MedImpact Drug Exclusions · 2019. 4. 2. · EPICERAM OTC emollients (Eucerin, Cetaphil, petroleum...
Transcript of MedImpact Drug Exclusions · 2019. 4. 2. · EPICERAM OTC emollients (Eucerin, Cetaphil, petroleum...
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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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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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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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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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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
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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)
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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)
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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
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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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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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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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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