Express Scripts 2020 National Preferred Formulary Exclusions
2023 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) Alzheimer's Agents Amyotrophic Lateral Sclerosis (ALS) Agents
Anticonvulsants
Antimigraine Agents
Antiparkinsonism Agents
Antipsychotics (Injectable) Antipsychotics (Oral) Antispasmodic Agents Anxiolytic Agents Central Nervous System Stimulants Duchenne Muscular Dystrophy (DMD) Agents Multiple Sclerosis (Beta Interferons) Narcotic Analgesics & Combinations
Excluded Medications
FIRVANQ
TOLSURA SITAVIG, XERESE LAMPIT
LUCEMYRA
ADUHELM RELYVRIO EPRONTIA FINTEPLA ZONISADE ONZETRA XSAIL, ZOLMITRIPTAN NASAL SPRAY 2.5 MG VYEPTI APOKYN DHIVY
GOCOVRI ER
ONGENTYS XADAGO, ZELAPAR INVEGA HAFYERA
LYBALVI
QUETIAPINE 150 MG TABLETS BACLOFEN SOLUTION, FLEQSUVY, LYVISPAH, OZOBAX LOREEV XR
XELSTRYM
AMONDYS 45, EXONDYS 51, VILTEPSO, VYONDYS 53 EMFLAZA EXTAVIA APADAZ, BENZHYDROCODONE/ACETAMINOPHEN CONZIP, QDOLO, TRAMADOL 100 MG TABLETS, TRAMADOL ER CAPSULES, TRAMADOL SOLUTION
Preferred Alternatives
vancomycin capsules, vancomycin oral solution
itraconazole acyclovir oral or cream, famciclovir, valacyclovir BENZNIDAZOLE
clonidine
No alternatives recommended No alternatives recommended topiramate sprinkle capsules DIACOMIT, EPIDIOLEX zonisamide sumatriptan nasal spray, ZOMIG NASAL 2.5 MG AIMOVIG, AJOVY, EMGALITY KYNMOBI carbidopa/levodopa amantadine capsules, amantadine tablets, amantadine oral solution entacapone rasagiline, selegiline ABILIFY MAINTENA, ARISTADA, RISPERDAL CONSTA aripiprazole, asenapine, olanzapine, paliperidone er, quetiapine, quetiapine er, ziprasidone, LATUDA quetiapine, quetiapine er baclofen tablets lorazepam tablets dextroamphetamine/amphetamine er, dextroamphetamine er, VYVANSE No alternatives recommended prednisone solution, prednisone tablets AVONEX, BETASERON, PLEGRIDY, REBIF hydrocodone/acetaminophen
tramadol er tablets, tramadol tablets
? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 1
(continued)
CRP2311_3229C 334293 EXCL-NPF-OE-23 (02/01/2023)
Drug Class
AUTONOMIC & CENTRAL NERVOUS SYSTEM Narcotic Analgesics & Combinations (continued)
Narcotic Antagonists Sedative-Hypnotic Agents Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants Transmucosal Fentanyl Analgesics
Miscellaneous Antidepressants
CARDIOVASCULAR ACE Inhibitors Alpha-Adrenergic Agonists
Angiotensin Receptor Blockers (ARBs) and Combinations
Anticoagulants Beta Blockers & Combinations
Calcium Channel Blockers
Diuretics
Fenofibrates HMG & Cholesterol Inhibitor Combinations PCSK9 & siRNA Inhibitors
Excluded Medications
NUCYNTA
NUCYNTA ER, OXYCODONE ER, XTAMPZA ER PRIMLEV, PROLATE SOLUTION ROXYBOND SEGLENTIS ZIMHI DORAL, QUAZEPAM CITALOPRAM CAPSULES, PEXEVA, SERTRALINE CAPSULES
DRIZALMA SPRINKLE, VENLAFAXINE BESYLATE ER FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS AUVELITY ER BUPROPION XL 450 MG, FORFIVO XL SPRAVATO
QBRELIS CLONIDINE ER 0.17 MG, NEXICLON XR EDARBI
EDARBYCLOR
VALSARTAN SOLUTION PRADAXA, SAVAYSA HEMANGEOL INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE CONJUPRI, LEVAMLODIPINE KATERZIA, NORLIQVA CAROSPIR SOAANZ THALITONE ANTARA, FENOFIBRATE CAPSULES (30 MG, 50 MG, 90 MG, 150 MG), LIPOFEN ALTOPREV, EZALLOR SPRINKLE ROSUVASTATIN/EZETIMIBE LEQVIO, PRALUENT
Preferred Alternatives
hydrocodone/acetaminophen, morphine sulfate, oxycodone, tramadol, tramadol/acetaminophen hydrocodone bitartrate er, hydromorphone er, morphine sulfate er, oxymorphone hcl er, HYSINGLA ER, OXYCONTIN oxycodone/acetaminophen oxycodone tramadol tablets plus celecoxib naloxone syringes estazolam, lorazepam citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
desvenlafaxine er, duloxetine, venlafaxine hcl er, FETZIMA
fentanyl citrate lozenges
bupropion, citalopram, duloxetine, paroxetine, sertraline, venlafaxine, FETZIMA bupropion xl 150 mg or 300 mg olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline
lisinopril
clonidine patches, clonidine tablets candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan candesartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, chlorthalidone plus valsartan valsartan tablets ELIQUIS, XARELTO propranolol solution propranolol er metoprolol succinate amlodipine, felodipine er, nifedipine er, nisoldipine amlodipine tablets spironolactone bumetanide, furosemide, torsemide chlorthalidone fenofibrate capsules (43 mg, 67 mg, 130 mg, 134 mg, 200 mg), fenofibrate tablets, fenofibric acid atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO ezetimibe plus atorvastatin or rosuvastatin REPATHA
? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 2
(continued)
CRP2311_3229C 334293 EXCL-NPF-OE-23 (02/01/2023)
Drug Class
CARDIOVASCULAR (continued) Miscellaneous Cardiovascular Agents DERMATOLOGICAL Agents for Hyperhidrosis Oral Agents for Acne Rosacea Agents (Oral) Rosacea Agents (Topical)
Topical Agents for Acne
Topical Agents for Actinic Keratosis Topical Antifungals Topical Corticosteroids Vitamin D Analogs (Topical)
Miscellaneous Topical Dermatological Agents
DIABETES Biguanidine Agents
Blood Glucose Meters & Test Strips
Excluded Medications
Preferred Alternatives
ASPRUZYO SPRINKLE ER CORLANOR NORPACE CR
ranolazine er
atenolol, bisoprolol, carvedilol, metoprolol succinate, metoprolol tartrate, propranolol
amiodarone, quinidine sulfate, sotalol
DRYSOL, QBREXZA
Over-the-Counter aluminum chloride containing products
ABSORICA LD
isotretinoin capsules
DORYX DR 80 MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80 MG
doxycycline hyclate, doxycycline monohydrate
MINOCYCLINE ER CAPSULES, XIMINO
minocycline er tablets
DOXYCYCLINE 40 MG CAPSULES, ORACEA
Oral: doxycycline hyclate, doxycycline monohydrate Topical: azelaic acid, ivermectin, metronidazole
NORITATE
metronidazole
ZILXI
azelaic acid, ivermectin, metronidazole, sodium sulfacetamide/sulfur, FINACEA FOAM
CLENIA PLUS, SULFACETAMIDE/SULFUR 9%-4.25% SUSPENSION
sodium sulfacetamide/sulfur 8%-4% suspension
FABIOR, TAZAROTENE FOAM
tazarotene cream, tretinoin
VELTIN
clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON
WINLEVI
azelaic acid, clindamycin phosphate gel, clindamycin/tretinoin, dapsone, erythromycin gel, tretinoin, ONEXTON
CARAC, FLUOROURACIL 0.5% CREAM, KLISYRI, ZYCLARA
diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream
ECOZA, ERTACZO, LULICONAZOLE, OXISTAT LOTION, SULCONAZOLE, XOLEGEL
ciclopirox, clotrimazole, econazole, ketoconazole, naftifine, oxiconazole
MICONAZOLE/ZINC OXIDE/PETROLATUM, VUSION
clotrimazole, ketoconazole, miconazole, nystatin
CLOCORTOLONE PUMP, IMPEKLO, HALOBETASOL 0.05% FOAM, IMPOYZ, LEXETTE, SERNIVO, ULTRAVATE, VERDESO FOAM
generic topical corticosteroids
CALCIPOTRIENE FOAM, SORILUX
calcipotriene, calcitriol
ALCORTIN A
generic topical corticosteroids plus mupirocin
CONDYLOX, VEREGEN
imiquimod 5% cream, podofilox solution
LIDOCAINE/TETRACAINE, PLIAGLIS
lidocaine cream, lidocaine/prilocaine cream
TAZORAC 0.05% CREAM
tazarotene 0.1% cream
TRI-LUMA
fluocinolone acetonide, hydroquinone, tretinoin
METFORMIN 625 MG TABLETS
metformin 500 mg or 850 mg tablets
ASCENSIA (CONTOUR) ONETOUCH SOLUTIONS STARTER KIT ROCHE (ACCU-CHEK) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED
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
? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 3
(continued)
CRP2311_3229C 334293 EXCL-NPF-OE-23 (02/01/2023)
Drug Class
Excluded Medications
DIABETES (continued) Diabetic Pen Needles & Syringes
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations Glucagon-Like Peptide-1 Agonists Glucose-Elevating Drugs
Insulins
Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors & Combinations EAR/NOSE Nasal Steroids Otic Antibiotics & Combination Products
ENDOCRINE Cushing's Agents Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty) Growth Hormones
Somatostatin Analogs
PEN NEEDLES & SYRINGES BY: ARKRAY HOME AIDE DIAGNOSTICS HTL-STREFA NOVO NORDISK OWEN MUMFORD PRODIGY DIABETES CARE SIMPLE DIAGNOSTICS TRIVIDIA (NIPRO DIAGNOSTICS) ULTIMED ALL OTHER DIABETIC PEN NEEDLES & SYRINGES THAT ARE NOT LISTED AS PREFERRED
ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA
ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, KOMBIGLYZE XR
ALOGLIPTIN/PIOGLITAZONE
QTERN
ADLYXIN, VICTOZA
GLUCAGEN HYPOKIT, GLUCAGON EMERGENCY KIT (by Fresenius), ZEGALOGUE
ADMELOG, AFREZZA, APIDRA, FIASP, INSULIN ASPART, INSULIN LISPRO, NOVOLOG, RELION NOVOLOG
INSULIN ASPART PROTAMINE, NOVOLOG 70/30 MIX, RELION NOVOLOG 70/30 MIX
INSULIN DEGLUDEC, INSULIN GLARGINE (BY WINTHROP), INSULIN GLARGINE-YFGN, LANTUS
NOVOLIN, RELION NOVOLIN
INVOKAMET, INVOKAMET XR
INVOKANA
BECONASE AQ, OMNARIS, QNASL, ZETONNA
CETRAXAL
CIPRO HC, CIPROFLOXACIN/FLUOCINOLONE OTIC
ISTURISA
KORLYM
RECORLEV
FENSOLVI
HUMATROPE, NUTROPIN AQ NUSPIN, SAIZEN, SAIZENPREP, SKYTROFA, ZOMACTON
LANREOTIDE, SANDOSTATIN LAR DEPOT
SIGNIFOR LAR
Testosterone Products Thyroid Replacement Therapy Miscellaneous Endocrine Agents
AVEED KYZATREX, TLANDO LEVOTHYROXINE CAPSULES, THYQUIDITY, TIROSINT, TIROSINT-SOL CORTROPHIN GEL
Preferred Alternatives
BD DIABETES PEN NEEDLES BD DIABETES SYRINGES
JANUVIA JANUMET, JANUMET XR pioglitazone plus JANUVIA GLYXAMBI, STEGLUJAN BYDUREON BCISE, BYETTA, OZEMPIC, TRULICITY glucagon emergency kit (by Amphastar), BAQSIMI, GVOKE HUMALOG, LYUMJEV HUMALOG 75/25 MIX LEVEMIR, SEMGLEE (YFGN), TOUJEO, TRESIBA HUMULIN SEGLUROMET, SYNJARDY, SYNJARDY XR, XIGDUO XR FARXIGA, JARDIANCE, STEGLATRO flunisolide, fluticasone, mometasone ciprofloxacin otic, ofloxacin otic ciprofloxacin/dexamethasone otic SIGNIFOR ketoconazole, LYSODREN, SIGNIFOR ketoconazole, LYSODREN LUPRON DEPOT-PED, TRIPTODUR GENOTROPIN, NORDITROPIN FLEXPRO, OMNITROPE SOMATULINE DEPOT For Acromegaly: SOMATULINE DEPOT For Cushing's Disease: SIGNIFOR testosterone cypionate, testosterone enanthate testosterone gel, testosterone solution, ANDRODERM PATCHES levothyroxine tablets No alternatives recommended
? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Page 4
(continued)
CRP2311_3229C 334293 EXCL-NPF-OE-23 (02/01/2023)
Drug Class
GASTROINTESTINAL Antidiarrheal Agents
Antiemetics (Oral)
Bowel Evacuants Corticosteroids (Rectal Formulations) Gallstone Dissolution Agents Gastroparesis Agents Helicobacter Pylori Agents
Hemorrhoidal Preparations
Inflammatory Bowel Agents Irritable Bowel Syndrome & Chronic Constipation Agents Pancreatic Enzymes Proton Pump Inhibitors Miscellaneous Gastrointestinal Agents HEMATOLOGICAL Antiplatelet Agents Erythropoiesis-Stimulating Agents
Factor Deficiency Agents & Related Products
Granulocyte Colony Stimulating Factors Iron Replacement Agents Sickle Cell Disease Agents Thrombocytopenia Agents HEPATITIS Hepatitis C
HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.
? 2023 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.
Excluded Medications
MYTESI AKYNZEO CAPSULES ANTIVERT ANZEMET BONJESTA EMEND POWDER PACKETS CLENPIQ, OSMOPREP, PLENVU, SUTAB CORTIFOAM RELTONE GIMOTI PYLERA HYDROCORTISONE/PRAMOXINE 25-18 MG SUPPOSITORIES PROCTOFOAM-HC DIPENTUM AMITIZA, IBSRELA, LUBIPROSTONE, MOTEGRITY, ZELNORM PERTZYE DEXILANT, DEXLANSOPRAZOLE 30 MG, ESOMEPRAZOLE STRONTIUM, NEXIUM PACKETS, PRILOSEC SUSPENSION, RABEPRAZOLE DR SPRINKLE DARTISLA ODT ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR ARANESP, EPOGEN, MIRCERA NOVOSEVEN RT NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE FYLNETRA, NEULASTA, NYVEPRIA, UDENYCA GRANIX, NEUPOGEN, RELEUKO MONOFERRIC OXBRYTA SIKLOS MULPLETA LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI
CABENUVA
COMPLERA
DELSTRIGO
PIFELTRO
Page 5
Preferred Alternatives
diphenoxylate/atropine, loperamide
granisetron, ondansetron, aprepitant, VARUBI TABLETS meclizine granisetron, ondansetron doxylamine/pyridoxine hcl aprepitant, VARUBI TABLETS magnesium sulfate/potassium sulfate/sodium sulfate solution, peg 3350/ascorbic acid powder packets hydrocortisone enema, UCERIS FOAM ursodiol No alternatives recommended lansoprazole/amoxicillin/clarithromycin, TALICIA hydrocortisone ac suppositories, pramoxine/hydrocortisone cream pramoxine/hydrocortisone cream balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA 250 MG CAPSULES LINZESS, TRULANCE CREON, PANCREAZE, ZENPEP
dexlansoprazole 60 mg, esomeprazole magnesium, lansoprazole, omeprazole, pantoprazole, rabeprazole
glycopyrrolate tablets aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole PROCRIT, RETACRIT SEVENFACT ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT FULPHILA, ZIEXTENZO NIVESTYM, ZARXIO sodium ferric gluconate complex, VENOFER hydroxyurea, DROXIA DROXIA DOPTELET
EPCLUSA, HARVONI, VOSEVI, ZEPATIER
atazanavir plus lamivudine, darunavir plus lamivudine, lopinavir/ritonavir plus lamivudine, DOVATO, JULUCA, TIVICAY plus lamivudine, TIVICAY plus EDURANT ODEFSEY efavirenz/emtricitabine/tenofovir disoproxil fumarate, efavirenz/lamivudine/tenofovir disoproxil fumarate, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ efavirenz, EDURANT
(continued)
CRP2311_3229C 334293 EXCL-NPF-OE-23 (02/01/2023)
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