CLORPRES CODITUSSIN AC CODITUSSIN DAC COLESTID CONDYLOX CONTROL TEST STRIPS CONZIP COOL GLUCOSE TEST STRIPS CORDRAN COTEMPLA XR-ODT CUVPOSA CYCLOGYL DAPSONE 7.5% PUMP TOPICAL DAYVIGO DDAVP decadron DEPO-SUBQ PROVERA 104 DEPO-TESTOSTERONE desloratadine odt desonide 0.5% gel desoximetasone spray* desrx DESVENLAFAXINE ER TABLET dexamethasone pack* DEXPAK DIATRUE PLUS TEST STRIPS DIFFERIN diltiazem 12hr er* diltiazem 24hr cd 360mg* diltiazem 24hr er (generic cardizem cd) * DORAL DORYX MPC doxepin tablet

Covered Drugs that Treat the Same Health Problems

ondansetron, granisetron ciprofloxacin, ofloxacin acetylcysteine ciprofloxacin (otic), ciprofloxacin-dexamethasone (otic), CIPRO HC

desloratadine tablet desloratadine tablet, montelukast polyethylene glycol 3350, peg-3350, gavilyte CONTOUR NEXT, TRUE METRIX, TRUETRACK clindamycin-benzoyl peroxide 1-5% gel, neuac gel, erythromycin-benzoyl peroxide

denta 5000 plus, dentagel, sf 5000 plus mometasone furoate, betamethasone valerate, fluocinolone mometasone furoate, betamethasone valerate, fluocinolone clonidine, chlorthalidone guaifenesin with codeine, cheratussin ac, guaifenesin ac guaifenesin dac, lortuss ex, tusnel c colestipol, prevalite, cholestyramine podofilox, imiquimod CONTOUR NEXT, TRUE METRIX, TRUETRACK tramadol er tablet CONTOUR NEXT, TRUE METRIX, TRUETRACK mometasone furoate, betamethasone valerate, fluocinolone dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er glycopyrrolate cyclopentolate, atropine sulfate dapsone (topical), clindamycin (topical), erythromycin (topical) zolpidem, zaleplon, eszopiclone desmopressin acetate dexamethasone medroxyprogesterone im testosterone cypionate, testosterone enanthate desloratadine tablet desonide 0.05% cream, hydrocortisone, alclometasone desoximetasone cream/ointment, mometasone furoate, betamethasone desonide 0.05% cream, hydrocortisone, alclometasone desvenlafaxine succinate er, duloxetine, venlafaxine immediate release, venlafaxine er capsule dexamethasone dexamethasone CONTOUR NEXT, TRUE METRIX, TRUETRACK adapalene cream/pump, tretinoin, tretinoin microsphere diltiazem er capsule (generics for dilt-xr, tiazac, and cartia xt) diltiazem er capsule (generics for dilt-xr, tiazac, and cartia xt) diltiazem er capsule (generics for dilt-xr, tiazac, and cartia xt)

lorazepam, temazepam, flurazepam doxycycline hyclate, doxycycline monohydrate, minocycline capsule zolpidem, zaleplon, eszopiclone

04HQ1504 R11/20 CLOSED NC ALTS Page 3 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

doxycycline hyclate tablet* doxycycline hyclate tablet dr* DOXYCYCLINE IR-DR doxycycline monohydrate capsule* DRIZALMA SPRINKLE DUOBRII DUTOPROL DUZALLO DYANAVEL XR EASY PLUS II TEST STRIPS EASY STEP TEST STRIPS EASY TALK TEST STRIPS EASY TOUCH TEST STRIPS EASY TRAK TEST STRIPS EASYGLUCO PLUS TEST STRIPS EASYGLUCO TEST STRIPS EASYMAX TEST STRIPS ECOZA EDARBI EDARBYCLOR ELEMENT TEST STRIPS ELIXOPHYLLIN EMBRACE TALK TEST STRIP EMBRACE TEST STRIPS EMFLAZA ENDARI ENVARSUS XR EPIDUO FORTE EPIFOAM EQ BLOOD GLUCOSE TEST STRIPS EUCRISA EVEKEO ODT EVENCARE TEST STRIPS EVOLUTION TEST STRIPS EVZIO EYSUVIS EZ SMART PLUS TEST STRIPS EZ SMART TEST STRIPS FABIOR FASENRA PEN FAZACLO FEMRING FENTORA FIFTY50 TEST STRIPS FLAREX FLOLIPID

Covered Drugs that Treat the Same Health Problems

doxycycline hyclate, doxycycline monohydrate, minocycline capsule doxycycline hyclate, doxycycline monohydrate, minocycline capsule doxycycline monohydrate, doxycycline hyclate, minocycline capsule doxycycline monohydrate tablet, doxycycline hyclate, minocycline capsule

duloxetine 20mg, venlafaxine immediate release, venlafaxine er capsule halobetasol propionate, clobetasol, calcipotriene, tazarotene metoprolol-hctz, atenolol-chlorthalidone, bisoprolol-hctz allopurinol, febuxostat dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK ketoconazole, clotrimazole, econazole valsartan, losartan, irbesartan valsartan-hctz, losartan-hctz, irbesartan-hctz CONTOUR NEXT, TRUE METRIX, TRUETRACK theophylline oral solution CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK prednisone hydroxyurea, DROXIA tacrolimus, cyclosporine adapalene cream/pump, clindamycin-benzoyl peroxide 1-5% gel, neuac gel hydrocortisone-pramoxine 2.5-1% cream, pramcort, hydrocortisone 1% cream CONTOUR NEXT, TRUE METRIX, TRUETRACK

halobetasol propionate, clobetasol, triamcinolone, tacrolimus dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK generic naloxone injection, NARCAN NASAL SPRAY fluorometholone, dexamethasone, loteprednol etabonate, DUREZOL, LOTEMAX CONTOUR NEXT, TRUE METRIX, TRUETRACK CONTOUR NEXT, TRUE METRIX, TRUETRACK tazarotene, tretinoin, tretinoin microsphere salmeterol-fluticasone, wixela inhub, SYMBICORT, BREO, DULERA, ADVAIR HFA clozapine estradiol vaginal cream/tablet, yuvafem, PREMARIN CREAM fentanyl lozenge on a handle CONTOUR NEXT, TRUE METRIX, TRUETRACK fluorometholone simvastatin, atorvastatin, pravastatin, rosuvastatin

04HQ1504 R11/20 CLOSED NC ALTS Page 4 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

Covered Drugs that Treat the Same Health Problems

FLO-PRED

prednisolone tablet/odt, millipred tablet/pack, prednisone

FLUORIDEX PASTE

denta 5000 plus, dentagel, sf 5000 plus

FLUORIDEX SENSITIVITY RELIEF denta 5000 plus, dentagel, sf 5000 plus

FLUOROPLEX FLUOROURACIL 0.5%*

fluorouracil 5% cream, fluorouracil solution, imiquimod 5% cream fluorouracil 5% cream, fluorouracil solution, imiquimod 5% cream

flurandrenolide

mometasone furoate, betamethasone valerate, fluocinolone

FORA TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

FORACARE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

FORADIL

STRIVERDI, SEREVENT

FORTEO

TYMLOS, alendronate, ibandronate

FORTISCARE GLUCOSE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

FOSAMAX PLUS D

alendronate, ibandronate

FOSRENOL

calcium acetate, sevelamer carbonate, VELPHORO

FREESTYLE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

GE100 BLOOD GLUCOSE TEST CONTOUR NEXT, TRUE METRIX, TRUETRACK STRIPS

GELNIQUE

oxybutynin er, tolterodine er, trospium er, darifenacin er

GEMTESA

tolterodine er/ir, oxybutynin er/ir, solifenacin

GENOTROPIN

NORDITROPIN

GENSTRIP TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

GLUCAGON EMERGENCY KIT glucagon hypokit, BAQSIMI, GVOKE

GLUCO NAVII TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

GLUCOCARD TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

GLUCOCOM GLUCOSE

CONTOUR NEXT, TRUE METRIX, TRUETRACK

GLYCATE

glycopyrrolate

GMATE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

GOCOVRI

amantadine ir, entacapone, rasagiline, selegiline, entacapone, pramipexole, bromocriptine

GOLYTELY 227.1 GM ORAL

polyethylene glycol 3350, peg-3350, gavilyte

GONITRO

generic nitroglycerin sl tablet/spray

GRALISE

gabapentin

GRASTEK

fluticasone nasal, montelukast

GUARDIAN SENSOR 3

DexCom G6 sensor, Freestyle Libre Sensor, Freesyle Libre 2 Sensor

halcinonide 0.1% cream

triamcinolone, betamethasone dipropionate, betamethasone valerate

HALOBETASOL PROPIONATE* halobetasol propionate, clobetasol, triamcinolone

HEALTHPRO GLUCOSE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

HEALTHPRO TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

hecoria HEPARIN SODIUM*

tacrolimus, cyclosporine heparin sodium

HORIZANT

gabapentin, pramipexole, ropinirole

HUMATROPE

NORDITROPIN

HUMULIN 70/30 KWIKPEN

NOVOLIN 70/30

HUMULIN 70-30

NOVOLIN 70/30

HUMULIN N

NOVOLIN N

HUMULIN N KWIKPEN

NOVOLIN N

HUMULIN R

NOVOLIN R

hydrocodone bitartrate er capsule*

hydrocodone bitartrate er tablet, morphine sulfate er (tablet, sustained action), tramadol hcl er tablet

04HQ1504 R11/20 CLOSED NC ALTS Page 5 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

Covered Drugs that Treat the Same Health Problems

hydrocodone-ibuprofen 10- 200mg*

hydrocodone-ibuprofen 5-200mg and 7.5-200mg

hydrocortisone butyrate 0.1% hydrocortisone butyrate, triamcinolone, betamethasone valerate lotion *

hydrocortisone in absorbase 1% hydrocortisone, alclometasone, fluocinolone

IBUDONE 5-200

hydrocodone-ibuprofen 5-200mg and 7.5-200mg

IGLUCOSE TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

IMBRUVICA 140mg TAB*

IMBRUVICA 70mg and 140 mg CAPSULES, IMBRUVICA 420mg and 560mg TABLETS

IMBRUVICA 280mg TAB*

IMBRUVICA 70mg and 140 mg CAPSULES, IMBRUVICA 420mg and 560mg TABLETS

IMIQUIMOD

imiquimod 5% cream, fluorouracil 5% cream, fluorouracil solution

IMPAVIDO

amphotericin b

IMPAX EPINEPHRINE

generic epinephrine auto-injector

IMPOYZ

clobetasol, betamethasone dipropionate, triamcinolone

IMVEXXY

estradiol vaginal cream/tablet, yuvafem

INBRIJA

rasagiline, selegiline, entacapone, pramipexole, ropinirole

INDERAL XL

propranolol, metoprolol, bisoprolol

INDOCIN

indomethacin immediate release 25mg or 50mg, indomethacin sustained release 75mg, ibuprofen, naproxen (not enteric coated)

INFINITY TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

INFINITY VOICE TEST STRIPS CONTOUR NEXT, TRUE METRIX, TRUETRACK

INNOPRAN XL

propranolol, metoprolol, bisoprolol

INSULIN ASPART

NOVOLOG, FIASP, NOVOLIN R

INSULIN ASPART FLEXPEN

NOVOLOG, FIASP, NOVOLIN R

INSULIN ASPART PROT-INSULN NOVOLOG MIX, NOVOLIN 70/30 ASP

INSULIN LISPRO

NOVOLOG, FIASP, NOVOLIN R

INSULIN LISPRO JUNIOR KWIKPEN

NOVOLOG, FIASP, NOVOLIN R

INSULIN LISPRO KWIKPEN U-100 NOVOLOG, FIASP, NOVOLIN R

INSULIN LISPRO PROTAMINE NOVOLOG MIX, NOVOLIN 70/30 MIX

INVELTYS

dexamethasone, loteprednol etabonate, DUREZOL, LOTEMAX

INVOKAMET

SEGLUROMET, SYNJARDY, SYNJARDY XR, XIGDUO XR

INVOKAMET XR

SEGLUROMET, SYNJARDY, SYNJARDY XR, XIGDUO XR

INVOKANA

FARXIGA, JARDIANCE, STEGLATRO

isosorbide dinitrate 40mg*

isosorbide dinitrate, isosorbide mononitrate

ivermectin topical

metronidazole, rosadan, azelaic acid gel, FINACEA foam

JATENZO

generic testosterone, testosterone cypionate, testosterone enanthate

JORNAY PM

metadate er, methylphenidate hcl er, methylphenidate la

JUBLIA

terbinafine (oral), itraconazole (oral), ciclopirox (topical)

JUXTAPID

REPATHA, rosuvastatin, atorvastatin

KADIAN

morphine sulfate er (tablet, sustained action), tramadol hcl er tablet, OXYCONTIN

KATERZIA

amlodipine, nifedipine/er, felodipine er

KAZANO

JANUMET/XR, JENTADUETO/XR

KERYDIN

terbinafine (oral), itraconazole (oral), ciclopirox (topical)

KEVZARA

ENBREL, HUMIRA, XELJANZ, RINVOQ

KHEDEZLA

desvenlafaxine succinate er, venlafaxine immediate release, venlafaxine er capsule, duloxetine

KLISYRI

fluorouracil 5% cream, fluorouracil solution, imiquimod 5% cream

klor-con 20meq pkt

potassium chloride/er

04HQ1504 R11/20 CLOSED NC ALTS Page 6 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

Covered Drugs that Treat the Same Health Problems

KLOR-CON 25 MEQ Oral

potassium chloride/er

klor-con sprinkle

potassium chloride/er

KOMBIGLYZE XR

JANUMET/XR, JENTADUETO/XR

K-PHOS NO.2

K-PHOS ORIGINAL

KRISTALOSE

lactulose oral solution

KROGER BLOOD GLUCOSE TEST CONTOUR NEXT, TRUE METRIX, TRUETRACK STRIPS

K-TAB ER

potassium chloride/er

KYNAMRO

rosuvastatin, atorvastatin, REPATHA

lactulose oral packet

lactulose oral solution

LAMICTAL XR (GREEN)*

lamotrigine, felbamate, topiramate

LAMICTAL XR (ORANGE)*

lamotrigine, felbamate, topiramate

lamotrigine (blue)*

lamotrigine, felbamate, topiramate

lamotrigine (green)*

lamotrigine, felbamate, topiramate

lamotrigine (orange)*

lamotrigine, felbamate, topiramate

lansoprazole delayed release lansoprazole delayed release capsule 30mg, omeprazole, pantoprazole dispersible tablet*

lanthanum carbonate

calcium acetate, sevelamer carbonate, VELPHORO

LAZANDA

fentanyl lozenge on a handle

LEDIPASVIR-SOFOSBUVIR

EPCLUSA, HARVONI

levorphanol tartrate 3 mg

morphine sulfate ir, oxycodone-acetaminophen, hydrocodone-acetaminophen

LEVOTHYROXINE CAPSULE* levothyroxine tablet

LEXETTE

halobetasol propionate, clobetasol, triamcinolone

LIBERTY TEST STRIPS

CONTOUR NEXT, TRUE METRIX, TRUETRACK

LO LOESTRIN FE

generic contraceptive

LONHALA MAGNAIR

STIOLTO, ANORO, arformoterol tartrate

LORTAB

hydrocodone-acetaminophen tablet, zamicet 10mg-325mg/15ml oral solution

LUBIPROSTONE

AMITIZA, LINZESS

LUCEMYRA

clonidine

LUFYLLIN

theophylline

LULICONAZOLE

ketoconazole, clotrimazole, econazole

LUMIGAN

latanoprost, travoprost

LUPKYNIS

BENLYSTA, mycophenolate mofetil, cyclophosphamide, prednisone

LYUMJEV

NOVOLOG, FIASP, NOVOLIN R

LYUMJEV KWIKPEN U-100

NOVOLOG, FIASP, NOVOLIN R

LYUMJEV KWIKPEN U-200

NOVOLOG, FIASP, NOVOLIN R

mafenide acetate

SULFAMYLON, silver sulfadiazine, ssd

matzim la

diltiazem cd 120/180/240/300mg, diltiazem er 24 hr beads 120/180/240/300mg

MAVYRET

HARVONI, EPCLUSA, VOSEVI

MAXIDEX

dexamethasone, fluorometholone, prednisolone

MEDROL

methylprednisolone, prednisolone tablet/odt, millipred tablet/pack

megestrol acetate 625mg/5ml megestrol 20mg tablet, 40mg tablet, 40mg/ml suspension suspension*

MEIJER BLOOD GLUCOSE TEST CONTOUR NEXT, TRUE METRIX, TRUETRACK STRIPS

MEMANTINE DOSE PACK

memantine

M-END PE

rydex, promethazine vc w/ codeine, promethazine-phenylephrine-codeine

metformin solution*

metformin, metformin er (generic glucophage xr)

04HQ1504 R11/20 CLOSED NC ALTS Page 7 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

Drugs Not Covered

methylphenidate er (xr) capsule* methyltestosterone metoclopramide odt* METOPROLOL SUCCINATE ER- HCTZ* MICRODOT TEST STRIPS MINITRAN MINOCYCLINE ER capsule minocycline hcl er* minocycline tablet* MINOLIRA ER MITIGARE mondoxyne nl MORPHABOND ER MOTEGRITY MYCAPSSA MYFEMBREE MYGLUCOHEALTH TEST STRIPS NALOCET NAMENDA NAMZARIC NATAZIA NATESTO NESINA NEUTEK 2TEK TEST STRIPS NEXLETOL NEXLIZET NEXTSTELLIS NITRO-DUR nitroglycerin spray (lingual)* NOCDURNA NOCTIVA nolix NOURIANZ NOVA MAX GLUCOSE TEST STRIPS NUCALA NUCYNTA ER NULYTELY NUTROPIN AQ NUSPIN OCALIVA ODACTRA okebo olanzapine-fluoxetine OLEPTRO ER OLUMIANT OMNITROPE

Covered Drugs that Treat the Same Health Problems

dextroamphetamine-amphetamine ir/er, dextroamphetamine ir/er, methylphenidate ir/er

METHITEST metoclopramide oral solution, metoclopramide oral tablet metoprolol-hctz, atenolol-chlorthalidone, bisoprolol-hctz

CONTOUR NEXT, TRUE METRIX, TRUETRACK nitro-bid, nitro-time, nitroglycerin oral capsule/patch minocycline capsule, doxycycline hyclate, doxycycline monohydrate minocycline capsule, doxycycline hyclate, doxycycline monohydrate minocycline capsule, doxycycline hyclate, doxycycline monohydrate minocycline capsule, doxycycline hyclate, doxycycline monohydrate colchicine tablet, COLCHICINE CAPSULE doxycycline monohydrate tablet, doxycycline hyclate, minocycline capsule morphine sulfate er (tablet, sustained action), tramadol hcl er tablet, OXYCONTIN LINZESS, AMITIZA octreotide generic contraceptive CONTOUR NEXT, TRUE METRIX, TRUETRACK oxycodone-acetaminophen, hydrocodone-acetaminophen memantine memantine, donepezil generic contraceptive generic testosterone JANUVIA, TRADJENTA CONTOUR NEXT, TRUE METRIX, TRUETRACK rosuvastatin, atorvastatin, ezetimibe rosuvastatin, atorvastatin, ezetimibe generic contraceptive nitro-bid, nitro-time, nitroglycerin oral capsule/patch generic nitroglycerin sl tablet/spray desmopressin, oxybutynin, tolterodine desmopressin, oxybutynin, tolterodine mometasone furoate, betamethasone valerate, fluocinolone carbidopa-levodopa, ropinirole, pramipexole CONTOUR NEXT, TRUE METRIX, TRUETRACK

salmeterol-fluticasone, wixela inhub, SYMBICORT, BREO, DULERA, ADVAIR HFA oxymorphone hcl er, morphine sulfate er (tablet, sustained action), tramadol hcl er tab polyethylene glycol 3350, peg-3350, gavilyte NORDITROPIN ursodiol fluticasone nasal, montelukast doxycycline monohydrate, doxycycline hyclate, minocycline capsule olanzapine PLUS fluoxetine capsule trazodone ENBREL, HUMIRA, XELJANZ, RINVOQ NORDITROPIN

04HQ1504 R11/20 CLOSED NC ALTS Page 8 of 13

Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are independent licensees of the Blue Cross and Blue Shield Association.

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