PHARMACY SERVICES

High-Cost Drug Exclusions The high cost medications listed below are excluded from coverage because lower cost similar alternatives are available. To help you get the best health benefit at the lowest cost, consider talking with your doctor about one of the therapeutically equivalent (similar safety and efficacy) or over-the-counter (OTC) alternatives listed below. We encourage you to talk to your doctor about whether one of these options is right for you. Coverage of alternatives will vary. Please visit your health plan’s website or contact Customer Service at the number listed on the back of your member ID card for more information about medication coverage. If your doctor believes that the listed alternatives are not right for you, your doctor may request an exception by contacting Customer Service at the number listed on the back of your member ID card.

Drug

Alternatives

Absorica

Claravis, Myorisan, and Zenatane

Acanya

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

AcipHex Sprinkles Acticlate

omeprazole, pantoprazole, and lansoprazole doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim

Aczone

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

adapalene 0.1% cream

over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel

adapalene 0.1% gel

over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel

adapalene 0.1% lotion

over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel

Altoprev

atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin

Amrix

cyclobenzaprine tablet

Antara

gemfibrozil and fenofibrate

ApexiCon E Beconase AQ

desoximetasone 0.05% cream and triamcinolone 0.5% cream fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

Belsomra

diphenhydramine, doxepin, and trazodone

Binosto

alendronate 70 mg fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

budesonide AQ

High-Cost Drug Exclusions Drug

Alternatives

Byvalson

Bystolic plus valsartan

Cambia packets

diclofenac tablet

Carac

fluorouracil 0.5% external cream

Centany

mupirocin 2% external ointment

Clindagel

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

clindamycin/ tretinoin clocortolone pivalate cream clocortolone pivalate pump

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

Cloderm cream

mometasone 0.1% cream and triamcinolone 0.1% cream

Cloderm pump

mometasone 0.1% cream and triamcinolone 0.1% cream

Clorpres

Cordran tape

chlorthalidone plus clonidine hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and fluocinolone 0.025% ointment hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and fluocinolone 0.025% ointment

Cuprimine

Depen Titratabs (penicillamine)

Daxbia

cephalexin 250 mg or cephalexin 500 mg

Dexilant

omeprazole, pantoprazole, and lansoprazole

Differin 0.1% cream

over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel

Differin 0.1% gel

over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel

Differin 0.1% lotion diflorasone diacetate cream diflorasone diacetate ointment

over-the-counter (OTC) Differin 0.1% External Gel, adapalene 0.3% gel

Cordran 0.05% ointment

mometasone 0.1% cream and triamcinolone 0.1% cream mometasone 0.1% cream and triamcinolone 0.1% cream

desoximetasone 0.05% cream and triamcinolone 0.5% cream desoximetasone 0.25% ointment and fluocinonide 0.05% ointment

Effective 1/1/18

High-Cost Drug Exclusions Drug

Alternatives

Doryx

doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim

Duexis

ibuprofen plus famotidine

Durlaza

aspirin 81 mg

Dutoprol Dymista

metoprolol plus HCTZ fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

Edarbi

irbesartan, losartan, valsartan, and olmesartan

Edarbyclor

valsartan/ HCTZ, irbesartan/ HCTZ, and losartan/ HCTZ

Edluar

zolpidem and zaleplon

Emflaza

prednisone, prednisolone, and methylprednisolone omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) esomeprazole magnesium medications, such as Nexium 24 HR. omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) esomeprazole strontium medications, such as Nexium 24 HR. Fabior

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

Flector

diclofenac topical gel and diclofenac topical solution

fluocinonide 0.1% cream flurandrenolide 0.05% ointment

halobetasol 0.05% cream and clobetasol 0.05% cream hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and fluocinolone 0.025% ointment

Fortamet

metformin and metformin ER (non-osmotic, non-modified release)

Glumetza

metformin and metformin ER (non-osmotic, non-modified release)

Gonitro

nitroglycerin SL (sublingual) tablet

Gralise

gabapentin

Halog cream

desoximetasone 0.25% cream and betamethasone AF 0.05% cream fluocinonide 0.05% ointment, desoximetasone 0.25% ointment, and betamethasone dipropionate 0.05% ointment

Halog ointment

Effective 1/1/18

High-Cost Drug Exclusions Drug

Alternatives

Horizant

gabapentin

Inderal XL

propranolol HCL ER

InnoPran XL

propranolol HCL ER

Intermezzo

zolpidem and zaleplon

Istalol

timolol eye drops

Lescol XL

atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin

Livalo

atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin

Locort 11 day

generic dexamethasone tablets

Locort 7 day

generic dexamethasone tablets

Lovaza metformin ER modified release metformin ER osmotic release

prescription or over-the-counter (OTC) omega-3 fatty acids metformin and metformin ER (non-osmotic, non-modified release)

Morgidox

metformin and metformin ER (non-osmotic, non-modified release) doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim

Nalfon

fenoprofen

Naprelan

naproxen ER (extended release) tablet fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

Minolira mometasone nasal

Nasonex Neuac Nexium

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) medications, such as Nexium 24 HR.

Effective 1/1/18

High-Cost Drug Exclusions Drug

Alternatives

Noctiva omeprazole- sodium bicarbonate omeprazole- sodium bicarbonate packet

oxybutynin, desmopressin nasal spray, and desmopressin tablets omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) medications, such as Zegerid OTC. omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) medications, such as Zegerid OTC. fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

Omnaris Onexton Pandel cream

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin hydrocortisone butyrate 0.1% cream, fluocinolone 0.025% cream, and betamethasone valerate 0.1% cream

Pennsaid

diclofenac topical gel and solution

Prestalia Prevacid SoluTab

perindopril plus amlodipine omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) medications, such as Prevacid 24 HR.

Prilosec packet

omeprazole, pantoprazole, and lansoprazole

Protonix packet

omeprazole, pantoprazole, and lansoprazole

Psorcon cream

desoximetasone 0.05% cream and triamcinolone 0.5% cream fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

Qnasl Rayos Rhinocort AQ Rozerem Solodyn Sprix

prednisone, prednisolone, and methylprednisolone fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. over-the-counter (OTC) melatonin doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim

Targadox

diclofenac tablet, etodolac, meloxicam, and nabumetone doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim

Tazorac Gel

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

Effective 1/1/18

High-Cost Drug Exclusions Drug

Alternatives

Tekturna

irbesartan, losartan, valsartan, and olmesartan

Tekturna HCT Texacort

valsartan/ HCTZ, irbesartan/ HCTZ, and losartan/ HCTZ hydrocortisone 0.05% ointment, triamcinolone, 0.1% ointment, and fluocinolone 0.025% ointment

Timoptic Ocudose

timolol eye drops

Tivorbex

indomethacin tablet

Topicort spray

desoximetasone 0.05% gel and fluocinonide 0.05% solution

Tretin-X

generic tretinoin

Trianex ointment

triamcinolone 0.025% ointment and triamcinolone 0.1% ointment

Triglide

gemfibrozil and fenofibrate

Vanos cream

halobetasol 0.05% cream and clobetasol 0.05% cream

Vascepa

prescription or over-the-counter (OTC) omega-3 fatty acids

Veltin

Vibramycin

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands. doxycycline immediate release (IR), minocycline IR, erythromycin, and sulfamethoxazole-trimethoprim

Vimovo

naproxen plus esomeprazole

Vivlodex

meloxicam tablet

Xerese

Zetonna

topical acyclovir plus topical hydrocortisone omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) medications, such as Zegerid OTC. omeprazole, pantoprazole, and lansoprazole as well as over-the-counter (OTC) medications, such as Zegerid OTC. fluticasone nasal spray and over-the-counter (OTC) nasal sprays, such as Flonase, Rhinocort Allergy, Nasacort Allergy, and store brands.

Ziana

benzoyl peroxide, clindamycin, clindamycin/benzoyl peroxide, and tretinoin

Veramyst

Zegerid Zegerid Packet

Effective 1/1/18

High-Cost Drug Exclusions Drug

Alternatives

Zipsor

diclofenac tablet

zolpidem SL

zolpidem and zaleplon

Zolpimist

zolpidem and zaleplon

Zonacort 11 day

generic dexamethasone tablets

Zonacort 7 day

generic dexamethasone tablets

Zorvolex

diclofenac tablet

Zyclara

imiquimod

Zypitamag

atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin

Institutional and Clinic Packs (e.g. medications packaged as unit dose)

non-unit-dose equivalent medication

Therapy Packs

individual drug products as appropriate

Questions? Call the Customer Service number on your member ID card.

Effective 1/1/18