Prescription Drugs Covered and Not Covered 2021 Information
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Prescription Drugs Covered and Not Covered
2021 Information
The drug listing on the following pages contains information about COVERED
and NOT COVERED medications under your State of Delaware Express Scripts
Prescription Drug Plan.
2021 Express Scripts National Preferred Formulary
Prescription drugs covered under the plan
………………………………………….…………………………………... Pages 1-2
2021 National Preferred Formulary Exclusions
Prescription drugs NOT covered by Express Scripts with preferred alternatives
………………………………………………………………………………. Pages 3-9
2021 State of Delaware Prescription Plan Level Exclusions
Medications NOT covered under the State of Delaware Prescription Drug Plan
………………………………………………………………………………. Page 10
Note: The drug listing is subject to change throughout the year. For a complete listing
please visit the Express Scripts Website or contact Express Scripts Member Services at
1-800-939-2142.The following is a list of the most commonly prescribed drugs. It represents an
abbreviated version of the drug list (formulary) that is at the core of your prescription
plan. The list is not all-inclusive and does not guarantee coverage. In addition to
using this list, you are encouraged to ask your doctor to prescribe generic drugs
whenever appropriate.
2021 Express Scripts PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic
version becomes available during the year. Not all the drugs listed are covered by
National Preferred Formulary all prescription plans; check your benefit materials for the specific drugs covered
and the copayments for your prescription plan. For specific questions about your
coverage, please call the phone number printed on your member ID card.
KEY BAQSIMI COMBIPATCH ergocalciferol GENVOYA
[INJ] - Injectable Drug BARACLUDE SOLUTION COMBIVENT RESPIMAT ERIVEDGE GILENYA
Brand-name drugs are listed BAXDELA COMETRIQ ERLEADA GLASSIA [INJ]
in CAPITAL letters. BD AUTOSHIELD CORLANOR erythromycin eye ointment glimepiride
Generic drugs are listed DUO NEEDLES CREON ESBRIET glipizide
in lower case letters. BD ULTRAFINE cyanocobalamin [INJ] escitalopram glipizide ext-release
INSULIN SYRINGES cyclobenzaprine esomeprazole magnesium GLUCAGEN [INJ]
A BD ULTRAFINE PEN NEEDLES delayed-release GLUCAGON [INJ]
BELBUCA D ESPEROCT [INJ] glyburide
ABILIFY MAINTENA [INJ] benazepril estradiol GLYXAMBI
acetaminophen/codeine benzonatate DALIRESP estradiol patches GONAL-F, GONAL-F RFF,
ACTEMRA [INJ] BETASERON [INJ] DAYTRANA estradiol/norethindrone GONAL-F RFF
acyclovir BEVESPI AEROSPHERE DESCOVY acetate REDI-JECT [INJ]
ADEMPAS BIKTARVY desloratadine ESTRING GRASTEK
ADVAIR HFA bisoprolol/hctz desvenlafaxine succinate eszopiclone guanfacine ext-release
ADVATE [INJ] blisovi fe ext-release etonogestrel-ee vaginal ring GVOKE [INJ]
ADYNOVATE [INJ] BOSULIF dexamethasone EUFLEXXA [INJ]
AFSTYLA [INJ] BREO ELLIPTA DEXCOM RECEIVER, SENSOR, ezetimibe H
AIMOVIG [INJ] BREZTRI AEROSPHERE TRANSMITTER ezetimibe/simvastatin
AJOVY [INJ] BRILINTA dexmethylphenidate HARVONI
albuterol nebulization budesonide nebulization ext-release F HUMALOG [INJ]
solution suspension dextroamphetamine/ HUMIRA [INJ]
albuterol sulfate hfa (by bupropion amphetamine famotidine HUMULIN [INJ]
Cipla, Lupin, Par, Perrigo, bupropion ext-release dextroamphetamine/ FARXIGA hydralazine
Proficient Rx & Teva) buspirone amphetamine ext-release FASENRA [INJ] hydrochlorothiazide
ALECENSA butalbital/acetaminophen/ diazepam fenofibrate hydrocodone/acetaminophen
alendronate caffeine diclofenac sodium fenofibrate micronized hydrocodone/
allopurinol BYDUREON [INJ] delayed-release fenofibric acid chlorpheniramine polistirex
ALPHAGAN P 0.1% BYETTA [INJ] dicyclomine delayed-release ext-release
alprazolam BYSTOLIC digoxin fentanyl patches hydrocortisone topical
ALUNBRIG diltiazem ext-release FETZIMA hydromorphone
amiodarone C dimethyl fumarate FINACEA FOAM hydroxychloroquine
amitriptyline diphenoxylate/atropine finasteride hydroxyzine hcl
amlodipine CABOMETYX divalproex delayed-release FLECTOR hydroxyzine pamoate
amlodipine/benazepril carbidopa/levodopa divalproex ext-release FLOVENT DISKUS HYSINGLA ER
amlodipine/valsartan carvedilol DIVIGEL FLOVENT HFA
amoxicillin cefdinir donepezil fluconazole I
amoxicillin/potassium cefuroxime axetil doxazosin fluocinonide
clavulanate celecoxib doxycycline hyclate fluoxetine ibandronate
AMZEEQ cephalexin doxycycline monohydrate fluticasone nasal spray IBRANCE
anastrozole CERDELGA DUAVEE folic acid ibuprofen
ANDRODERM CEREZYME [INJ] DULERA FORTEO [INJ] INBRIJA
ANORO ELLIPTA CETROTIDE [INJ] duloxetine delayed-release FRAGMIN [INJ] INCRUSE ELLIPTA
ARALAST NP [INJ] CHANTIX DUPIXENT [INJ] FREESTYLE KITS/METERS: indomethacin
ARIKAYCE chlorhexidine gluconate DYANAVEL XR FREESTYLE FREEDOM, INLYTA
aripiprazole chlorthalidone FREESTYLE FREEDOM LITE, INVELTYS
ARISTADA [INJ] CIMDUO E FREESTYLE INSULINX, INVOKAMET
ARNUITY ELLIPTA ciprofloxacin FREESTYLE LITE INVOKAMET XR
ASMANEX HFA citalopram EDARBI FREESTYLE LIBRE & LIBRE 2 INVOKANA
ASMANEX TWISTHALER clarithromycin EDARBYCLOR READER, SENSOR irbesartan
atenolol CLENPIQ ELIQUIS FREESTYLE TEST STRIPS: IRESSA
atenolol/chlorthalidone clindamycin hcl ELOCTATE [INJ] FREESTYLE, isosorbide mononitrate
atomoxetine clindamycin phosphate EMGALITY [INJ] FREESTYLE INSULINX, ext-release
atorvastatin topical EMVERM FREESTYLE LITE
AUSTEDO clindamycin phosphate/ enalapril FULPHILA J
AVONEX [INJ] benzoyl peroxide ENBREL [INJ] furosemide
AZASITE clobetasol propionate ENDOMETRIN FYCOMPA JANUMET, JANUMET XR
azelastine nasal spray clomiphene citrate enoxaparin [INJ] JANUVIA
azithromycin clonazepam ENSTILAR G JARDIANCE
AZOPT clonidine ENTRESTO JIVI [INJ]
clopidogrel EPCLUSA gabapentin JULUCA
B clotrimazole/betamethasone EPIDIOLEX GAMMACORE junel
dipropionate epinephrine auto-injector GELNIQUE junel fe
baclofen colchicine tablets (by Mylan, Teva) [INJ] gemfibrozil
BAFIERTAM COMBIGAN EPIPEN, EPIPEN JR [INJ] GENOTROPIN [INJ]
(continued)
Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com.
© 2020 Express Scripts. All Rights Reserved. CRP2005_003097.1 #1702 NP-A
All trademarks are the property of their respective owners. Page 1 PRMT22157-21 (01/01/21)K montelukast P S TRESIBA [INJ]
morphine sulfate ext-release triamcinolone topical
KESIMPTA [INJ] MOVANTIK PANCREAZE SAVELLA triamterene/hctz
ketoconazole topical pantoprazole delayed-release SEGLUROMET
moxifloxacin eye solution TRIJARDY XR
ketorolac mupirocin paroxetine hcl SEREVENT DISKUS tri-lo-marzia
KITABIS PAK MUSE penicillin v potassium sertraline TRIPTODUR [INJ]
KOGENATE FS [INJ] PENTASA
MVASI [INJ] sildenafil tri-sprintec
KOVALTRY [INJ] MYDAYIS PERFOROMIST SIMPONI 100 MG (for TRIUMEQ
KYLEENA MYRBETRIQ PHOSLYRA ulcerative colitis only) [INJ] TRULANCE
KYNMOBI pioglitazone simvastatin TRULICITY [INJ]
N PLEGRIDY [INJ] SKYLA TYMLOS [INJ]
L polymyxin/trimethoprim SKYRIZI [INJ]
nabumetone eye solution SOLIQUA [INJ] U
labetalol NAMZARIC POMALYST SOLOSEC
lamotrigine naproxen, naproxen sodium potassium chloride SOMATULINE DEPOT [INJ] UCERIS FOAM
lansoprazole delayed-release NARCAN NASAL SPRAY ext-release SPIRIVA HANDIHALER UPTRAVI
LANTUS [INJ] NASCOBAL pramipexole SPIRIVA RESPIMAT
latanoprost eye solution NATESTO pravastatin spironolactone V
LATUDA NAYZILAM PRECISION XTRA METERS, sprintec
LEVEMIR [INJ] neomycin/polymyxin/ TEST STRIPS, SPRYCEL valacyclovir
levetiracetam hydrocortisone ear solution B-KETONE STRIPS STEGLATRO valsartan
levocetirizine NEXLETOL prednisolone acetate STEGLUJAN valsartan/hctz
levofloxacin NEXLIZET eye suspension STELARA SC [INJ] VARUBI
levothyroxine sodium niacin ext-release prednisolone sodium STIOLTO RESPIMAT VASCEPA
LICART nifedipine ext-release phosphate STRENSIQ [INJ] VELPHORO
lidocaine patches NINLARO prednisone SUBLOCADE [INJ] venlafaxine
LINZESS nitrofurantoin macrocrystal pregabalin sulfamethoxazole/ venlafaxine ext-release
liothyronine NITYR PREMARIN CREAM trimethoprim verapamil ext-release
LIPOFEN NIVESTYM [INJ] PREMARIN TABLETS sumatriptan VERZENIO
lisinopril NORDITROPIN [INJ] PREMPHASE SUNOSI VIBERZI
lisinopril/hctz nortriptyline PREMPRO SUPREP VIIBRYD
LIVALO NOVAREL [INJ] PROCRIT [INJ] SUTENT VIMPAT
LO LOESTRIN FE NOVOEIGHT [INJ] progesterone micronized SYMBICORT VIOKACE
LOKELMA NOVOFINE AUTOSHIELD PROLASTIN C [INJ] SYMFI VIZIMPRO
lorazepam NEEDLES promethazine SYMFI LO VOSEVI
LORBRENA NOVOFINE NEEDLES promethazine/ SYMJEPI [INJ] VUMERITY
losartan NOVOTWIST NEEDLES dextromethorphan SYMLINPEN [INJ] VYVANSE
losartan/hctz NUBEQA propranolol SYMPROIC
LOTEMAX GEL, OINTMENT NUCALA [INJ] propranolol ext-release SYMTUZA W
LOTEMAX SM NUEDEXTA PULMICORT FLEXHALER SYNJARDY, SYNJARDY XR
loteprednol eye suspension nystatin warfarin
lovastatin nystatin topical Q T
LUMIGAN X
LUPANETA PACK [INJ] O QNASL tacrolimus topical
LUPRON DEPOT QUDEXY XR tadalafil XALKORI
3.75 MG, 11.25 MG [INJ] ODACTRA quetiapine TAKHZYRO [INJ] XARELTO
LUPRON DEPOT-PED [INJ] ODEFSEY QUILLICHEW ER TALICIA XELJANZ, XELJANZ XR
LYNPARZA ODOMZO QUILLIVANT XR TALTZ [INJ] XIFAXAN
LYUMJEV [INJ] OFEV quinapril TALZENNA XIGDUO XR
ofloxacin QVAR REDIHALER tamoxifen XIIDRA
M olanzapine tamsulosin ext-release XOLAIR [INJ]
olmesartan R TASIGNA XTANDI
MAYZENT olmesartan/hctz TAYTULLA XULTOPHY [INJ]
meclizine omega-3 acid ethyl esters rabeprazole delayed-release TAZORAC GEL XYREM
medroxyprogesterone omeprazole delayed-release RAGWITEK TAZORAC 0.05% CREAM XYWAV
meloxicam ondansetron raloxifene TEGSEDI [INJ]
metaxalone ondansetron orally ramipril TEKTURNA HCT Y
metformin disintegrating tablets RASUVO [INJ] TEMIXYS
metformin ext-release ONETOUCH KITS/METERS: REBIF [INJ] terazosin YONSA
methimazole ULTRA 2, ULTRAMINI, RECTIV terconazole vaginal YUPELRI
methocarbamol VERIO, VERIO FLEX RELISTOR [INJ] testosterone cypionate [INJ] yuvafem
methotrexate ONETOUCH TEST STRIPS: RELISTOR TABLETS THALOMID
methylphenidate ULTRA, VERIO REMICADE [INJ] timolol maleate eye solution Z
methylphenidate ext-release ONEXTON REPATHA [INJ] tizanidine
methylprednisolone OPSUMIT RESTASIS TOBI PODHALER ZARXIO [INJ]
metoclopramide ORALAIR RETACRIT [INJ] TOBRADEX OINTMENT ZEJULA
metoprolol succinate ORIAHNN REVLIMID TOBRADEX ST ZENPEP
ext-release ORILISSA RHOPRESSA tobramycin eye solution ZEPATIER
metoprolol tartrate ORTHOVISC [INJ] RINVOQ ER tobramycin/dexamethasone ZEPOSIA
metronidazole oseltamivir risperidone eye suspension ZERVIATE
metronidazole topical OTEZLA rizatriptan topiramate ZIEXTENZO [INJ]
metronidazole vaginal OTOVEL ropinirole TOUJEO [INJ] ZIOPTAN
microgestin fe OVIDREL [INJ] rosuvastatin TOVIAZ ZIRABEV [INJ]
minocycline oxcarbazepine RUBRACA TRACLEER SUSPENSION zolpidem
MIRENA oxybutynin ext-release RUCONEST [INJ] tramadol zolpidem ext-release
mirtazapine oxycodone RUXIENCE [INJ] travoprost eye solution ZOMIG NASAL
MIRVASO oxycodone/acetaminophen RYBELSUS TRAZIMERA [INJ] ZTLIDO
MITIGARE OXYCONTIN trazodone ZUBSOLV
mometasone OZEMPIC [INJ] TRELEGY ELLIPTA ZYLET
MONOVISC [INJ] TREMFYA [INJ] ZYTIGA 500 MG
Go to express-scripts.com/2021drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2021 THROUGH DECEMBER 31, 2021. THIS LIST IS SUBJECT TO CHANGE. You can find more information at express-scripts.com.
© 2020 Express Scripts. All Rights Reserved. CRP2005_003097.1 #1702 NP-A
All trademarks are the property of their respective owners. Page 2 PRMT22157-21 (01/01/21)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. Log on to express-scripts.com/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 Excluded Medications Preferred Alternatives
ANTIINFECTIVES
FIRVANQ vancomycin capsules, vancomycin oral solution
Antibiotic Agents - Vancomycins (Oral)
Antifungal Agents (Oral) TOLSURA itraconazole
Antivirals (Oral) SITAVIG acyclovir oral or cream, famciclovir, valacyclovir
AUTONOMIC & CENTRAL NERVOUS SYSTEM
LUCEMYRA clonidine
Alpha-2 Adrenergic Agonists (for Opioid Withdrawal)
carbamazepine, oxcarbazepine, pregabalin, topiramate,
APTIOM
VIMPAT
Anticonvulsants
FINTEPLA DIACOMIT, EPIDIOLEX
TOPIRAMATE ER CAPSULES topiramate tablets, QUDEXY XR
Antimigraine Agents VYEPTI AIMOVIG, AJOVY, EMGALITY
amantadine capsules, amantadine tablets,
GOCOVRI ER
Antiparkinsonism Agents amantadine oral solution
XADAGO, ZELAPAR rasagiline, selegiline
aripiprazole, olanzapine, quetiapine er, quetiapine fumarate,
Antipsychotics (Oral) CAPLYTA
risperidone, ziprasidone, LATUDA
Antispasmodic Agents OZOBAX baclofen, tizanidine
dextroamphetamine er, dextroamphetamine/amphetamine er,
Central Nervous System Stimulants AMPHETAMINE ER SUSPENSION DYANAVEL XR, MYDAYIS, QUILLICHEW ER, QUILLIVANT XR,
VYVANSE
EMFLAZA prednisone solution, prednisone tablets
Duchenne Muscular Dystrophy (DMD) Agents
EXONDYS 51, VILTEPSO, VYONDYS 53 No alternatives recommended
Lambert-Eaton Myasthenic Syndrome Agents FIRDAPSE RUZURGI
MORPHABOND ER, NUCYNTA ER, OXYCODONE ER, hydromorphone er, morphine sulfate er, oxymorphone er,
Long-Acting Opioid Oral Analgesics
XTAMPZA ER HYSINGLA ER, OXYCONTIN
AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON,
Multiple Sclerosis (Beta Interferons) EXTAVIA
PLEGRIDY, REBIF, REBIF REBIDOSE
APADAZ, BENZHYDROCODONE/ACETAMINOPHEN hydrocodone/acetaminophen
hydrocodone/acetaminophen, morphine sulfate, oxycodone,
Narcotic Analgesics & Combinations NUCYNTA
tramadol, tramadol/acetaminophen
PRIMLEV oxycodone/acetaminophen
BUNAVAIL buprenorphine/naloxone, ZUBSOLV
Narcotic Antagonists
EVZIO, NALOXONE AUTO-INJECTOR naloxone syringes, NARCAN NASAL SPRAY
Neuropathic Agents LYRICA CR gabapentin, pregabalin
Sedative-Hypnotic Agents DORAL, QUAZEPAM estazolam, lorazepam
Continued
© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612
All trademarks are the property of their respective owners. Page 3 DL44109Q-SD-21 (12/01/2020)Drug Class Excluded Medications Preferred Alternatives
AUTONOMIC & CENTRAL NERVOUS SYSTEM (continued)
Serotonin/Norepinephrine Reuptake Inhibitor DRIZALMA SPRINKLE desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA
Antidepressants
Tardive Dyskinesia Therapy INGREZZA AUSTEDO
FENTANYL CITRATE BUCCAL TABLETS, FENTORA,
Transmucosal Fentanyl Analgesics fentanyl citrate lozenges
LAZANDA, SUBSYS
olanzapine/fluoxetine, bupropion, desvenlafaxine er,
Miscellaneous Antidepressants SPRAVATO
duloxetine, escitalopram, mirtazapine, sertraline
CARDIOVASCULAR EPANED enalapril
ACE Inhibitors QBRELIS lisinopril
Anticoagulants PRADAXA, SAVAYSA ELIQUIS, XARELTO
INDERAL XL, INNOPRAN XL propranolol er
KAPSPARGO SPRINKLE metoprolol succinate
Beta Blockers & Combinations
metoprolol tartrate/hydrochlorothiazide,
DUTOPROL
metoprolol succinate er plus hydrochlorothiazide
Calcium Channel Blockers KATERZIA amlodipine
atorvastatin, fluvastatin er, lovastatin, pravastatin,
HMG & Cholesterol Inhibitor Combinations ALTOPREV, EZALLOR SPRINKLE
rosuvastatin, simvastatin tablets, LIVALO
PCSK9 Inhibitors PRALUENT REPATHA
DERMATOLOGICAL
MINOCYCLINE ER CAPSULES, XIMINO minocycline er tablets
Oral Agents for Acne
Rosacea Agents (Oral) DOXYCYCLINE 40 MG CAPSULES doxycycline hyclate, doxycycline monohydrate
Topical Acne Combinations EPIDUO FORTE adapalene/benzoyl peroxide
clindamycin/benzoyl peroxide, clindamycin/tretinoin,
Topical Acne/Antibiotic Combinations VELTIN
erythromycin/benzoyl peroxide, ONEXTON
CARAC, FLUOROURACIL 0.5% CREAM, diclofenac 3% gel, fluorouracil 2% solution,
Topical Agents for Actinic Keratosis
IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA fluorouracil 5% cream, imiquimod 5% cream
CLINDAGEL,
Topical Antibiotics for Acne clindamycin phosphate gel, erythromycin gel, AMZEEQ
CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE)
Topical Antifungals ECOZA, LULICONAZOLE, SULCONAZOLE, XOLEGEL ciclopirox, econazole, ketoconazole, naftifine, oxiconazole
betamethasone valerate, fluocinolone acetonide,
CLOCORTOLONE
triamcinolone acetonide
Topical Corticosteroids
desonide 0.05% cream/lotion/ointment,
VERDESO FOAM
desoximetasone 0.25% cream/ointment
Vitamin D Analogs (Topical) CALCIPOTRIENE FOAM calcipotriene, calcitriol
ALCORTIN A hydrocortisone, mupirocin
Miscellaneous Topical Dermatological Agents
LIDOCAINE/TETRACAINE lidocaine cream, lidocaine/prilocaine cream
FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE
FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE
ASCENSIA (CONTOUR)
FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX,
ROCHE (ACCU-CHEK)
DIABETES FREESTYLE LITE
TRIVIDIA (TRUETEST, TRUETRACK)
Blood Glucose Meters & Test Strips ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO,
ALL OTHER METERS & TEST STRIPS
VERIO FLEX
THAT ARE NOT LISTED AS PREFERRED
ONETOUCH TEST STRIPS: ULTRA, VERIO
PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS
Continued
© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612
All trademarks are the property of their respective owners. Page 4 DL44109Q-SD-21 (12/01/2020)Drug Class Excluded Medications Preferred Alternatives
ALOGLIPTIN, NESINA, ONGLYZA, TRADJENTA JANUVIA
DIABETES (continued) ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR,
JANUMET, JANUMET XR
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations KAZANO, KOMBIGLYZE XR
ALOGLIPTIN/PIOGLITAZONE pioglitazone plus JANUVIA
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose
QTERN GLYXAMBI, STEGLUJAN
Co-Transporter-2 (SGLT-2) Inhibitors Combinations
Glucagon-Like Peptide-1 Agonists ADLYXIN, VICTOZA BYDUREON, BYETTA, OZEMPIC, TRULICITY
NOVOLIN, RELION NOVOLIN HUMULIN
ADMELOG, APIDRA, FIASP, INSULIN ASPART,
Insulins HUMALOG, LYUMJEV
INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG
SEMGLEE LANTUS, LEVEMIR, TOUJEO, TRESIBA
EAR/NOSE
BECONASE AQ, OMNARIS, ZETONNA budesonide, flunisolide, fluticasone, mometasone, QNASL
Nasal Steroids
Otic Fluoroquinolone Antibiotics CIPROFLOXACIN/FLUOCINOLONE OTIC ciprofloxacin/dexamethasone otic, OTOVEL
ENDOCRINE (OTHER)
Gonadotropin-Releasing Hormone (GnRH) Analogs FENSOLVI LUPRON DEPOT-PED, TRIPTODUR
(for Central Precocious Puberty)
HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE,
Growth Hormones GENOTROPIN, NORDITROPIN FLEXPRO
SAIZEN, SAIZENPREP, ZOMACTON
Somatostatin Analogs SANDOSTATIN LAR DEPOT, SIGNIFOR LAR SOMATULINE DEPOT
Testosterone Products AVEED testosterone cypionate, testosterone enanthate
Miscellaneous Endocrine Drugs KORLYM ketoconazole, LYSODREN, SIGNIFOR
GASTROINTESTINAL
MYTESI diphenoxylate/atropine, loperamide
Antidiarrheal Agents
AKYNZEO CAPSULES granisetron, ondansetron, aprepitant, VARUBI TABLETS
Antiemetics (Oral)
EMEND POWDER PACKETS aprepitant, VARUBI TABLETS
Bowel Evacuants OSMOPREP peg-electrolyte solution, CLENPIQ, SUPREP
Corticosteroids (Rectal Formulations) CORTIFOAM hydrocortisone enema, UCERIS FOAM
Helicobacter Pylori Agents HELIDAC, PYLERA lansoprazole/amoxicillin/clarithromycin, TALICIA
Hemorrhoidal Preparations PROCTOFOAM-HC pramoxine/hydrocortisone
balsalazide disodium, mesalamine dr, mesalamine er,
Inflammatory Bowel Agents DIPENTUM
sulfasalazine, PENTASA
Irritable Bowel Syndrome & Chronic Constipation Agents AMITIZA LINZESS, TRULANCE
Pancreatic Enzymes PERTZYE CREON, PANCREAZE, ZENPEP
ACIPHEX SPRINKLE, ESOMEPRAZOLE STRONTIUM,
esomeprazole magnesium, lansoprazole, omeprazole,
Proton Pump Inhibitors NEXIUM PACKETS, PRILOSEC SUSPENSION,
pantoprazole, rabeprazole
RABEPRAZOLE DR SPRINKLE
HEMATOLOGICAL aspirin plus omeprazole, esomeprazole, lansoprazole,
ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR
Antiplatelet Agents pantoprazole or rabeprazole
Erythropoiesis-Stimulating Agents ARANESP, EPOGEN, MIRCERA PROCRIT, RETACRIT
ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, ESPEROCT, JIVI,
Factor VIII Recombinant Products NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE
KOGENATE FS, KOVALTRY, NOVOEIGHT
Continued
© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612
All trademarks are the property of their respective owners. Page 5 DL44109Q-SD-21 (12/01/2020)Drug Class Excluded Medications Preferred Alternatives
HEMATOLOGICAL (continued) GRANIX, NEUPOGEN NIVESTYM, ZARXIO
Granulocyte Colony Stimulating Factors NEULASTA, UDENYCA FULPHILA, ZIEXTENZO
Iron Replacement Agents MONOFERRIC sodium ferric gluconate complex, VENOFER
OXBRYTA hydroxyurea, ADAKVEO, DROXIA
Sickle Cell Disease Agents
SIKLOS DROXIA
MULPLETA DOPTELET
Thrombocytopenia Agents
TAVALISSE DOPTELET, PROMACTA, NPLATE
HEPATITIS LEDIPASVIR/SOFOSBUVIR, MAVYRET,
EPCLUSA, HARVONI, VOSEVI, ZEPATIER
Hepatitis C SOFOSBUVIR/VELPATASVIR, SOVALDI
efavirenz/emtricitabine/tenofovir disoproxil fumarate,
efavirenz/lamivudine/tenofovir disoproxil fumarate,
DELSTRIGO
BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO,
SYMTUZA, TRIUMEQ
COMPLERA ODEFSEY
HIV
Antiretrovirals PIFELTRO efavirenz, EDURANT
Note: Current patients established on therapy
are allowed to continue therapy. PREZCOBIX atazanavir, ritonavir, KALETRA TABLETS, PREZISTA
Coverage may be approved for the treatment of human
RUKOBIA ER immunodeficiency virus-1 infection in heavily treatment-
experienced patients with multidrug-resistant infection.
STRIBILD BIKTARVY, GENVOYA
MUSCULOSKELETAL & RHEUMATOLOGY
COLCHICINE CAPSULES colchicine tablets, MITIGARE
Gout Therapy
DICLOFENAC 35 MG CAPSULES,
diclofenac, etodolac, ibuprofen, indomethacin,
INDOMETHACIN 20 MG CAPSULES, KETOROLAC NASAL SPRAY,
meloxicam, nabumetone, naproxen, piroxicam
TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) fenoprofen calcium tablets, diclofenac, ibuprofen,
FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES
indomethacin, meloxicam, nabumetone, naproxen
nabumetone, diclofenac, ibuprofen, indomethacin,
RELAFEN DS
meloxicam, naproxen, piroxicam
diclofenac sodium topical,
Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) DICLOFENAC EPOLAMINE PATCHES, PENNSAID
FLECTOR PATCHES, LICART PATCHES
OBSTETRICAL & GYNECOLOGICAL
CLIMARA PRO COMBIPATCH
Combination Patches
Barrier methods of contraception, such as condoms,
PHEXXI
diaphragms, spermicides or sponges.
Contraceptives
generic oral and ring contraceptives, xulane patches,
TWIRLA
LO LOESTRIN FE, TAYTULLA
estradiol cream, estradiol patches, estradiol tablets,
Estrogen & Estrogen Modifiers for Vaginal Symptoms FEMRING, INTRAROSA
yuvafem, ESTRING, PREMARIN CREAM, PREMARIN TABLETS
Human Chorionic Gonadotropin CHORIONIC GONADOTROPIN, PREGNYL NOVAREL, OVIDREL
Ovulatory Stimulants (Follitropins) FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT
Prenatal Vitamins PREGENNA, TRINAZ generic prenatal vitamins
Topical Estrogen Gels ELESTRIN, ESTROGEL DIVIGEL
CRINONE 4% medroxyprogesterone, megestrol, norethindrone, progesterone
Vaginal Progesterones
CRINONE 8% ENDOMETRIN
Continued
© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612
All trademarks are the property of their respective owners. Page 6 DL44109Q-SD-21 (12/01/2020)Drug Class Excluded Medications Preferred Alternatives
ONCOLOGY
AVASTIN MVASI, ZIRABEV
Bevacizumab-Containing Agents
Breast Cancer Agents KISQALI, KISQALI FEMARA CO-PACK, PIQRAY IBRANCE, VERZENIO
Chronic Lymphocytic Leukemia (CLL) Agents CALQUENCE IMBRUVICA, VENCLEXTA
DARZALEX, KYPROLIS, NINLARO, POMALYST, REVLIMID,
Multiple Myeloma Agents BLENREP, XPOVIO
THALOMID, VELCADE
Myelodysplastic Syndrome Agents INQOVI decitabine
Myelofibrosis Agents INREBIC JAKAFI
Prostate Cancer Agents TRELSTAR ELIGARD, FIRMAGON
Rituximab-Containing Agents RITUXAN, RITUXAN HYCELA, TRUXIMA RUXIENCE
HERCEPTIN, HERCEPTIN HYLECTA, HERZUMA, OGIVRI,
KANJINTI, TRAZIMERA
Trastuzumab-Containing Agents ONTRUZANT
PHESGO PERJETA plus KANJINTI or TRAZIMERA
imatinib, NEXAVAR, SPRYCEL, STIVARGA, SUTENT, TASIGNA,
Tyrosine Kinase Inhibitors QINLOCK
VOTRIENT
betaxolol drops, brimonidine 0.15% drops,
OPHTHALMIC
TIMOPTIC OCUDOSE brimonidine 0.2% drops, levobunolol drops, timolol drops,
Antiglaucoma Drugs (Non-Prostaglandins)
ALPHAGAN P 0.1%, AZOPT, COMBIGAN
bimatoprost drops, latanoprost drops, travoprost drops,
Antiglaucoma Drugs (Ophthalmic Prostaglandins) DURYSTA, XELPROS
LUMIGAN, ZIOPTAN
Blepharoptosis Agents UPNEEQ No alternatives recommended
Ophthalmic Agents - Other CYSTADROPS CYSTARAN
azelastine drops, cromolyn drops, epinastine drops,
Ophthalmic Anti-Allergic ALOCRIL, ALOMIDE, LASTACAFT, PAZEO
ketotifen drops, olopatadine drops, ZERVIATE
dexamethasone drops, fluorometholone drops,
Ophthalmic Anti-Inflammatory FML FORTE, FML S.O.P., MAXIDEX, PRED MILD loteprednol drops, prednisolone drops,
INVELTYS, LOTEMAX GEL/OINTMENT
Ophthalmic Non-Steroidal Anti-Inflammatory Drugs
ACUVAIL, NEVANAC bromfenac drops, diclofenac drops, ketorolac drops
(NSAIDs)
ciprofloxacin drops, gatifloxacin drops, levofloxacin drops,
Ophthalmic Quinolone Antibiotics CILOXAN OINTMENT
moxifloxacin drops, ofloxacin drops
DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN,
OSTEOARTHRITIS
HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, EUFLEXXA, MONOVISC, ORTHOVISC
Hyaluronic Acid Derivatives
SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3
OSTEOPOROSIS alendronate, ibandronate, risedronate, zoledronic acid,
EVENITY, PROLIA
Bone Modifiers FORTEO, TYMLOS
RENAL DISEASE
PROCYSBI CYSTAGON
Nephropathic Cystinosis Medications
lanthanum, sevelamer carbonate, sevelamer hcl,
Phosphate Binders FOSRENOL POWDER PACKETS
PHOSLYRA, VELPHORO
RESPIRATORY epinephrine auto-injector (by Mylan, Teva),
AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX)
Epinephrine Auto-Injector Systems EPIPEN, EPIPEN JR
Immunological Agents for Asthma CINQAIR DUPIXENT, FASENRA, NUCALA
Long-Acting Beta Agonist Inhalers STRIVERDI RESPIMAT SEREVENT DISKUS
Long-Acting Muscarinic Antagonist Inhalers TUDORZA PRESSAIR INCRUSE ELLIPTA, SPIRIVA HANDIHALER, SPIRIVA RESPIMAT
Continued
© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612
All trademarks are the property of their respective owners. Page 7 DL44109Q-SD-21 (12/01/2020)Drug Class Excluded Medications Preferred Alternatives
RESPIRATORY (continued)
Long-Acting Muscarinic Antagonist/ DUAKLIR PRESSAIR ANORO ELLIPTA, BEVESPI AEROSPHERE, STIOLTO RESPIMAT
Long-Acting Beta-Agonist Combination Inhalers
ARNUITY ELLIPTA, ASMANEX HFA, ASMANEX TWISTHALER,
Pulmonary Anti-Inflammatory Inhalers ARMONAIR DIGIHALER FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER,
QVAR REDIHALER
AIRDUO DIGIHALER, AIRDUO RESPICLICK,
Pulmonary Anti-Inflammatory/ fluticasone/salmeterol (by Prasco, Proficient Rx),
BUDESONIDE/FORMOTEROL,
Beta-Agonist Combination Inhalers ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT
FLUTICASONE/SALMETEROL (BY A-S MEDICATION, TEVA)
ALBUTEROL SULFATE HFA (BY A-S MEDICATION, PRASCO),
albuterol sulfate hfa (by Cipla, Lupin, Par, Perrigo,
Short-Acting Beta2-Agonist Inhalers LEVALBUTEROL HFA, PROAIR DIGIHALER, PROAIR RESPICLICK,
Proficient Rx & Teva)
VENTOLIN HFA, XOPENEX HFA
MISCELLANEOUS AGENTS
PALFORZIA No alternatives recommended
Allergen Immunotherapy
Cushing’s Agents ISTURISA SIGNIFOR
Gaucher Disease Agents ELELYSO CEREZYME
Hereditary Angioedema BERINERT RUCONEST
CUTAQUIG SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY
IV: GAMMAGARD LIQUID, GAMMAGARD S-D, GAMUNEX-C
Immune Globulins GAMMAKED
SC: GAMMAGARD LIQUID, GAMUNEX-C, XEMBIFY
HIZENTRA SC: XEMBIFY
OTREXUP RASUVO
Immunosuppressant Agents
XATMEP methotrexate
Neuromyelitis Optica Spectrum Disorder Agents UPLIZNA ENSPRYNG
Nocturnal Polyuria Agents NOCTIVA desmopressin tablets
Polyneuropathy of Hereditary
ONPATTRO TEGSEDI
Transthyretin-Mediated Amyloidosis
Potassium Binders VELTASSA LOKELMA
Indication Based Management
Drug Class Excluded Medications Preferred Alternatives
Spinal Conditions (nr-axSpA) COSENTYX TALTZ, CIMZIA
TALTZ, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC,
Inflammatory Conditions‡ where COSENTYX is indicated COSENTYX
TREMFYA, XELJANZ, XELJANZ XR
Drug Class Nonpreferred Medications Preferred Alternatives
All other Brand Name medications for Inflammatory Preferred: ENBREL, HUMIRA, OTEZLA, RINVOQ ER, SKYRIZI,
Conditions are Nonpreferred. Approval may be granted STELARA SC, TALTZ, TREMFYA, XELJANZ, XELJANZ XR
following a coverage review. A trial of one or more Preferred
Inflammatory Conditions‡ medications is required prior to initiating therapy with a Preferred after Step through HUMIRA: ACTEMRA
Nonpreferred medication. A formulary exception may be
granted for a patient already established on therapy with a ULCERATIVE COLITIS ONLY Preferred after Step through
Nonpreferred medication. HUMIRA: SIMPONI 100 MG, XELJANZ, XELJANZ XR
‡ Please note that product placement for treatment of Inflammatory Conditions in the Inflammatory Conditions Care Value (ICCV) Program are subject to change throughout the year based
upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.
Continued
© 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612
All trademarks are the property of their respective owners. Page 8 DL44109Q-SD-21 (12/01/2020)Excluded Medications/Products at a Glance ABILIFY^ CUPRIMINE^ INDERAL XL, INNOPRAN XL ONGLYZA TEKTURNA^ ACANYA^ CUTAQUIG INDOMETHACIN 20 MG CAPSULES ONPATTRO TESTIM^ ACIPHEX^ CYMBALTA^ INGREZZA ONTRUZANT TIKOSYN^ ACIPHEX SPRINKLE CYSTADROPS INQOVI OSMOPREP TIMOPTIC OCUDOSE ACUVAIL CYTOMEL^ INREBIC OTREXUP TIVORBEX ADCIRCA^ DELSTRIGO INSULIN ASPART, OXBRYTA TOBI SOLUTION^ ADDERALL^ DELZICOL^ INSULIN ASPART PROTAMINE OXYCODONE ER TOLSURA ADLYXIN DETROL^, DETROL LA^ INSULIN LISPRO OZOBAX TOPAMAX^ ADMELOG DICLOFENAC 35 MG CAPSULES INTRAROSA PALFORZIA TOPICORT SPRAY^ AGGRENOX^ DICLOFENAC EPOLAMINE PATCHES INTUNIV^ PATADAY^ TOPIRAMATE ER CAPSULES AIRDUO DIGIHALER, DIOVAN^, DIOVAN HCT^ ISTALOL^ PAZEO TOPROL XL^ AIRDUO RESPICLICK DIPENTUM ISTURISA PENNSAID TRADJENTA AKYNZEO CAPSULES DORAL JADENU^, JADENU SPRINKLE^ PERCOCET^ TRANSDERM-SCOP^ ALBUTEROL SULFATE HFA DOXYCYCLINE 40 MG CAPSULES JENTADUETO, JENTADUETO XR PERTZYE TRAVATAN Z^ (BY A-S MEDICATION, PRASCO) DRIZALMA SPRINKLE KAPSPARGO SPRINKLE PHESGO TRELSTAR ALCORTIN A DUAKLIR PRESSAIR KATERZIA PHEXXI TREXIMET^ ALOCRIL DURAGESIC^ KAZANO PIFELTRO TRIBENZOR^ ALOGLIPTIN DUROLANE KEPPRA^, KEPPRA XR^ PIQRAY TRICOR^ ALOGLIPTIN/METFORMIN DURYSTA KETOROLAC NASAL SPRAY PLAQUENIL^ TRILEPTAL^ ALOGLIPTIN/PIOGLITAZONE DUTOPROL KISQALI, KISQALI FEMARA CO-PACK PLAVIX^ TRILURON ALOMIDE ECOZA KOMBIGLYZE XR PRADAXA TRINAZ ALTOPREV EFFEXOR XR^ KORLYM PRALUENT TRIVIDIA (TRUETEST, TRUETRACK) AMBIEN^, AMBIEN CR^ ELELYSO LAMICTAL^, LAMICTAL ODT^, PRAVACHOL^ TRIVISC AMITIZA ELESTRIN LAMICTAL XR^ PRED MILD TRUXIMA AMPHETAMINE ER SUSPENSION ELIDEL^ LASTACAFT PREGENNA TUDORZA PRESSAIR AMPYRA^ EMEND CAPSULES^, TRIFOLD PACK^ LAZANDA PREGNYL TWIRLA AMRIX^ EMEND POWDER PACKETS LEDIPASVIR/SOFOSBUVIR PREVACID^, PREVACID SOLUTAB^ UDENYCA ANDROGEL^ EMFLAZA LETAIRIS^ PREZCOBIX ULORIC^ ANUSOL-HC^ EPANED LEVALBUTEROL HFA PRILOSEC SUSPENSION UPLIZNA APADAZ EPIDUO^ LEXAPRO^ PRIMLEV UPNEEQ APIDRA EPIDUO FORTE LIALDA^ PRISTIQ^ UROXATRAL^ APTIOM EPINEPHRINE AUTO-INJECTOR LIBRAX^ PROAIR DIGIHALER, VAGIFEM^ ARANESP (BY IMPAX) LIDOCAINE/TETRACAINE PROAIR RESPICLICK VALIUM^ ARIMIDEX^ EPOGEN LIDODERM^ PROAIR HFA^ VALTREX^ ARMONAIR DIGIHALER ESOMEPRAZOLE STRONTIUM LIPITOR^ PROCTOFOAM-HC VANOS^ ASACOL HD^ ESTRACE CREAM^ LOCOID^, LOCOID LIPOCREAM^ PROCYSBI VELTASSA ASCENSIA (CONTOUR) ESTROGEL LOESTRIN^, LOESTRIN FE^ PROLIA VELTIN ASPIRIN/OMEPRAZOLE DR ESTROSTEP FE^ LOTREL^ PROTONIX^ VENTOLIN HFA ATACAND^, ATACAND HCT^ EVENITY LOTRONEX^ PROVENTIL HFA^ VERDESO FOAM ATRALIN^ EVZIO LOVENOX^ PROVIGIL^ VESICARE^ ATRIPLA^ EXFORGE^, EXFORGE HCT^ LUCEMYRA PROZAC^ VIAGRA^ AUVI-Q EXJADE^ LULICONAZOLE PULMICORT RESPULES^ VICTOZA AVALIDE^, AVAPRO^ EXONDYS 51 LUNESTA^ PYLERA VILTEPSO AVASTIN EXTAVIA LYRICA^ QBRELIS VISCO-3 AVEED EZALLOR SPRINKLE LYRICA CR QINLOCK VIVELLE-DOT^ AVODART^ FEMRING MAVYRET QTERN VIVLODEX AZOR^ FENOPROFEN CAPSULES MAXALT^, MAXALT MLT^ QUARTETTE^ VYEPTI BARACLUDE TABLETS^ FENORTHO MAXIDEX QUAZEPAM VYONDYS 53 BECONASE AQ FENSOLVI MESTINON^ RABEPRAZOLE DR SPRINKLE VYTORIN^ BENICAR^, BENICAR HCT^ FENTANYL CITRATE BUCCAL TABLETS MICARDIS^, MICARDIS HCT^ RANEXA^ WELCHOL 3.75 GM PACKETS^ BENZHYDROCODONE/ FENTORA MINASTRIN 24 FE^ RAPAFLO^ WELLBUTRIN SR^, WELLBUTRIN XL^ ACETAMINOPHEN FIASP MINIVELLE^ RECOMBINATE XADAGO BERINERT FINTEPLA MINOCYCLINE ER CAPSULES RELAFEN DS XALATAN^ BLENREP FIRAZYR^ MIRCERA RENAGEL^ XANAX^, XANAX XR^ BRISDELLE^ FIRDAPSE MIRCETTE^ RETIN-A MICRO 0.04% & 0.1%^ XATMEP BUDESONIDE/FORMOTEROL FIRVANQ MONOFERRIC RITUXAN, RITUXAN HYCELA XELPROS BUNAVAIL FLUOROURACIL 0.5% CREAM MORPHABOND ER ROCHE (ACCU-CHEK) XENAZINE^ BUPAP^ FLUTICASONE/SALMETEROL MOVIPREP^ ROZEREM^ XIMINO BUTRANS^ (BY A-S MEDICATION, TEVA) MULPLETA RUKOBIA ER XOLEGEL CALCIPOTRIENE FOAM FML FORTE, FML S.O.P. MYTESI SAFYRAL^ XOPENEX HFA CALQUENCE FOCALIN^, FOCALIN XR^ NALFON CAPSULES SAIZEN, SAIZENPREP XPOVIO CAPLYTA FOLLISTIM AQ NALOXONE AUTO-INJECTOR SANDOSTATIN LAR DEPOT XTAMPZA ER CARAC FOSRENOL CHEWABLE TABLETS^ NAMENDA XR^ SAVAYSA XYNTHA, XYNTHA SOLOFUSE CELEBREX^ FOSRENOL POWDER PACKETS NASONEX^ SEASONIQUE^, LOSEASONIQUE^ YASMIN^ CELEXA^ GAMMAKED NATROBA^ SEMGLEE YOSPRALA DR CHORIONIC GONADOTROPIN GANIRELIX ACETATE^ NESINA SENSIPAR^ ZAVESCA^ CIALIS^ GEL-ONE NEULASTA SEROQUEL^, SEROQUEL XR^ ZEGERID^ CILOXAN OINTMENT GELSYN-3 NEUPOGEN SIGNIFOR LAR ZELAPAR CINQAIR GENERESS FE^ NEURONTIN^ SIKLOS ZETIA^ CIPROFLOXACIN/FLUOCINOLONE OTIC GENVISC 850 NEVANAC SINGULAIR^ ZETONNA CLIMARA PRO GLEEVEC^ NEXIUM CAPSULES^ SITAVIG ZIPSOR CLINDAGEL GLUCOPHAGE^, GLUCOPHAGE XR^ NEXIUM PACKETS SODIUM HYALURONATE ZOCOR^ CLINDAMYCIN PHOSPHATE 1% GEL GLUMETZA^ NOCTIVA SOFOSBUVIR/VELPATASVIR ZOHYDRO ER^ (BY OCEANSIDE) GOCOVRI ER NORCO^ SOVALDI ZOLOFT^ CLOCORTOLONE GRANIX NORVASC^ SPRAVATO ZOMACTON COLCHICINE CAPSULES HELIDAC NOVOLIN, RELION NOVOLIN STRATTERA^ ZOMIG TABLETS^, ZOMIG ZMT^ COMPLERA HERCEPTIN, HERCEPTIN HYLECTA NOVOLOG STRIBILD ZONEGRAN^ CONCERTA^ HERZUMA NOXAFIL TABLETS^ STRIVERDI RESPIMAT ZORVOLEX COREG^ HIZENTRA NUCYNTA, NUCYNTA ER SUBSYS ZOVIRAX OINTMENT^ CORTIFOAM HUMATROPE NUTROPIN AQ NUSPIN SULCONAZOLE ZYCLARA COSENTYX HYALGAN NUVIGIL^ SUPARTZ FX ZYTIGA 250 MG^ COSOPT^ HYMOVIS NUWIQ SYNVISC, SYNVISC-ONE COZAAR^, HYZAAR^ IMIQUIMOD 3.75% CREAM PUMP OGIVRI TARGRETIN CAPSULES^ CRESTOR^ IMITREX^ OMNARIS TAVALISSE CRINONE INDERAL LA^ OMNITROPE TAZORAC 0.1% CREAM^ ^ 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. © 2020 Express Scripts. All Rights Reserved. CRP2011_006156.1 204612 All trademarks are the property of their respective owners. Page 9 DL44109Q-SD-21 (12/01/2020)
2021 State of Delaware Prescription Plan Level Exclusions
The following list of Excluded Medications are NOT Covered under the State of Delaware Prescription
Drug Plan effective January 1, 2021.
Please note:
Some medications on this Plan Level Exclusions list may be included in the Express Scripts Formulary of
covered drugs. In those cases, the State of Delaware Prescription Drug Plan Level Exclusions list takes
precedence when determining coverage.
If you fill a prescription for one of the Excluded Medications listed below, the claim will be denied coverage
under your prescription plan. You will need to pay out-of-pocket for the medication.
Excluded Medications
Non-Federal Legend Drugs (OTC drugs) except where mandated by ACA
Investigational Drugs
Rx drugs that have OTC equivalents
Ostomy Supplies
Blood Glucose Monitors not issued by Livongo®
Mifeprex
Cosmetic & hypopigmentation Drugs
Anti-Obesity Preparations, Weight Loss Medications
Dental Fluoride Products except where mandated by ACA
Allergy Sera & Blood Products
Erectile Dysfunction Agents
Hypoactive Sexual Desire Disorder (HSDD) Agents
Drugs on the State of Delaware Prescription Drug Plan Level Exclusions list are not eligible for
consideration under the Coverage Review program.
Page 10You can also read
