Clinical Prior Authorization (CPA)
Prescription Management Program

Certain medications may be exlcuded from coverage under the OPEH&W Health Plan. Just because a medication is excluded under the OPEH&W Health Plan, it does not mean it cannot be filled, only that the OPEH&W Health Plan will not provide any assistance in meeting the cost.

Use the following links to access the Express Scripts (ESI) Formulary for each health coverage option:
   Diamond https://www.express-scripts.com/DIAMOND Link
   Platinum https://www.express-scripts.com/PLATINUM Link
   Gold https://www.express-scripts.com/GOLD Link
   Silver https://www.express-scripts.com/SILVER Link
   Bronze https://www.express-scripts.com/BRONZE Link
The OPEH&W Health Plan reserves the right to adjust this list from time to time as required
If in doubt, contact the Health Plan Administration Office to verify whether a covered medication is subject to Exclusion

Excluded Medications:
Acthar Gel
   》Except for Infantile Spasms in Children Aged 2 & 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
Dental Products such as:
   》Gels
   》Pastes
   》Fluorides (except those covered under the 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
Tobacco Cessation Products in the follow forms:
   》E-Cigarettes
   》Nasal Sprays
   》Inhalers
Male Condoms
Miscellaenous Items such as:
   》Band-Aids
   》Hosiery
   》Medical Devices
   》Ostomy Supplies
   》Splints
   》Surgical Supplies
   》Wraps
Multi-Source Brands which have an equivalent generic available such as:
   》Abilify
   》Benicar
   》Celebrex
   》Crestor
   》Diovan
   》Lipitor
   》Vytorin
   》Zetia
   》Nasal Sprays
Multi-Vitamins such as:
   》Mebolic
   》Niacor
   》Vasculera
   》Zyvit
   》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
Weight Loss Medications
Zohydro
Yospral