Exclusions
Prescription Management Program

Certain medications may be exlcuded from coverage under the Health Plan. Just because a medication is excluded under the Health Plan, it does not mean it cannot be filled. It just means that the Health Plan will not provide any assistance in meeting the cost of the medication.
 
The document link below provides a listing of the Express Scripts (ESI) National Preferred Formulary Exclusions and the Preferred Alternatives by drug class. The Health Plan may exclude additional medications not listed in the linked document, and reserves the right to adjust excluded medications from time to time as required. Contact the Health Plan Administration Office to verify whether a covered medication is subject to Exclusion.
 
Express Scripts (ESI) National Preferred Formulary Exclusions Listing
 
Impacted Medications
Acthar Gel except for infantile spasms for children aged 2 and under
Alcohol Swabs
Topical Androgens (Testosterone) such as Axiron
Antidepressant Drug - Pristiq
Anti-Fungal Nail Polishes such as Jubila, Kerydin & Penlac
AuviQ
Brand Sleep Hypnotics such as Belsomra, Ambien & Lunesta
Anti-Hemophiliac Drugs
Bulk Chemical Powders such as Fentanyl, Gabapentin, Ketamine & Baclofen
Combo Medications such as Vimovo & Duexis
Compounded Pain Kits
Cosmetic Agents such as hair growth, hair reduction, facial wrinkle agents such as Botox, bleaching agents, melanin stimulating agents, etc
Dental Products such as fluorides, gels and pastes except those fluorides covered under Patient Protection & Affordable Care Act
Dermatologicals such as Doxepin 5%, Prudoxin, Vanos 0.1%, & Zonolon External Cream Endari
Durlaza
Electrolyte Replacement
Erectile Dysfunction / Impotence Agents in ALL forms, such as Viagra & Caverject
Experimental / Investigational Drugs
Female Libido Drugs such as Addyi & Vyleesi
Gaucher's Disease Medications
Gralise
Horizant
Hysingla
Infertility Agents (Oral or Injectable)
Insulin Pumps covered under medical benefits
Microsomal Triglyceride Transfer Proteins such as Juxtapid & Kynamro
Kuvan
E-Cigarettes, Nasal Sprays or Inhalers used for Tobacco Cessations
Male Condoms
Multi-Source Brands (Brands that have an equivalent generic available) such as Abilify, Benicar, Celebrex, Crestor, Diovan, Lipitor, Vytorin or Zetia to name a few; generics are covered Multi-Vitamins such as Mebolic, Niacor, Vasculera, Zyvit or Xyzbac
Non-Sedating Antihistamines (Brand Names Only) such as Clarinex & Xyzal
Over-The-Counter (OTC) Medications except those specifically covered
Parkinson Drugs such as Azilect, Gocovri & Osmolex ER (amantadine is covered)
Passive Immunizing Agents such as Gammagard & Gamunex
Proton Pump Inhibitors (Brand Names) such as Dexilant & Nexium
Proton Pump Inhibitors (Generics) such as Omeprazole Sodium Bicarbonate
Restasis
Surgical Supplies, Medical Devices, Ostomy Supplies, Band-Aids, Splints, Wraps & Hosiery
Weight Loss Medications
Zohydro
Yospral