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Page 1

MedImpact Drug Exclusions

4-1-2019

Rebate-Driven Exclusions

Excluded Drug Preferred Alternative

ADLYXIN Trulicity, Bydureon, Bydureon BCise, Byetta

ADMELOG Humalog

ADMELOG SOLOSTAR Humalog

ADZENYS ER Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine, Vyvanse

ADZENYS XR-ODT Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine, Vyvanse

AEROSPAN Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler

AIRDUO RESPICLICK

(brand and authorized generic)

Advair Diskus/HFA, Breo Ellipta, Dulera, Symbicort

AJOVY Aimovig, Emgality

ALVESCO Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler

APIDRA Humalog

APIDRA SOLOSTAR Humalog

APTENSIO XR methylphenidate, dexmethylphenidate, Concerta, Quillichew ER, Quillivant XR

ARMONAIR RESPICLICK Arnuity Ellipta, Flovent Diskus/HFA, Qvar Redihaler

BASAGLAR KWIKPEN U-100 Lantus, Toujeo, Tresiba, Levemir

BECONASE AQ OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl

BELBUCA Butrans

BELVIQ/XR Contrave

BEPREVE azelastine, olopatadine

CEQUA Restasis, Xiidra

COTEMPLA XR-ODT methylphenidate, dexmethylphenidate, Concerta, Quillichew ER, Quillivant XR

DELZICOL Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine

DIPENTUM Apriso, balsalazide disodium, Lialda, Pentasa, sulfasalazine

EMADINE azelastine, olopatadine

ESTROGEL Divigel

EXTAVIA Aubagio, Avonex, glatiramer, Gilenya, Glatopa, Plegridy, Rebif

GENOTROPIN Norditropin

HUMATROPE Norditropin

INVOKANA Jardiance, Farxiga

INVOKAMET Synjardy, Synjardy XR, Xigduo XR

INVOKAMET XR Synjardy, Synjardy XR, Xigduo XR

KAZANO Janumet, Janumet XR, Jentadueto, Jentadueto XR

KEVZARA Actemra, Enbrel, Humira, Xeljanz

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Page 2

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

KOMBIGLYZE XR Janumet, Janumet XR, Jentadueto, Jentadueto XR

LASTACAFT azelastine, olopatadine

LEVALBUTEROL TARTRATE ProAir HFA, ProAir RespiClick, Ventolin HFA

MYDAYIS Adderall XR, dextroamphetamine/amphetamine, dextroamphetamine,Vyvanse

NESINA

(brand and authorized generic)

Januvia, Tradjenta

NOVOLIN Humulin

NOVOLOG Humalog

NUTROPIN Norditropin

NUTROPIN AQ Norditropin

OLUMIANT Actemra, Enbrel, Humira, Xeljanz

OMNARIS OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl

OMNITROPE Norditropin

ONGLYZA Januvia, Tradjenta

OSENI

(brand and authorized generic)

Januvia, Tradjenta, pioglitazone

OZEMPIC Trulicity, Bydureon, Bydureon BCise, Byetta

PANCREAZE Creon, Zenpep

PAZEO azelastine, olopatadine

PERTZYE Creon, Zenpep

PRADAXA Eliquis, Xarelto

PROVENTIL HFA ProAir HFA, ProAir RespiClick, Ventolin HFA

QSYMIA Contrave

QTERN Glyxambi

SAIZEN Norditropin

SAXENDA Contrave

SEEBRI NEOHALER Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta

SEGLUROMET Synjardy, Synjardy XR, Xigduo XR

SIMPONI (50 mg) Actemra, Cosentyx, Enbrel, Humira, Stelara, Xeljanz

STEGLATRO Jardiance, Farxiga

STEGLUJAN Glyxambi

SYMPROIC Linzess, Movantik

TALTZ Cosentyx, Enbrel, Humira, Otezla, Stelara

TECHNIVIE Epclusa, Harvoni, Mavyret, Vosevi

TRULANCE Linzess

TUDORZA PRESSAIR Spiriva Handihaler, Spiriva Respimat, Incruse Ellipta

UTIBRON NEOHALER Anoro Ellipta, Stiolto Respimat, Bevespi Aerosphere

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Page 3

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

VIEKIRA PAK Epclusa, Harvoni, Mavyret, Vosevi

VIEKIRA XR Epclusa, Harvoni, Mavyret, Vosevi

XOPENEX HFA ProAir HFA, ProAir Respiclick, Ventolin HFA

ZEPATIER Epclusa, Harvoni, Mavyret, Vosevi

ZETONNA OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl

ZOMACTON Norditropin

Non-Essential Drugs

Excluded Drug Preferred Alternative

ABSORICA generic isotretinoin capsules

ABSTRAL fentanyl citrate lozenge

ACUICYN OTC OCuSOFT lid scrub, ocular antibiotics, OTC artificial tears

ADAPALENE SOLUTION Rx generic adapalene cream or lotion, Rx generic/OTC adapalene gel, EpiDuo, generic topical tretinoin

ALEVICYN/SPRAY GEL OTC emollients or creams, OTC generic hydrocortisone, OTC wound care products

ALLZITAL generic butalbital/acetaminophen (50mg-325mg tablet)

ALZAIR Chloraseptic Allergen Block

AMRIX cyclobenzaprine (5mg or 10mg)

ANTARA fenofibrate, micronized/nanocrystallized

APLENZIN bupropion extended release, bupropion

AQUORAL OTC saliva mouthwash, powder, or spray/pump

ASPIRIN/OMEPRAZOLE OTC aspirin, omeprazole

ASTERO topical lidocaine

ATOPADERM OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids, OTC wound care products

AUGMENTIN

(125MG/5ML SUSPENSION)

generic amoxicillin/clavulanate suspension

AVENOVA OTC OCuSOFT lid scrub, ocular antibiotics, OTC artificial tears

AVO CREAM OTC hyaluronate products, OTC wound dressings, barrier creams

BEAU RX Kelocote, Recedo

BENZACLIN generic clindamycin/benzoyl peroxide

BENZEPRO generic or OTC topical benzoyl peroxide

BENZONATATE (Solubiomix) generic benzonatate

BIAFINE OTC hyaluronate products, OTC wound dressings, barrier creams

BINOSTO alendronate, ibandronate

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Page 4

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

BIONECT OTC hyaluronate products

BOCASAL OTC saliva mouthwash, powder, or spray/pump

BONJESTA OTC doxylamine, OTC pyridoxine

BPCO OTC wound care products, barrier creams and ointments

BRYHALI Generic halobetasol ointment or cream, clobetasol propionate lotion; generic betamethasone; generic fluocinonide

BUTALBITAL-ACETAMINOPHEN (50MG-300MG CAPSULE)

generic butalbital/acetaminophen (50mg-325mg tablet)

CAROSPIR generic spironolactone tablets

CELACYN OTC Mederma, OTC Scarguard MD, OTC ScarAway

CERACADE OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids

CERAMAX OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion

CHLORZOXAZONE 375 mg, 750 mg generic chlorozoxazone (500 mg tablets)

CONZIP generic tramadol extended-release capsules or tablets

COREMINO generic immediate-release minocycline capsules or tablets, doxycycline

DERMULCERA OTC wound care products, barrier creams and ointments

DESVENLAFAXINE ER desvenlafaxine succinate ER, desvenlafaxine ER (Ranbaxy)

DEXERYL OTC emollients or creams, OTC generic hydrocortisone

DEXPAK dexamethasone tablets (1.5 mg)

DICLOFENAC SODIUM topical diclofenac

DICLOFENAC SUBMICRONIZED generic oral NSAIDs, generic oral diclofenac

DIFENOXIN HCL/ATROPINE SULFATE generic Lomotil tablets

DUEXIS famotidine & ibuprofen

DULOXETINE HCL generic duloxetine

DURLAZA RX/OTC aspirin, clopidogrel

DUTOPROL generic metoprolol, hydrochlorothiazide

EDLUAR eszopiclone, zaleplon, zolpidem

ELETONE OTC emollients or creams, OTC generic hydrocortisone

ENTTY OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids

EPICERAM OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids

EPICYN OTC benzoyl peroxide cleansers

ERTACZO generic clotrimazole, econazole, ketoconazole, terbinafine

EURAX generic topical permethrin, oral ivermectin

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Page 5

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

EVZIO Narcan

EXTINA 2% ketoconazole shampoo or cream

FENOFIBRATE generic fenofibrate, micronized/nanocrystallized

FENOPROFEN CALCIUM generic oral NSAIDs

FENTORA fentanyl citrate lozenge

FEXMID (brand and generic) cyclobenzaprine (5mg or 10mg)

FORFIVO XL bupropion extended release

GENADUR OTC nail strengthener

GLUMETZA generic Glucophage XR

GLYCATE generic glycopyrrolate (1mg tablets)

GOCOVRI generic amantadine IR (100mg tablets)

GONITRO generic nitroglycerin sublingual tablets, generic nitroglycerin translingual spray

GRALISE gabapentin immediate-release

HORIZANT gabapentin immediate-release

HPR/PLUS/MB/HYDROGEL generic topical clobetasol or hydrocortisone, OTC emollient products (CeraVe, etc.)

HYCLODEX Di-Dak Sol (sodium hypochlorite 0.0125%), Dakin’s solution (sodium hypochlorite 0.125%, 0.25%, and 0.50%), Hysept (sodium hypochlorite 0.5%), and H-Chlor (0.062/0.125%)

HYCOFENIX OTC 1% hydrocortisone

HYDROCODONE-ACETAMINOPHEN

(10MG-325MG ORAL SOLUTION)

hydrocodone-acetaminophen 10mg-300mg tablets, 10mg-325mg tablets, 7.5-325mg oral solution

HYLATOPIC PLUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids, OTC wound care products

IMPOYZ betamethasone dipropionate, clobetasol propionate, fluocinonide, triamcinolone acetonide

INDOCIN diclofenac oral and capsicum

INDERAL XL Inderal LA capsules, propranolol tablets

INNOPRAN XL Inderal LA capsules, propranolol tablets

INTERMEZZO eszopiclone, zaleplon, zolpidem

ISOTRETINOIN generic isotretinoin capsules

KAMDOY topical lidocaine

KELARX OTC Mederma, OTC Scarguard MD

KERAGELT OTC wound care products

KHEDEZLA (brand and generic) desvenlafaxine succinate extended release, desvenlafaxine extended release (Ranbaxy)

LACTULOSE PACKETS (generic) generic lactulose solution

LAZANDA fentanyl citrate lozenge

MedImpact Healthcare Systems, Inc. pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved.

Page 6

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

LEVICYN/SG OTC emollients or creams, OTC generic hydrocortisone, OTC wound care products

LEXETTE generic halobetasol ointment or cream; generic clobetasol; generic betamethasone; generic fluocinonide

LIDOCAINE HCL/ALOE/COLLAGEN lidocaine, OTC aloe, OTC emollients

LIDOCAINE/TETRACAINE generic lidocaine 5% topical, lidocaine-prilocaine topical cream

LIDOCAINE/PRILOCAINE 2.5%/2.5% (KIT)

generic lidocaine 5% topical, lidocaine-prilocaine topical cream

LIDOTREX lidocaine, OTC vitamin E, OTC aloe, OTC emollients

LORZONE generic chlorzoxazone (500 mg tablets)

LOYON topical dimethicone

LURADROX OTC hyaluronate products

LUXAMEND OTC hyaluronate products, OTC wound dressings, barrier creams

LYRICA CR immediate-release gabapentin, immediate-release Lyrica

METFORMIN HCL ER generic metformin IR, generic Glucophage XR (metformin ER)

MICROCYN OTC wound care products

MINOCYCLINE HCL ER generic immediate-release minocycline capsules or tablets, doxycycline

MINOCYCLINE HCL MICROSPHERES generic immediate-release minocycline capsules or tablets, doxycycline

MINOLIRA ER generic immediate-release minocycline capsules or tablets, doxycycline

NALFON generic oral NSAIDs

NAPRELAN naproxen

NAPROXEN SODIUM ER naproxen

NAPROXEN/ESOMEPRAZOLE MAG naproxen & esomeprazole magnesium, lansoprazole, omeprazole, or pantoprazole

NATESTO generic topical testosterone, IM testosterone

NEOCERA OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids

NEOSALUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids

NEUTRASAL OTC saliva mouthwash, powder, or spray/pump

NIVATOPIC PLUS OTC emollients (Eucerin, Cetaphil, petroleum jelly, Aquaphor), pramoxine, Sarna lotion, topical diphenhydramine, generic topical steroids, OTC wound care products

NORITATE 0.75% metronidazole cream or lotion

NORTRIPTYLINE 20 MG/10ML UNIT-DOSE CUPS

Generic nortriptyline capsules and oral solution (10mg/5mL)

MedImpact Healthcare Systems, Inc. pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved.

Page 7

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

NUVAIL OTC nail strengthener

ONSOLIS fentanyl citrate lozenge

ONZETRA XSAIL sumatriptan

OSMOLEX ER generic amantadine IR (100mg tablets)

PENNSAID diclofenac

PEXEVA paroxetine

PLIXDA Rx generic adapalene cream or lotion, Rx generic/OTC adapalene gel, EpiDuo, generic topical tretinoin

PRESTALIA amlodipine and benazepril

PROMISE B OTC topical antifungal products, OTC topical steroids, OTC ketoconazole/dandruff shampoos

PRUTECT OTC hyaluronate products, OTC wound dressings, barrier creams

RADIAPLEX RX OTC hyaluronate products, OTC aloe, OTC emollient products, OTC wound care products

RAMELTEON eszopiclone, zaleplon, zolpidem

RAYOS prednisone IR

REGENECARE lidocaine, OTC vitamin E, OTC aloe, OTC emollients

RESTIZAN OTC Mederma, OTC Scarguard MD, OTC ScarAway

ROZEREM eszopiclone, zaleplon, zolpidem

RYCLORA (brand and generic) OTC diphenhydramine, OTC chlorpheniramine

RYVENT (brand and generic) generic carbinoxamine (4 mg tablets)

SALIVAMAX OTC saliva mouthwash, powder, or spray/pump

SCARCARE OTC Mederma, OTC Scarguard MD, OTC Bio Oil

SCARCIN OTC Mederma, OTC Scarguard MD, OTC ScarAway

SEBUDERM OTC topical antifungal products, OTC topical steroids, OTC ketoconazole/dandruff shampoos

SEYSARA generic immediate-release minocycline capsules or tablets, doxycycline

SILIPAC OTC Mederma, OTC Scarguard MD, OTC Bio Oil

SOLODYN generic immediate-release minocycline capsules or tablets, doxycycline

SONAFINE OTC hyaluronate products, OTC wound dressings, barrier creams

SP SCAR MANAGEMENT OTC Mederma, OTC Scarguard MD, OTC ScarAway

SPRIX ibuprofen, naproxen

SUBSYS fentanyl citrate lozenge

SULFACLEANSE generic sulfur/sodium sulfacetamide topical products

SUVICORT lidocaine, OTC aloe, OTC emollients

SYNERDERM palm oil

TAPERDEX dexamethasone tablets (1.5 mg)

MedImpact Healthcare Systems, Inc. pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved.

Page 8

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

TETRIX OTC wound care products, barrier creams and ointments

TIROSINT generic levothyroxine tablets

TIVORBEX indomethacin

TREXIMET sumatriptan, naproxen

TREZIX (brand and generic) acetaminophen/codeine

TRIANEX generic triamcinolone acetonide 0.03%-0.1% ointment

ULTRAVATE Generic halobetasol ointment or cream, clobetasol propionate lotion; generic betamethasone; generic fluocinonide

VANATOL LQ butalbital/acetaminophen/caffeine (50mg-325mg-40mg) tablets/capsules

VANATOL S butalbital/acetaminophen/caffeine (50mg-325mg-40mg) tablets/capsules

VELTIN (brand and generic) generic clindamycin topical, generic tretinoin topical

VENELEX OTC wound care products, barrier creams and ointments

VERDESO generic desonide 0.05% cream, lotion, or ointment

VIMOVO naproxen & esomeprazole

VIVLODEX meloxicam

XERESE oral acyclovir, famciclovir, valacyclovir

XEROFORM PETROLATUM DRESSING OTC wound care products

XHANCE OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl

XIMINO generic immediate-release minocycline capsules or tablets, doxycycline

XOLEGEL 2% ketoconazole shampoo or cream

YOSPRALA Rx/OTC aspirin, RX/OTC omeprazole

ZECUITY sumatriptan

ZEMA-PAK dexamethasone tablets (1.5 mg)

ZEMBRACE SYMTOUCH sumatriptan

ZIANA (brand and generic) generic clindamycin topical, generic tretinoin topical

ZILEUTON ER montelukast , zafirlukast

ZIPSOR diclofenac

ZOLPIMIST eszopiclone, zaleplon, zolpidem

ZONACORT dexamethasone tablets (1.5 mg)

ZONALON topical corticosteroid

ZORVOLEX diclofenac

ZTLIDO immediate-release gabapentin, immediate-release Lyrica, generic lidocaine 5% topical patches, OTC lidocaine cream, generic Rx lidocaine cream, solution, or ointment

ZUPLENZ ondansetron ODT

ZYCLARA imiquimod 5% cream

ZYFLO montelukast , zafirlukast

MedImpact Healthcare Systems, Inc. pbm.medimpact.com Copyright © 2019 MedImpact Healthcare Systems, Inc. All rights reserved.

Page 9

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

ZYFLO CR montelukast , zafirlukast

High-Cost, Non-Essential Products

Excluded Drug Preferred Alternative

ACCUCAINE lidocaine topical

ACTIVE-PAC generic gabapentin IR and lidocaine/menthol topical

ADAZIN OTC lidocaine, benzocaine, methyl salicylate, capsaicin creams

ALCORTIN A hydrocortisone-iodoquinol cream, ciclopirox cream, clotrimazole cream

ALLEVESS PATCH topical capsaicin and menthol

ALOQUIN hydrocortisone-iodoquinol cream

ATOPICLAIR OTC hyaluronate products

AVIDOXY DK generic doxycycline, OTC salicylic acid

BENSAL HP topical hydrocortisone, OTC emollients, salicylic acid

BENZODOX 30 generic doxycycline, OTC benzoyl peroxide

BENZEPRO generic OTC or Rx topical benzoyl peroxide products

CAPHOSOL OTC saliva mouthwash, powder, or spray/pump

CAPXIB celecoxib, capsaicin/menthol

CLINDAMYCIN PHOS/SKIN CLNSR 19 Acanya (clindamycin 1.2%/benzoyl peroxide 2.5%); Benzaclin generic (clindamycin 1%/benzoyl peroxide 5%); erythromycin 3%, benzoyl peroxide 5%

CLINDAMYCIN/BENZOYL/EMOL CMB94 Acanya (clindamycin 1.2%/benzoyl peroxide 2.5%); Benzaclin generic (clindamycin 1%/benzoyl peroxide 5%; erythromycin 3%, benzoyl peroxide 5%

CYCLOBENZAPRINEPAX generic cyclobenzaprine 10 mg tablets

CYCLOTENS cyclobenzaprine 10 mg tablets

DERMACINRX CINLONE-I CPI triamcinolone 40mg injectable; lidocaine/prilocaine

DERMACINRX LEXITRAL topical diclofenac, topical capsaicin cream

DERMACINRX PHN PAK topical generic lidocaine

DERMACINRX PRIZOPAK topical lidocaine, prilocaine

DERMACINRX PUREFOLIX folic acid and vitamin D

DERMACINRX SILAPAK triamcinolone, dimethicone

DERMACINRX SILAZONE triamcinolone, dimethicone

DERMACINRX SURGICAL PHARMAPAK mupirocin and chlorhexidine

DERMACINRX THERAZOLE PAK clotrimazole/betamethasone cream or lotion

DERMACINRX ZRM PAK lidocaine/dimethicone cream

DERMAPAK PLUS topical tretinoin

DERMASORB HC hydrocortisone cream

DERMASORB TA triamcinolone cream

DERMASORB XM urea cream

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Page 10

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

DICLO GEL-XRYLIX SHEET topical diclofenac

DICLOFENAC SODIUM/MENTHOL topical diclofenac, OTC menthol/methyl salicylate

DICLOPAK topical diclofenac

DICLOPR topical diclofenac, OTC menthol/methyl salicylate

DICLOZOR topical diclofenac

DMT SUIK injectable dexamethasone

DOLOTRANZ lidocaine/prilocaine cream, lidocaine topical gel

DS PREP PAK topical diclofenac

DURACHOL OTC vitamin D3, folic acid

DYZBAC folic acid, vitamin B12, OTC multivitamin

ESOMEP-EZS Generic or OTC omeprazole, lansoprazole, OTC Pill Glide spray

EZ FLU KIT Seasonal influenza virus vaccine

FLEXIPAK diclofenac tablets, capsaicin cream

HYDROCORTISONE betamethasone dipropionate, clobetasol propionate, fluocinonide, triamcinolone acetonide

INFLAMMACIN diclofenac solution; methyl salicylate/menthol/camphor patch

INFLAMMA-K diclofenac solution; methyl salicylate/menthol/camphor patch

IV INFUSION CPI lidocaine/prilocaine cream

KERALAC urea cream

KERALYT OTC topical salicyclic acid gel or cream

KRISTALOSE generic lactulose syrup

LENZAPATCH topical lidocaine and menthol

LIDO-K generic lidocaine 5% ointment

LIDOCAINE/PRILO/M.SALICY/MENTH topical lidocaine/prilocaine cream, lidocaine gel, methyl salicylate/menthol

LIDOPAC topical lidocaine

LIDOPATCH topical lidocaine and menthol

LIDORX OTC lidocaine 4% gel

LIDORXKIT topical lidocaine

LIDOTRAL topical lidocaine

LIDOTRANS 5 PAK topical lidocaine

LIDOVEX topical lidocaine

LIDOXIB celecoxib and topical lidocaine/menthol

LIDOZION generic lidocaine 5% ointment

LOPROX KIT OTC clotrimazole 1%, terbinafine 1%, and tolnaftate 1%

MEBOLEX multivitamin, folic acid, cholecalciferol, resveratrol

MEDROX topical capsaicin and menthol

MENTHO-CAINE lidocaine/menthol spray OTC, lidocaine cream OTC

METFORMIN/BLOOD SUGAR DIAGNOST

generic metformin and formulary glucose test strips

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Page 11

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

METHAVER folic acid, multivitamin

METOPIC urea cream

MIGRANOW sumatriptan, camphor/menthol gel

MORGIDOX generic doxycycline

MULTIVIT #34/FA/NADH/UBIQUINON folic acid, vitamin B12, OTC multivitamin

NAPROPAK COOL naproxen

NAPROXENPAX naproxen

NOVACORT hydrocortisone/pramoxine creams

NOXIFOL-D3 OTC vitamin D3, folic acid

NOXIPAK fluocinolone/urea/silicone

NUDROXIPAK Rx generic celecoxib capsules, OTC topical capsaicin/methyl salicylate

NUDROXIPAD DSDR-50/75 Rx generic diclofenac delayed-release tablets, OTC topical capsaicin/methyl salicylate

NUDROXIPAK E-400 Rx generic etodolac tablets, OTC topical capsaicin/methyl salicylate

NUDROXIPAK I-800 OTC/Rx generic Ibuprofen tablets, OTC topical capsaicin/methyl salicylate

NUDROXIPAK N-500 OTC/Rx generic nabumetone, OTC topical capsaicin/methyl salicylate

NYATA topical nystatin

PEDIPAK ciclopirox

PHENOBARB/HYOSCY/ATROPINE/SCOP dicyclomine, hyoscyamine

PRUCLAIR OTC hyaluronate products

REVESTA OTC vitamin D3, folic acid

ROSADAN metronidazole cream

ROXIFOL-D OTC vitamin D3, folic acid

RYNODERM urea cream

SALEX KIT OTC salicylic acid cream, OTC hydrating cleanser or lotion

SMARTRX GABAKIT gabapentin, topical lidocaine/menthol

SMARTRX GABA-V KIT gabapentin, topical lidocaine/menthol

SOLUPAK topical lidocaine

SULFACETAMIDE/SULFUR/CLEANSR23 sulfacetamide and sulfur lotion

TICALAST azelastine, fluticasone

TICANASE OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl

TICASPRAY OTC budesonide, flunisolide, RX/OTC fluticasone, mometasone, OTC triamcinolone, Qnasl

TRIXYLITRAL topical diclofenac, OTC kinesiology therapy tape, OTC lidocaine cream, generic Rx lidocaine solution, cream, or ointment

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Page 12

MedImpact Drug Exclusions

4-1-2019

Excluded Drug Preferred Alternative

ULTRAVATE X halobetasol cream

UREA urea cream

URE-K urea cream

UREVAZ urea cream

VENIPUNCTURE CPI topical lidocaine

VEREGEN imiquimod cream, podofilox solution

VOPAC MDS generic diclofenac gel

WHYTEDERM SURGIPAK ciclopirox

WHYTEDERM TRILASIL PAK triamcinolone, dimethicone

WOUND DEBRIDEMENT-LIDOCAINE topical lidocaine solution

WPR PLUS OTC lidocaine cream, generic Rx lidocaine cream, solution, or ointment, OTC methyl salicylate/menthol cream

XILAPAK topical fluocinolone solution

XRYLIDERM topical lidocaine patches

XRYLIX topical diclofenac