Express Scripts 2019 National Preferred Formulary Exclusions

2020 National Preferred Formulary Exclusions

The excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

Take action to avoid paying full price. If you're currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of the following preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specific questions about your coverage, please call the number on your member ID card.

Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund. These excluded medications do not apply to Medicare plans.

Drug Class

ANTIINFECTIVES Antibiotics Antifungal Agents (Oral) Antivirals (Oral) AUTONOMIC & CENTRAL NERVOUS SYSTEM Alpha-2 Adrenergic Agonists (for Opioid Withdrawal) Anticonvulsants Anti-Migraine Therapy

Antiparkinsonism Agents

Antispasmodic Agents

Duchenne Muscular Dystrophy (DMD) Agents

Long-Acting Opioid Oral Analgesics

Multiple Sclerosis (Beta Interferons) Multiple Sclerosis (Oral)

Narcotic Analgesics & Combinations

Narcotic Antagonists Neuropathic Agents Sedative-Hypnotic Agents Serotonin/Norepinephrine Reuptake Inhibitor Antidepressants Tardive Dyskinesia Therapy Transmucosal Fentanyl Analgesics

Miscellaneous Antidepressants

Miscellaneous Central Nervous System Agents

Excluded Medications

DOXYCYCLINE HYCLATE DR 80 MG XIFAXAN 200 MG TABLETS~ TOLSURA SITAVIG

LUCEMYRA TOPIRAMATE ER CAPSULES ONZETRA XSAIL GOCOVRI ER, OSMOLEX ER XADAGO, ZELAPAR~ OZOBAX EMFLAZA EXONDYS 51, VYONDYS 53 EMBEDA, OXYCODONE ER, XTAMPZA ER~

EXTAVIA AUBAGIO APADAZ, BENZHYDROCODONE/ACETAMINOPHEN BUTRANS PRIMLEV~ EVZIO LYRICA CR DORAL~ DRIZALMA SPRINKLE INGREZZA ABSTRAL, FENTANYL CITRATE BUCCAL TABLETS, FENTORA, LAZANDA, SUBSYS SPRAVATO

NORTHERA~

Preferred Alternatives

doxycycline hyclate dr azithromycin, ciprofloxacin, levofloxacin, ofloxacin itraconazole acyclovir oral or cream, famciclovir, valacyclovir

clonidine

topiramate tablets, QUDEXY XR sumatriptan nasal spray, ZOMIG NASAL SPRAY amantadine capsules, amantadine tablets, amantadine oral solution rasagiline, selegiline baclofen, tizanidine prednisone solution, prednisone tablets No alternatives recommended hydromorphone er, morphine sulfate er, oxymorphone er, HYSINGLA ER, NUCYNTA ER, OXYCONTIN AVONEX ADMINISTRATION PACK, AVONEX PEN, BETASERON, PLEGRIDY, REBIF, REBIF REBIDOSE GILENYA, MAYZENT, TECFIDERA, VUMERITY hydrocodone/acetaminophen buprenorphine patches, BELBUCA oxycodone/acetaminophen naloxone syringes, NARCAN NASAL SPRAY gabapentin, pregabalin estazolam, lorazepam

desvenlafaxine er, duloxetine, venlafaxine er, FETZIMA

AUSTEDO

fentanyl citrate lozenges

olanzapine/fluoxetine, bupropion, desvenlafaxine er, duloxetine, escitalopram, mirtazapine, sertraline desmopressin acetate tablets, desmopressin acetate nasal, fludrocortisone, indomethacin, midodrine, pyridostigmine

~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (04/01/2020)

Drug Class

CARDIOVASCULAR ACE Inhibitors Anticoagulants Beta Blockers & Combinations Calcium Channel Blockers Calcium Channel Blockers & Combinations HMG & Cholesterol Inhibitor Combinations DERMATOLOGICAL Oral Agents for Acne Rosacea Agents (Oral) Topical Acne Combinations Topical Acne/Antibiotic Combinations Topical Agents for Actinic Keratosis Topical Antibiotics for Acne Topical Antifungals

Topical Corticosteroids

Vitamin D Analogs (Topical)

Miscellaneous Topical Dermatological Agents

DIABETES Blood Glucose Meters & Test Strips

Dipeptidyl Peptidase-4 Inhibitors & Combinations

Glucagon-Like Peptide-1 Agonists Insulins

Excluded Medications

EPANED QBRELIS PRADAXA, SAVAYSA KAPSPARGO SPRINKLE

DUTOPROL, METOPROLOL SUCCINATE/HCTZ ER

KATERZIA CONSENSI

ALTOPREV, EZALLOR SPRINKLE, SIMVASTATIN SUSPENSION

MINOLIRA, XIMINO~

DOXYCYCLINE 40 MG CAPSULES EPIDUO FORTE~

AKTIPAK, VELTIN

CARAC~, FLUOROURACIL 0.5% CREAM, IMIQUIMOD 3.75% CREAM PUMP, ZYCLARA CLINDAGEL~, CLINDAMYCIN PHOSPHATE 1% GEL (BY OCEANSIDE)~ LULICONAZOLE, SULCONAZOLE

CLOCORTOLONE

TOPICORT SPRAY, VERDESO FOAM

CALCIPOTRIENE FOAM

CALCIPOTRIENE/BETAMETHASONE SUSPENSION

ALCORTIN A LIDOCAINE/TETRACAINE

ASCENSIA (BREEZE, CONTOUR) ROCHE (ACCU-CHEK) TRIVIDIA (TRUETEST, TRUETRACK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED

ALOGLIPTIN, NESINA, ONGLYZA ALOGLIPTIN/METFORMIN, KAZANO, KOMBIGLYZE XR ALOGLIPTIN/PIOGLITAZONE ADLYXIN, VICTOZA NOVOLIN, RELION NOVOLIN ADMELOG, APIDRA, FIASP, INSULIN ASPART, INSULIN ASPART PROTAMINE, INSULIN LISPRO, NOVOLOG

Preferred Alternatives

enalapril lisinopril ELIQUIS, XARELTO metoprolol succinate metoprolol tartrate/hydrochlorothiazide, metoprolol succinate er plus hydrochlorothiazide amlodipine amlodipine benzoate plus celecoxib

atorvastatin, fluvastatin er, lovastatin, pravastatin, rosuvastatin, simvastatin tablets, LIVALO

minocycline er

ORACEA adapalene/benzoyl peroxide clindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, ONEXTON

diclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream, PICATO

clindamycin phosphate gel, erythromycin gel, AMZEEQ

ciclopirox, econazole, ketoconazole, naftifine, oxiconazole betamethasone valerate, fluocinolone acetonide, triamcinolone acetonide

desonide 0.05% cream/lotion/ointment, desoximetasone 0.25% cream/ointment calcipotriene, calcitriol calcipotriene/betamethasone ointment, ENSTILAR, TACLONEX SUSPENSION hydrocortisone, mupirocin

lidocaine cream, lidocaine/prilocaine cream

FREESTYLE KITS/METERS: FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE FREESTYLE TEST STRIPS: FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE ONETOUCH KITS/METERS: ULTRA2, ULTRAMINI, VERIO, VERIO FLEX ONETOUCH TEST STRIPS: ULTRA, VERIO PRECISION XTRA METERS, TEST STRIPS, B-KETONE STRIPS

JANUVIA, TRADJENTA JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR pioglitazone plus JANUVIA or TRADJENTA BYDUREON, BYETTA, OZEMPIC, TRULICITY HUMULIN

HUMALOG

~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (04/01/2020)

EAR/NOSE Nasal Steroids

Drug Class

Otic Fluoroquinolone Antibiotics

ENDOCRINE (OTHER) Combination Patches

Estrogen and Estrogen Modifiers for Vaginal Symptoms

Gonadotropin-Releasing Hormone (GnRH) Analogs (for Central Precocious Puberty)

Growth Hormones

Somatostatin Analogs Testosterone Products (Injectable) Topical Estrogen Gels Miscellaneous Endocrine Drugs

GASTROINTESTINAL Antiemetics (Oral) Bowel Evacuants Corticosteroids (Rectal Formulations) Helicobacter Pylori Agents

Inflammatory Bowel Agents

Pancreatic Enzymes

Proton Pump Inhibitors

HEMATOLOGICAL Antiplatelet Agents Chelating Agents Erythropoiesis-Stimulating Agents

Factor VIII Recombinant Products

Granulocyte Colony Stimulating Factors

Sickle Cell Disease Agents

Thrombocytopenia Agents

HEPATITIS Hepatitis C

Excluded Medications

BECONASE AQ, OMNARIS, ZETONNA

CETRAXAL

CIPROFLOXACIN/FLUOCINOLONE OTIC

CLIMARA PRO

FEMRING

SUPPRELIN LA~

HUMATROPE, NUTROPIN AQ NUSPIN, OMNITROPE, SAIZEN, SAIZENPREP, ZOMACTON SANDOSTATIN LAR DEPOT, SIGNIFOR LAR AVEED~ ESTROGEL KORLYM~ AKYNZEO CAPSULES EMEND POWDER PACKETS OSMOPREP~ CORTIFOAM PYLERA~ DIPENTUM PANCREAZE, PERTZYE ACIPHEX SPRINKLE, PRILOSEC SUSPENSION, PROTONIX SUSPENSION, RABEPRAZOLE DR SPRINKLE

ASPIRIN/OMEPRAZOLE DR, YOSPRALA DR JADENU, JADENU SPRINKLE ARANESP, EPOGEN, MIRCERA NUWIQ, RECOMBINATE, XYNTHA, XYNTHA SOLOFUSE GRANIX, NEUPOGEN OXBRYTA SIKLOS MULPLETA TAVALISSE~ LEDIPASVIR/SOFOSBUVIR, MAVYRET, SOFOSBUVIR/VELPATASVIR, SOVALDI

Preferred Alternatives

budesonide, flunisolide, fluticasone, mometasone, QNASL

ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEX, OTOVEL CIPRODEX, OTOVEL

COMBIPATCH

estradiol patches, estradiol tablets, yuvafem, ESTRING, PREMARIN CREAM, PREMARIN TABLETS

LUPRON DEPOT-PED, TRIPTODUR

GENOTROPIN, NORDITROPIN FLEXPRO

SOMATULINE DEPOT testosterone cypionate, testosterone enanthate DIVIGEL ketoconazole, LYSODREN, SIGNIFOR granisetron, ondansetron, aprepitant, VARUBI TABLETS aprepitant, VARUBI TABLETS peg-electrolyte solution, PREPOPIK, SUPREP hydrocortisone enema, UCERIS FOAM lansoprazole/amoxicillin/clarithromycin, TALICIA balsalazide disodium, mesalamine dr, mesalamine er, sulfasalazine, PENTASA CREON, ZENPEP esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, NEXIUM PACKETS aspirin plus omeprazole, esomeprazole, lansoprazole, pantoprazole or rabeprazole deferasirox PROCRIT, RETACRIT ADVATE, ADYNOVATE, AFSTYLA, ELOCTATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT NIVESTYM, ZARXIO hydroxyurea, ADAKVEO, DROXIA DROXIA DOPTELET DOPTELET, PROMACTA, NPLATE

EPCLUSA, HARVONI, VOSEVI, ZEPATIER

~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (04/01/2020)

Drug Class

HIV Antiretrovirals Note: Current patients established on therapy are allowed to continue therapy.

MUSCULOSKELETAL & RHEUMATOLOGY Gout Therapy

Excluded Medications

ATRIPLA, DELSTRIGO COMPLERA PIFELTRO PREZCOBIX STRIBILD COLCHICINE ZURAMPIC FENOPROFEN CAPSULES, FENORTHO, NALFON CAPSULES

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

RELAFEN DS

Topical Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

OBSTETRICAL & GYNECOLOGICAL Human Chorionic Gonadotropin Ovulatory Stimulants (Follitropins) Vaginal Progesterones

ONCOLOGY ALK Positive Lung Cancer Agents Bevacizumab-Containing Agents Breast Cancer Agents

Multiple Myeloma Agents

Myelofibrosis Agents Prostate Cancer Rituximab-Containing Agents Trastuzumab-Containing Agents OPHTHALMIC Antiglaucoma Drugs (Beta-Adrenergic Blockers)

Antiglaucoma Drugs (Ophthalmic Prostaglandins)

TIVORBEX, VIVLODEX, ZIPSOR, ZORVOLEX DICLOFENAC EPOLAMINE PATCHES PENNSAID

CHORIONIC GONADOTROPIN, PREGNYL FOLLISTIM AQ ENDOMETRIN ALECENSA~ ALUNBRIG~ AVASTIN~ KISQALI, KISQALI FEMARA CO-PACK, PIQRAY NINLARO~ XPOVIO INREBIC TRELSTAR~ RITUXAN~, RITUXAN HYCELA~, TRUXIMA~ HERCEPTIN~, HERCEPTIN HYLECTA~, OGIVRI~

TIMOPTIC OCUDOSE

XELPROS

Ophthalmic Anti-Allergic

ALOCRIL, ALOMIDE

Ophthalmic Anti-Inflammatory

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

FML FORTE, FML S.O.P., MAXIDEX, PRED MILD ACUVAIL, NEVANAC

Preferred Alternatives

BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ ODEFSEY efavirenz, EDURANT atazanavir, ritonavir, KALETRA TABLETS, PREZISTA BIKTARVY, GENVOYA

COLCRYS, MITIGARE allopurinol, probenecid fenoprofen calcium tablets, diclofenac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen nabumetone, diclofenac, ibuprofen, indomethacin, meloxicam, naproxen, piroxicam diclofenac, etodolac, ibuprofen, indomethacin, meloxicam, nabumetone, naproxen, piroxicam FLECTOR PATCHES diclofenac sodium topical, FLECTOR PATCHES

NOVAREL, OVIDREL

GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT CRINONE 8% GEL

If medically necessary, request prior authorization. XALKORI, ZYKADIA MVASI, ZIRABEV IBRANCE, VERZENIO KYPROLIS, VELCADE DARZALEX, KYPROLIS, POMALYST, REVLIMID, THALOMID, VELCADE JAKAFI ELIGARD, FIRMAGON RUXIENCE KANJINTI, TRAZIMERA

betaxolol drops, levobunolol drops, timolol drops, ALPHAGAN P 0.1%, COMBIGAN bimatoprost drops, latanoprost drops, travoprost drops, LUMIGAN, ZIOPTAN azelastine drops, cromolyn drops, olopatadine drops, ALREX, BEPREVE, PAZEO dexamethasone drops, fluorometholone drops, loteprednol drops, prednisolone drops, INVELTYS, LOTEMAX

bromfenac drops, diclofenac drops, ketorolac drops, ILEVRO, PROLENSA

~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (04/01/2020)

Drug Class

OSTEOARTHRITIS Hyaluronic Acid Derivatives

OSTEOPOROSIS Bone Modifiers RENAL DISEASE Nephropathic Cystinosis Medications

Phosphate Binders

RESPIRATORY Epinephrine Auto-Injector Systems Immunological Agents for Asthma Long-Acting Beta Agonist Inhalers Long-Acting Muscarinic Antagonist Inhalers Long-Acting Muscarinic Antagonist/ Long-Acting Beta-Agonist Combination Inhalers

Pulmonary Anti-Inflammatory Inhalers

Pulmonary Anti-Inflammatory/ Beta-Agonist Combination Inhalers

Short-Acting Beta2-Agonist Inhalers

WEIGHT LOSS Weight Loss Agents MISCELLANEOUS AGENTS Hereditary Angioedema Immunosuppressant Agents Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis Potassium Binders

Excluded Medications

DUROLANE, GEL-ONE, GELSYN-3, GENVISC 850, HYALGAN, HYMOVIS, SODIUM HYALURONATE, SUPARTZ FX, SYNVISC, SYNVISC-ONE, TRILURON, TRIVISC, VISCO-3

EVENITY, PROLIA

Preferred Alternatives

EUFLEXXA, MONOVISC, ORTHOVISC

alendronate, ibandronate, risedronate, zoledronic acid, FORTEO, TYMLOS

PROCYSBI~

CYSTAGON

FOSRENOL POWDER PACKETS

lanthanum, sevelamer carbonate, sevelamer hcl, PHOSLYRA, VELPHORO

AUVI-Q, EPINEPHRINE AUTO-INJECTOR (BY IMPAX)

epinephrine auto-injector (by Mylan), EPIPEN, EPIPEN JR

CINQAIR

FASENRA, NUCALA

STRIVERDI RESPIMAT

SEREVENT DISKUS

SPIRIVA HANDIHALER, SPIRIVA RESPIMAT, TUDORZA PRESSAIR INCRUSE ELLIPTA

DUAKLIR PRESSAIR, STIOLTO RESPIMAT

ANORO ELLIPTA, BEVESPI AEROSPHERE

ALVESCO

ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR REDIHALER

BUDESONIDE/FORMOTEROL

ADVAIR HFA, BREO ELLIPTA, DULERA, SYMBICORT

ALBUTEROL SULFATE HFA (BY A-S MEDICATION, PAR, PRASCO), albuterol sulfate hfa (by Perrigo, Proficient Rx & Teva),

LEVALBUTEROL HFA, PROVENTIL HFA, XOPENEX HFA

PROAIR HFA/RESPICLICK, VENTOLIN HFA

QSYMIA

benzphetamine, diethylpropion, phentermine

NOCTIVA BERINERT XATMEP

desmopressin tablets RUCONEST methotrexate

ONPATTRO

No alternatives recommended

VELTASSA

LOKELMA

Drug Class

Indication Based Management Excluded Medications

Preferred Alternatives

INFLAMMATORY CONDITIONS

TALTZ

COSENTYX, ENBREL, HUMIRA, OTEZLA, SKYRIZI, STELARA SC, TREMFYA

Drug Class

Nonpreferred Medications

Preferred Alternatives

INFLAMMATORY CONDITIONS

All other Brand Name medications for Inflammatory Conditions are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred medications is required prior to initiating therapy with a Nonpreferred medication. A formulary exception may be granted for patients already established on therapy with a Nonpreferred medication.

ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, RINVOQ ER, SIMPONI 100 MG (FOR ULCERATIVE COLITIS ONLY), SKYRIZI, STELARA SC, TREMFYA, XELJANZ, XELJANZ XR

Please note that product placement for treatment for Inflammatory Conditions are subject to change throughout the year based upon changes in market dynamics, new indications for existing products, biosimilar and new product launches.

~ Due to Covid-19, medications will be excluded for patients new to therapy only beginning on 07/01/2020.

? 2020 Express Scripts. All Rights Reserved. All trademarks are the property of their respective owners.

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334293 DL44109Q-OE-20 (04/01/2020)

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