bluechoice excluded drug list, effective february 1, 2021...cholecal df chorionic gonadotropin (#)...
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BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association.
Check your benefit information to verify coverage or view your personal benefit information on our website. This list may contain trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with your health plan. This list may change or expand from time to time without prior notice.
BlueChoice Drug Exclusions List – Effective 2/1/21 1
Drug Exclusions February 1, 2021
Why Doesn’t My Health Plan Cover Some Drugs? From time to time, our pharmacy committee decides to no longer cover, or exclude, some drugs because other safe, effective, less costly alternatives are available. The committee is composed of independent doctors and pharmacists who regularly review and compare prescription drugs to ensure the ones we cover include proven medications for treating the majority of medical conditions.
Newly-launched products and new variations of products already on the market are not automatically added to your health plan’s list of covered drugs, also known as a formulary. A product can be added to the formulary only if our pharmacy committee decides that it is clinically appropriate and cost-effective.
What Should I Do If My Drug Is Excluded? Talk to your doctor to see if a covered alternative drug is a good option for treating your condition. Note that many excluded brand-name drugs have covered generic alternatives.
Of course, you and your doctor make the final decision about the medications that are right for you. If your doctor believes no alternative drug will work for your medical condition, you or your doctor can request a formulary exception to have an excluded drug covered. Just follow these steps:
Providers To request a formulary exception for a drug noted on the list with a (+), call 877-440-0089. To request a formulary exception for all other listed drugs, call the precertification number on the member’s ID card.
Members To request a formulary exception for all drugs listed, call the Customer Service number on your ID card.
Note: Formulary exceptions can only be considered with required documentation from the member’s health care provider.
What Happens If I Have A Prescription Filled For An Excluded Drug? You will be able to get your drug, but you will pay the full cost of it.
What Drugs Are Excluded From Coverage? The drugs on the following pages are excluded from coverage as of the date of this list.
Your pharmacy benefit may not cover certain categories of drugs, such as those used to treat weight loss or sexual dysfunction. Please check your plan materials for details about coverage for a specific drug category.
BlueChoice Drug Exclusions List – Effective 2/1/21 2
Excluded Drug List
Specialty drugs are noted with a (#).
A Abilify (brand) Abilify Mycite Absorica/LD Acanya Aciphex Acnefree Acthrel (#) Acticlate (brand & gen.) Acuicyn Acyclovir 5% cream Aczone 5% (brand) Adagen (#) Adakveo (#) Adapalene-Benzoyl
Peroxide-Clindamycin Gel
Adapalene-Benzoyl Peroxide-Niacinamide Gel
Adderall (brand) Adhansia XR Adlyxin Admelog Adzenys XR Aemcolo Aerospan Afstyla (#) Airduo Ajovy Aklief Alavert Alcortin A Aldara (brand) Alevicyn Antipruritic/Plus Allegra/Allegra-D Allzital Aloquin Alora (brand) Altoprev (brand) Altreno Alvesco Alzair Amcinonide 0.1% cream
& ointment Ameluz Amphetamine ER Susp Amrix (brand) Amzeeq Andexxa (#) Androgel 1.62% (brand) Android-10 (brand) Antara (brand) Apadaz Aplenzin Apligraf (#) Aptensio XR (brand) Arakoda Arazlo Arestin Arikayce (#) Armonair Digihaler Armonair Respiclick Arymo ER Asacol HD (brand) Asceniv (#) Asmanex
Asparlas (#) Aspergillus Fumigatus Aspirin/Omeprazole Atacand/HCT (brand) Ativan (brand) Atopiclair Atralin Atrapro spray/gel/kit Aurstat Austedo (#) Auvi-Q Avar (brand) Aveed (brand) (#) Avenova Avsola (#) Azelex (brand) Azesco Azor (brand) Azelaic Acid-Niacinamide
Cream Azeschew
B Baclofen 5 mg Balcoltra Bafiertam (#) Baxdela Beau Rx Belbuca Benicar/HCT (brand) Bensal HP Benz Per-Clindamycin-
Niacinamide-Tretinoin Gel
Benzaclin (brand) Benzamycin (brand) Benzepro (brand) Benzocaine-Lidocaine-
Tetracaine Oint Benzhydrocodone/
Acetaminophen Benzonatate 150 mg Beovu (#) Betamethasone
Dipropionate-Minoxidil
Betapace/AF tablet Bevacizumab prefilled
syr. (#) Bevyxxa Biafine Bijuva Binosto (brand) Bionect Blenrep (#) Bocasal oral rinse Bonjesta Bortezemib (#) Botox Cosmetic (#) Bravelle (#) Breztri Aerosphere Brineura (#) Briviact Bromsite Brukinsa (#) Bryhali Budesonide/Formoterol
Bunavail (brand) Bupap (brand) Bupivacaine HCL Butalbital/APAP 50/300 Bynfezia Pen (#) Byvalson
C Cafergot tablet Calcipotriene-
Betamethasone Calcipotriene-Clobetasol
Propionate Caldolor Cambia Candida Albicans Extract Caplyta Carac (brand & generic) Carbinoxamine 6 mg Cardizem CD/LA (brand) Carnitor/SF Carospir Carteolol Ophthalmic Celacyn Cequa Ceracade Cerave Cholecal DF Chorionic
Gonadotropin (#) Chlorzoxazone 250 mg,
375 mg & 750 mg Cicatrace Pad Ciclopirox-Clobetasol
Shampoo Ciclopirox-Clobetasol-
Salicylic Acid Shampoo Ciclopirox-Salicylic Acid
Shampoo Ciprofloxacin/Fluocinol
one Otic Cimetidine-Lidocaine-
Salicylic Acid Cream Cinqair (#) Clarinex/Clarinex-D Claritin/Claritin-D Clenpiq Clindagel Clindamycin Phos-
Niacinamide-Tretinoin Cream
Clindamycin Phosphate-Niacinamide Lotion 1-4%
Clindamycin Phosphate-Niacinamide Gel
Clindamycin-Benzoyl Peroxide-Niacinamide Gel
Clindamycin-Niacinamid-Spironolac-Tretinoin Gel
Clobetasol Propionate-Levocetirizine Dihyd Shampoo
Clobetasol Propionate-Niacinamide Cream/Oint/Soln
Colcrys (brand) Conjupri Consensi Conzip (brand) Cordran Cortaid max. strength Cotempla Crysvita (#) Cuprimine (#) Cutaquig (#) Cuvitru (#) Cyclobenzaprine ext rel Cyfolex Cymbalta (brand) Cystadane (#) Cystadrops (#) Cytomel (brand)
D D.H.E. (brand) Daklinza (#) Dandelion Allergenic Ext. Danyelza (#) Dapsone-Niacinamide
Gel Dapsone-Niacinamide-
Spironolactone Gel Daxbia Dayvigo Defitelio (#) Deflux Delstrigo Denavir Dermatop (brand) Desloratadine Desowen Dexchlorpheniramine syr. Dexeryl Dexilant Dexpak Dextenza (#) Dexycu Diclegis (brand and gen.) Diclofenac caps Diclofenac Sodium-
Sodium Hyaluronate-Niacinamide Gel
Diclofono Diflorasone cream and
oint. Dihydroergotamine
spray Dimercaptopropane-
Sulfonate Diuril Divigel (brand) Doptelet (#) Doryx/MPC (brand) Doxepin cream/tabs Doxycycline DR 80mg Doxycycline
Monohydrate cap 75mg
Drizalma
Duaklir Duexis Duobrii Dutoprol Duzallo Dxevo Dyanavel XR (brand) Dyrenium capsule
E Econazole Nitrate-
Niacinamide Cream Edecrin (brand) Edex EES granules Effexor XR (brand) Efudex (brand) Elestrin (brand) Eletone Emflaza (#) Endari Enspryng (#) Enstilar Entty Spray Emulsion Envarsus XR (#) Epaned (brand) Epiceram Epicoccum Nigrum EpiPen/EpiPen Jr.
(brand) EryPed susp. 200 & 400
mg Esomeprazole Esperoct (#) esterified estrogen/
methyl-testosterone Eucrisa Eurax lotion Evekeo/ODT (brand) Evenity (#) Evivo Evomela (#) Evrysdi (#) Exondys 51 (#) Ezallor
F Fasenra (#) Fenoglide (brand) fenoprofen (generic) Fenortho (brand) Fetroja Fexofenadine fexofenadine-
pseudoephedrine Finasteride-Minoxidil Firdapse (#) First Atenolol susp. First-Lansoprazole
(excluded only for members 17 years and older)
First-Omeprazole (excluded only for members 17 years and older)
Flolipid
BlueChoice Drug Exclusions List – Effective 2/1/21 3
Fluconazole-Ibuprofen-Itraconazole-Terbinafine
Fluocinolone Acetonide-Niacinamide Cream
Fluocinonide 0.1% cream
Fluorouracil cream 0.5% Fluoroplex (brand) Fluticasone/salmeterol
inhaler Folene Folika-V Folite Folvite-FE Forfivo XL (brand) Fortamet (brand & gen.) Fulphila (#) Fungoid-D
G Gamifant (#) Gatifloxacin
dexamethasone Gavreto (#) Gelclair Gel Genadur Genvisc (#) Giazo (brand) Gimoti Gloperba Glumetza (brand &
generic) Glycopyrrolate 1.5mg Gocovri GPL Pak Gralise (brand) Grastek Gvoke PFS
H Halcinonide cream 0.1% Halog Hemady Hemlibra (#) Herzuma (#) Horizant (brand) HPR Plus HPR Plus MB Hydrogel
Kit Hyaluronate Sodium-
Niacinamide-Tacrolimus
Hyaluronate Sodium-Niacinamide-Tretinoin
Hycofenix (brand) Hydrisalic Hydrocodone 2.5mg/
guaifenesin 200mg hydrocortisone 1% in
asorbase Hydroquinone
Emulsion Hydroquinone-
Hydrocortisone Emulsion
Hydroquinone-Hydrocortisone-Tretinoin Emulsion
Hylatopic Plus Hymovis (#) Hyperhep B (#) Hyperrab (#) Hyperrab S/D (#)
I IBU 600-EZS Idelvion (#) Idhifa (#) Ilumya (#) Iluvien (#) imiquimod cream 3.75% Imiquimod-
Levocetirizine Dihcl-Niacinamide Gel
Imiquimod-Levocetirizine Dihcl-Tretinoin Gel
Imitrex (brand) Imlygic (#) Imogam (#) Impoyz Imvexxy Inbrija (#) Inderal LA/XL Indocin caps./supp./
susp. Indomethacin Infugem (#) Ingrezza (#) Innopran XL Inqovi (#) Inrebic (#) Intrarosa Intuniv (brand) Inveltys Iodoquinol-
Hydrocortisone-Ketoconazole Cream
Ionil liquid Ipamorelin Acetate (#) Isturisa (#) Ivermectin-
Metronidazole-Niacinamide Gel
J Jatenzo Jelmyto (#) Jivi (#) Jornay PM Jublia Juluca
K Kadian (brand) Kamdoy Kanjinti (#) Kapspargo Katerzia Kedrab (#) Kelarx (silicone) Scar
Care Gel Keramatrix Kerydin Kesimpta (#) Ketoconazole 2% foam Ketoconazole-
Hydrocortisone Cream
Ketamine HCL Ketodan Ketorolac spray Keveyis (#) Khapzory (#) Kinerase Klor-Con oral pack for
solution Kovaltry (#) Krintafel Kristalose pak Krystexxa (#) Kymriah (#)
L Lactinol HX Lactic Acid-Niacinamide
Cream Lactulose oral packet
10gm Lanoxin 125 & 250 mcg
tablet Lansoprazole Lazanda Ledipasvir/Sofosbuvir (#) Levicyn dermal spray Levitra Levorphanol Levulan Kerastik
(brand) Lexapro (brand) Lexette Lialda (brand) Librax (brand) Libtayo (#) Licart Lidocaine-Tetracaine
Cream Lidocaine cream 4.12% Lidoderm (brand) Lidotrex (lidocaine)
2% gel Lipofen (brand) Locoid (brand) Lodrane D Lokelma Lonhala Loprox (brand) Loyon Lucemyra Lumoxiti (#) Lunesta (brand) Luradrox gel Lutathera (#) Luxturna (#) Luzu Lyrica CR Lyumjev
M Macrilen (#) Macrodantin capsules Mavenclad (#) Mayzent (#) Mepsevii (#) Metformin ER (only
excluded when prescribed as a generic for brand Fortamet or brand Glumetza)
Methionine-Inos-Choline-Levocarn
Methylcobala Methylphenidate 72 mg
ER Miacalcin injection/
nasal spray Micort Microvix LP Midaz/ketamine troche/
ondansetron Midazolam Migranal (brand) Millipred/DP Minastrin 24 FE (brand) Minitran (brand) Minivelle (brand) Minocin (brand) Minocycline ER caps Minolira ER Minoxidil-Progesterone-
Tretinoin Mircera (#) Mitigare (brand) Mitomycin (#) Monodox (brand) Mondoxyne (brand) Monjuvi (#) Morgidox (brand) Morphabond ER Moxatag (brand) Mugard Mulpleta (#) Mupirocincream Mvasi (#) Mycapssa (#) Mydayis Mylotarg (#)
N Nabi-HB (#) Nalfon (brand) Nandrolone decanoate Naprosyn susp. 125 mg/
5 mL (brand) naproxen/
esomeprazole Naproxen sodium ER
(generic Naprelan) Nascobal Nasonex (brand) Nayzilam Neocera Neosalus/CP Neutrasal Nevestym Nexium Niacin (generic) tab
500mg Niacinamide-
Spironolactone Gel Niacinamide-
Spironolactone-Tretinoin Gel
Niacinamide-Sulfacetamide Sodium
Niacinamide-Tacrolimus Oint
Niacinamide-Triamcinolone Acetonide Cream
Niacinamide-Tazarotene Cream
Niacinamide-Tretinoin Cream/Gel
Niacinamide-Spironolactone-Tretinoin Gel
Niacor Nilandron (#) Nilutamide (#) Nitro-Dur (brand) Nitroglycerin lingual
(brand) Nitrolingual Nitromist Nityr (#) Nivatopic Plus Nocdurna (#) Noctiva (#) Noritate Nourianz Novacort Novolin Relion Nucala (#) Nuplazid (#) Nurtec ODT Nutraderm Nutraplus Nutraseb Nuvail Nuvigil (brand) Nuwiq (#) Nuzyra Nyvepria (#)
O Ocaliva (#) Ocean for Kids Odactra Ogivri (#) Olumiant (#) omeprazole (OTC only) omeprazole/sodium
bicarbonate Onexton Onpattro (#) Ontruzant (#) Onureg (#) Onzetra Opana ER Oracea (both brand &
generic doxycycline (Rosacea) delayed release capsules are excluded)
Orafate (#) Oravig Orladeyo (#) Ortikos Osmolex ER Otiprio Otovel Ovace Plus/Wash (brand) Oxbryta (#) Oxervate (#) Oxlumo (#) Oxtellar XR (brand) Ozobax
P Palforzia (#)
BlueChoice Drug Exclusions List – Effective 2/1/21 4
Palynziq (#) Panhematin (#) Panzyga (#) Parsabiv (#) Pennsaid 1.5% & 2% sol. Pepcid (brand) Pexeva (brand) Phenobarbital/Belladonna
Alkaloids Phenol Pifeltro Piqray (#) Plaquenil (brand) Plavix (brand) Plenvu Plexion/Cleanser (brand) Pliaglis cream Polivy (#) Portrazza (#) Praluent Pred-Gati Prednisone Intensol
(brand) Pregenna Prenara Prenatal 19 Pretomanid Prevacid Prevymis (#) Prilopentin Prilosec Primlev Pristiq (brand) Probuphine Procentra (brand) Progesterone-Minoxidil Prolate Prolensa Promiseb Protexa Prothelial(#) Protonix Proventil HFA Provigil (brand) Prozac (brand) Pulmicort Respules
(brand) Pyridostigmine tablet
30mg Pyridoxal-5 Phosphate Pyrimethamine-
Leucovorin
Q Qbrexza pad Qmiiz ODT Qtern Quartette (brand) Qudexy XR (brand) Quillichew ER (brand) Quillivant XR (brand) Qutenza (#) Quzyttir
R Rabeprazole Ragwitek Rayaldee Rayos (brand) Rebinyn (#)
Reblozyl Recarbrio Recedo Red Algae Relafen DS Relexxii Relistor injection/
tablets Remedient Remodulin (#) Renflexis (#) Resveratrol Retacrit (#) Retisert (#) Retin-A/Micro (brand) Revcovi (#) Revesta Reyvow Rexaphenac (brand) Rhofade cream Rhopressa Riomet ER Rocklatan Romidepsin (#) Roxybond Rozlytrek (#) Ruxience (#) Ruzurgi (#) Rynoderm
S S2 Salex (brand) Salicylic Acid-Sulfaceta-
mide Sodium Salisol Salivamax Samsca Scarcin Gel Scarsilk gel/pad Scenesse (#) Sebuderm Secuado Segluromet selenium sulfide
shampoo 2.25% Semglee Sernivo Seroquel/XR (brand) Sevenfact (#) Seysara Siklos (#) Silenor (brand) Siliq (#) Sil-K Pad Simvastatin Singulair (brand) Sitavig Sitzmarks Sodium Hyaluronate-
Hydroquinone Emulsion
Sofosbuvir/Velpatasvir (#) Solaravix Solaraze (brand) Solesta (#) Soliqua Solodyn Solosec Sovaldi (#)
Spinraza (#) Spravato (#) Sprix (brand) Staxyn Steglatro Steglujan Stendra Strattera (brand) Striant (brand) Sublocade (#) Sumadan wash (brand) Sumaxin (brand) Sunosi Symdeko (#) Symjepi Sympazan Symproic Symtuza Synderderm Syndros Synera (brand) Syprine (#)
T Taclonex Tacrolimus Cream Takhzyro (#) Talicia Targadox (brand) Targretin (#) Tasigna (#) Tavalisse (#) Taytulla cap 1 mg/20 mc Tecartus (#) Tegsedi (#) Tepezza (#) Teriparatide (#) Testopel (brand) Tetravex gel Tetrix Thiola EC (#) Thrombate III (#) Tiazac (brand) Tibsovo (#) Ticalast Tiglutik (#) Tirosint capsule/sol. Tivorbex (brand) Tobi solution (brand) (#) Tolak (brand) Tolsura Topicort Spray Tosymra Trazimera (#) Treprostinil (#) Treximet (brand) Trezix (brand) Trianex oint. 0.05%
(brand) Tridesilon (brand) Triglide (brand) Trijardy XR Trimo-San gel Trinaz Triptodur (#) Trivisc (#) Trogarzo (#) Trokendi XR Tronvite Trop-Phenyl
Trulance Truxima (#) Turalio (#) Tussicaps (brand) Tuxarin ER Twirla Tymlos (#)
U Ubrelvy Udenyca (#) Ultomiris (#) Ultravate lotion Uplizna Upneeq Uplizna (#) Uroxatral tablet Utibron Neohaler
V Vabomere Valium (brand) Valtoco Valtrex (brand) Vanatol LQ (brand) Vanos (brand) Vanoxide-HC lotion Varizig Varubi Vaseretic (brand) Vasotec (brand) Veltassa (#) Vemlidy (#) Ventavis (#) Ventolin HFA Verdeso foam 0.05%
(brand) Veregen ointment Vexasyn gel Vibramycin (brand) Viekira Pak/XR (#) Viltepso (#) Vimovo Visco-3 (#) Visbiome Vitafol strips Vitafol FE Vitasure Vitrase Vivlodex Vizimpro (#) Voltaren gel (brand) Vonvendi (#) Vosol HC VP-Vite Rx VSL#3 Vtol LQ Vumerity (#) Vyepti Vyleesi Vyndaqel (#) Vyndamax (#) Vyondys 53 (#) Vytorin (brand) Vyxeos (#) Vyzulta
W Wakix Wellbutrin SR/XL (brand)
Wixela Inhub
X Xadago Xanax/XR (brand) Xaquil XR Xatmep (#) Xelpros Xembify (#) Xenazine (brand) (#) Xenleta Xepi Xerese Xhance Ximino Xofluza Xopenex HFA Xpovio Pak (#) Xtampza ER Xultophy Xuriden (#) Xvite Xyosted Xywav (#)
Y Ybuphen Yescarta (#) Yonsa (#) Yosprala Yupelri Yutiq (#)
Z Zalvit Zavara Zegerid (brand & generic) Zelac Zembrace Zenzedi (brand) Zepatier (#) ZEPOSIA (#) Zerviate Zetia (brand) Ziana (brand) Ziextenzo (#) Zilretta (#) Zilxi Zinc Sulfate Zinplava Zipsor (brand) Zirabev (#) Zofran/ODT (brand) Zolgensma (#) Zoloft (brand) Zolpimist Zonegran 25 & 100 mg
caps Zorvolex (brand) Zovirax Zuplenz (brand) Zurampic Zyclara Zyflo CR (brand) Zypitamag Zyrtec/Zyrtec-D
BlueChoice Drug Exclusions List – Effective 2/1/21 5
Generics Excluded from Certain Manufacturers
These generic drugs are excluded from coverage only when produced by certain manufacturers, but can be available from alternate sources — consult your pharmacist for more information.
acetic acid/alum acetate
albuterol sulfate anusol-hc atropine sulfate bacitracin/neomycin/
polymyxin bacitracin/polymyxin b brimonidine tartrate carteolol hcl
castellani paint cormax scalp
application cromolyn sodium cyclopentolate hcl dorzolamide hcl/
timolol m flunisolide flurbiprofen sodium latanaprost
levobunolol hcl neomycin/polymyxin/
dexamethasone neomycin/polymyxin/
gramicidin opium pedi-boro soak pads pedi-dry phenylephrine hcl podofilox
polymycin b sulfate/ trimethoprim
proparacaine hcl salactic film sal-plant sulfacetamide sodium sulfacetamide sodium/
prednisolone sulfacetamide sodium/
sulfur
tetracaine hcl timolol maleate
ophthalmic tobramycin/
dexamethasone tropazone tropicamide ureacin
Excluded Compound Bases, Bulk Powders & Compound Kits
This list contains many ingredients that are not covered under your prescription benefit coverage when included in certain bases and bulk powders used in compounded drugs, as well as compound kits. Please note that this list is not comprehensive; other compound ingredients are also excluded.
0-9
2-Deoxy-D-Glucose 5-Fluorouracil 5-Methyltetra-
Hydrofolate 5-Methyltetra-
Hydrofolic A 7-Keto DHEA
A
Acacia Acetone Acetyl Hexapeptide-8 Acidophilus
Lactobacillus Albendazole Almond oil, sweet Alprostadil Amitriptyline HCL Amphotericin B Apple flavor Arbem H-Cosmetic Ascorbic Acid Aspirin Auxipro Plasticized Avicel Ph 105
Microcrysta Azithromycin
B
Baclofen Bacteriostatic Water Banana creme flavor Base C Polyethyl-Ene
Glyco Base cream with
Liposome Base gelatin Gummy
Troche
Base X Base-Pcca Mbk (Fatty
Acid) Beclomethasone
Dipropiona Benzocaine Benzoin compound
tincture Benzyl alcohol Betahistine HCL/
Dihydrochlori Betamethasone Sodium
Phos Bethanechol Chloride BHRT base Biotin Bitter drug powder Boric Acid Bromfenac Sodium Budesonide Bupropion HCL
C
Cannabidiol Capsublend-P Capsule Clear Veggie Lo
(All) Capsule Coni-Snap (All) Carboxymethylcellu-
lose So Carnitine (L) Celecoxib Cellulose Microcrystallin Cellulose/Cmc Na
Microcry Cetaphil moisturizing
cream Cetyl Myristoleate Cherry syrup
Chloramphenicol Cholesterol Chorionic Gonadotropin Chrysaderm Day Cimetidine Ciprofloxacin HCL Citric Acid Anhydrous Clindamycin HCL/
Monohydra Clindamycin Phosphate Clobetasol Propionate/
Micronized Clotrimazole Coal Tar Cocaine HCL Cocoa butter Coenzyme Q10 Copasil Corn oil Curcumin Cyanocobalamin Cyclobenzaprine HCL
D
Dehydroepiandroster-one
Dermabase Dexamethasone/
Acetate Anh/Sodium Phos
Diazepam Dichloralphen-Azone Diclofenac Sodium Diltiazem HCL Dimercapto-1-
Propanesulfo Dimercaptosucc-Inic
Acid Dimethyl Sulfoxide
Doxepin HCL Doxycycline Hyclate Drcaps size 1 clear
E
Edetate Disodium Dihydrat
EGCG Emollient cream/base Empty capsule, all sizes
& colors Emu oil Erythromycin
Ethylsuccina Estradiol/Micronized/
Valerate Estriol/Micronized Ethoxy Diglycol Ethyl Alcohol Ethyl Oleate
F
Fagron Capfill Pro/ Dispersapro/ Supreme cream
Fattibase Fattyblend Ferulic Acid First-Baclofen 5 First-Dukes mouthwash First-Lansoprazole First-Metronida-Zole 50 First-Mouthwash Blm First-Omeprazole First-Progester-One Vgs
10/ 20/50 First-Testosterone/Mc First-Vancomycin 25/50 Flavor blend
Flavor Plus Flavor Sweet-SF Fluconazole Fluocinonide Fluorouracil Flurbiprofen F-Melt Freedom Derma-N Freedom Poloxitol
G
Gabapentin Gentamicin Sulfate Glutamine Glutathione-L Glycerin Glycolic Acid Glycopyrrolate Grape flavor Guaifenesin Gum base gelatin
H
Hormone cream base Botani
Hrt base (All) Hrt Natural/Supreme
cream base Hyaluronic Acid Sodium Sa Hydrocodone Bitartrate Hydrocortisone/
Acetate/ Micronized Hydrogel Hydromorphone HCL Hydroquinone Hydroxyethyl Cellulose
45 Hydroxyprogester-One
Capro
BlueChoice Drug Exclusions List – Effective 2/1/21 6
Hydroxypropyl Cellulose 1/ Methylcellu
Hydroxyurea Hypromellose
Methocel K1
I
Ibuprofen Imiquimod Isometheptene Mucate Itraconazole Ivermectin
J
N/A
K
Ketamine HCL Ketoconazole Ketoprofen/Micronized/
Ultra Micronized Ketotifen Hydrogen
Fumara Kinetin
L
Lactic Acid Lactose/Anhydrous Lactose Monohydrate/
spray Lanolin Anhydrous Lansoprazole L-Arginine Leucovorin Calcium Leuprolide Acetate Levofloxacin
Hemihydrate L-Glutamine Lidocaine/HCL Liothyronine Sodium Lipmax Lipopen/Absorption
Enhanc Lipopen Ultra/base L-Methylfolate Calcium Lollibase Lollipop base Lorazepam Loxoral base Lozibase S L-Thyroxine Sodium Lugols
M
Magnesium Glycinate Mannitol
Marshmallow flavor Mediderm Medi-Rdt base Medium Chain
Triglyceride Melatonin Mercaptopurine
Monohydrat Metformin HCL Methocel E4m Premium Methscopolamine
Bromide Methylcellulose Methylcobalamin Methyltestosterone Metoprolol Tartrate Metronidazole/
Benzoate Miconazole/Nitrate Midazolam Mineral oil light Mometasone Furoate Morphine Sulfate Mucolox Mupirocin
N
Nabumetone Naltrexone HCL/
Anhydrous Natapres Niacinamide Nifedipine Nourivan Antiox cream
base Nystatin/Foreign
O
Ointment base emulsifying
Olive oil Omeprazole Ondansetron HCL
Dihydrate Ora-Blend/SF Oral mix flavored susp. Oral suspension Ora-Plus Ora-Sweet/SF Oxycodone HCL Oxytocin
P
Palmitoyl Pentapeptide-3
Papaverine HCL
Paraffin PCCA Anhydrous
Lipoderm B PCCA cosmetic HRT base PCCA custom Lipo-Max PCCA DMAE complex PCCA emollient cream
base PCCA Emulsifix-205 base PCCA fixed oil base PCCA gelatin base PCCA Lecithin Isopropyl
P PCCA Lipoderm base/
HMW PCCA Loxasperse base PCCA Natacream PCCA plasticized base PCCA Pluronic F127
base PCCA Polyglycol Troche PCCA Pracasil Tm-Plus
base PCCA rapid-dissolve
tablets PCCA Sorbitol lollipop
base PCCA Spira-wash base PCCA Sweet-SF PCCA syrup vehicle PCCA T3 Sodium Dilution PCCA T4 Sodium
Dilution PCCA vanishing cream/
light/ lotion PCCA Vanpen base PCCA Xylifos base PCCA -Plus Penderm Pentravan/Plus Peppermint oil Phentermine
Hydrochloride Phentolamine Mesylate Phytobase Plo Gel – Mediflo pre-
mix Pluronic F127 Polox Polyethylene
Glycol/blend/ 300/400/1450/3350
Polypeg suppository base
Povidone-Iodine Praziquantel
Pregnenolone/ micronized
Prilocaine HCL Progesterone/Microniz
ed/Ultra Micronized Progesterone wettable Promethazine HCL Propylene Glycol Prostaglandin E1 Purified water Pyrantel Pamoate Pyridoxal-5-Phosphate
Mon
Q
Quinacrine HCL Quinine Sulfate
Dihydrate
R
Ranitidine HCL Resveratrol 98%
S
Salicylic Acid Salt durable cream Salt Stable Lo/Ls
Advanced Sermorelin Acetate Sesame oil Sildenafil Citrate Silica gel Simethicone Simple syrup Sirolimus Sodium Bicarbonate Sodium Chloride/
Bacterios Sodium Hyaluronate Sodium Metabisulfite Solu-K gel Sorbitol Spg Supposi-Base Spironolactone Sterile water for
injection Stevia extract Steviol Glycosides Succimer DMSA Sucralfate Sulfacetamide Sodium Sulfadiazine Sulfamethoxazole Sulfapyridine Supposibase F Suspendit
Synapsin Syrspend SF/Alka
T
Tamoxifen Citrate Tea tree oil Terbinafine HCL Testosterone/
Cypionate Testosterone
micronized/S/Y Testosterone non-
micronized Testosterone
Propionate Tetracaine/HCL Tetracycline HCL Thymol Thyroid Porcine Tobramycin/Sulfate Tofacitinib Citrate Topiramate Tramadol HCL Transdermal pain base Tretinoin Triamcinolone
Acetonide Troche base Tutti Frutti flavor
U
Ubiquinol Ursodiol
V
Vancomycin HCL Verapamil HCL Versabase/foam Versapro Versatile cream base
W
Watermelon flavor Wax paraffin beads White Petrolatum Wiley Basic Elements
BHRT Witepsol H15/Base F
X
Xylitol
Y
Yellow Petrolatum
Z
N/A
BlueChoice Drug Exclusions List – Effective 2/1/21 7
Topical Pain Formulations
Excluded Product Categories and Examples Camphomex (CAMPHOR-HISTAMINE-MENTHOL-LIQUID SPRAY) Lidocaine HCL cream/lotion 3% Lidocin (LIDOCAINE HCL GEL) Lidorx (LIDOCAINE HCL GEL) Lidovex (lidocaine cream) Livixil Pak (lidocaine-prilocaine kit) Medi-Derm/L-RX (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL
SALICYLATE CREAM) Medi-Derm-RX (CAPSAICIN-MENTHOL-METHYL SALICYLATE CREAM) Mentholix (LIDOCAINE-MENTHOL LIQUID SPRAY) Silmanix Pain Relieving (CAPSAICIN-MENTHOL-HISTAMINE
CREAM) Tetramex (TETRACAINE-MENTHOL-CAMPHOR LIQUID SPRAY)
Formulary Alternatives • OTC Capsaicin patches, cream, gel
• Lidoderm or generic Lidocaine 5% patches
• Lidocaine 5% ointment
• Lidocaine 2% gel
• Voltaren 1% gel
• Generic Diclofenac 1.5% solution
Topical Pain Patches
Excluded Product Categories and Examples Anodynerx (CAPSAICIN-LIDOCAINE-MENTHOL) Atendia (LIDOCAINE-MENTHOL) Captracin (CAPSAICIN-MENTHOL) Levatio patch (CAPSAICIN-MENTHOL) Lidenza (LIDOCAINE-MENTHOL) Medi-patch (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL SALICYLATE) Menthocin/Lidocaine (LIDOCAINE-CAPSAICIN-MENTHOL-METHYL
SALICYLATE) Qroxin (CAPSAICIN-MENTHOL) Reciphexamin (LIDOCAINE-MENTHOL) Relyyks (LIDOCAINE-MENTHOL) Relyyt (CAPSAICIN-MENTHOL) Renovo (CAPSAICIN-MENTHOL) Sinelee (CAPSAICIN-MENTHOL) Solaice (CAPSAICIN-MENTHOL) Synvexia (LIDOCAINE-MENTHOL) Velma Pain Relief (METHYL SALICYLATE-LIDOCAINE-MENTHOL)
Formulary Alternatives • OTC Capsaicin patches
• Lidoderm or generic Lidocaine 5% patches
Ear Pain Formulations and Combinations
Excluded Product Categories and Examples Antipyrine/Benzocaine Otic (Generic) Cortane B-Otic (PRAMOXINE-HC-CHLOROXYLENOL OTIC SOLUTION) Otic Care (ANTIPYRINE-BENZOCAINE-POLYCOSANOL OTIC SOLUTION) Oticin drops (CHLOROXYLENOL-PRAMOXINE) Oto-End 10 solution (CHLOROXYLENOL-PRAMOXINE-
HYDROCORTISONE) Otozin drops (BENZOCAINE-ANTIPYRINE-ZINC ACETATE) Pinnacaine 20% Drops (BENZOCAINE)
Formulary Alternatives • Dexamethasone otic
• Pediotic
• Neomycin/polymyxin/hydrocortisone otic
• Acetic acid/hydrocortisone
• Ciprodex
• Cipro otic
• Cortisporin
BlueChoice Drug Exclusions List – Effective 2/1/21 8
Scar Products
Excluded Product Categories and Examples Renuu (ALLANTOIN-LIDOCAINE-PETROLATUM) Scar patch (ALLANTOIN-LIDOCAINE-PETROLATUM)
Formulary Alternatives • Lidoderm or generic Lidocaine 5% patches
• Lidocaine 5% ointment
• Lidocaine 2% gel
• Miscellaneous emollients (petrolatum, lanolin, glycerin, mineral oil, aloe vera, dimethicone)
Convenience Multi-Product Kits
Excluded Product Categories and Examples Active-Medicated specimen (URINE SPECIMEN COLLECTION KIT) Active-PAC/Gabapentin (GABAPENTIN CAPS, LENZAGEL
[LIDOCAINE-MENTHOL]) Advanced DNA Medicated CO (DNA COLLECTION PRODUCT KIT) Analpram Advanced (HC-PRAMOXINE CREAM, DIET MANAGE
PROD TAB, CLEAN WIPE KIT) Bupivilog kit (TRIAMCINOLONE INJECTION, BUPIVACAINE HCL
INJECTION KIT) DermacinRX Inflammatral Pak (DICLOFENAC DELAYED-RELEASE
TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) DermacinRX Kit Silapak (TRIAMCINOLONE ACET CREAM,
DIMETHICONE CREAM, SILICONE TAPE) DermacinRX Lexitral (DICLOFENAC SOLUTION, CAPSAICIN CREAM) DermacinRX surgical (CHLORHEXIDINE GLUCONATE 4%
SOLUTION) DermacinRX Ticanase Pak (FLUTICASONE NASAL SUSPENSION,
SODIUM CHLORIDE SPRAY) Derma SilkRX Anodynexa Pak (DICLOFENAC DELAYED-RELEASE
TABLETS, RANITIDINE TABLETS, CAPSAICIN CREAM) Derma SilkRX Diclopak (DICLOFENAC DELAYED-RELEASE TABLETS,
CAPSAICIN CREAM) Derma SilkRX SDS Pak (TRIAMCINOLONE CREAM, DIMETHICONE,
SILICONE TAPE) DermaWerx Surgical Plus P (CHLORHEXIDINE SOL 4%-
MUPIROCIN, DIMETHICONE, TAPE KIT) DNA collection kit (LIDOCAINE ORAL SOLUTION, GLYCERIN SWAB,
BUCCAL SWAB) Genadur kit (DERMATOLOGICAL PRODUCTS MISC TOPICAL/ORAL –
KIT) Inflammacin (DICLOFENAC SODIUM, CAPSAICIN CREAM THERA
PACK) Morgidox (DOXYCYCLINE HYCLATE CAPSULES WITH CLEANSER KIT) SanadermRX Skin Repair (TRIAMCINOLONE ACET CREAM,
DIMETHICONE CREAM, SILICONE TAPE) Silazone PharmaPak (TRIAMCINOLONE ACET CREAM, SILICONE
SHEET PACK)
Formulary Alternatives • OTC Capsaicin patches, cream, gel
• Lidoderm or generic Lidocaine 5% patches
• Lidocaine 5% ointment
• Lidocaine 2% gel
• Lidocaine 2% or 4% solution
• Voltaren 1% gel
• Generic Diclofenac 1.5% solution
• Generic topical steroids – alclomethasone, betamethasone, clobetasol, desonide, fluocinoline, fluocinonide, fluticasone, halobetasol, mometasone, triamcinolone
• Chlorhexidine gluconate solution
Rvs 3/13/2017 1 19199-‐3-‐2017
Rvs 3/13/2017 2 19199-‐3-‐2017