Excluded Drug List. Drug Class Excluded Product Clinical Alternative(s) ABSORICA ONEXTON GEL ANDRODERM FORTESTA VOGELXO BRINTELLIX DESVENLAFAXINE ER

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1 Value Formulary Excluded Drug List Catamaran offers diverse formulary alternatives that help our clients select what works best for them. The Value Formulary is a partially-closed formulary that excludes coverage of brand-name drugs that offer no clear clinical advantage over less-costly brand or generic alternatives. New drugs are immediately added as excluded on the Value Formulary until reviewed. Once reviewed, if it has been determined that they should be maintained on this list, then these new drugs along with their alternatives will be added to this list at that time. Drug Class Excluded Product Clinical Alternative(s) ACNE TREATMENTS ANDROGENS ABSORICA ONEXTON GEL VELTIN ANDRODERM AVEED FORTESTA TESTIM VOGELXO AMNESTEEM, CLARAVIS, MYORISAN, ZENATANE clindamycin/benzoyl peroxide, tretinoin gel, ZIANA ANDROGEL, AXIRON ANTICOAGULANTS PRADAXA XARELTO, ELIQUIS ANTICONVULSANTS LAMICTAL ODT lamotrigine BRINTELLIX ANTIDEPRESSANTS DESVENLAFAXINE ER KHEDEZLA FETZIMA FORFIVO XL VIIBRYD venlafaxine, PRISTIQ bupropion XL citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline ANTI-FUNGALS ORAL ORAVIG clotrimazole troches ANTI-FUNGALS TOPICAL NAFTIN clotrimazole, econazole, ketoconazole, miconazole, nystatin ANTI-GOUT TREATMENTS MITIGARE COLCRYS

2 ANTIHYPERLIPIDEMICS ANTIHYPERTENSIVES ANTI-MIGRAINE AGENTS ADVICOR ALTOPREV LESCOL XL LIVALO EDARBI EDARBYCLOR TEVETEN HCT EPANED ALSUMA AXERT FROVA SUMAVEL DOSEPRO TREXIMET ZOMIG NASAL SPRAY niacin ER AND lovastatin, SIMCOR lovastatin, fluvastatin, simvastatin, atorvastatin, CRESTOR irbesartan, losartan, BENICAR candesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, BENICAR HCT enalapril sumatriptan, naratriptan, rizatriptan, RELPAX ANTI-NAUSEA AGENTS ZUPLENZ ondansetron ANTI-PARASITIC AGENTS EURAX permethrin cream, malathion lotion BENIGN PROSTATIC HYPERPLASIA TREATMENTS BETA-2 ADRENERGIC AGONISTS JALYN MAXAIR AUTOHALER PROVENTIL HFA XOPENEX HFA VENTOLIN HFA tamsulosin, finasteride, RAPAFLO PROAIR HFA CONTRACEPTIVES QUARTETTE levonorgestrel/ethinyl estradiol (91-day) CORTICOSTEROIDS ORAL CORTICOSTEROIDS TOPICAL COUGH/COLD/ALLERGY RAYOS APEXICON E All single source brand cough and cold medications methylprednisolone; prednisolone; immediaterelease prednisone betamethasone dipropionate, diflorasone diacetate, fluocinonide Multiple generic cough and cold products

3 ACCU-CHEK BREEZE DIABETES TESTING SUPPLIES MONITORS AND TEST STRIPS DIABETES TREATMENTS INJECTABLE DIABETES TREATMENTS ORAL DIGESTIVE AIDS CONTOUR FREESTYLE PRECISION TRUETEST TRUETRACK APIDRA/APIDRA SOLOSTAR HUMALOG HUMULIN LEVEMIR/LEVEMIR FLEXPEN TANZEUM JENTADUETO KAZANO OSENI NESINA TRADJENTA GLUMETZA FARXIGA PANCREAZE PERTZYE ULTRESA ONETOUCH NOVOLOG NOVOLIN LANTUS BYDUREON, BYETTA, VICTOZA JANUMET, JANUMET XR, KOMBIGLYZE XR JANUVIA, ONGLYZA metformin INVOKANA CREON, PANCRELIPASE EPINEPHRINE AUTO INJECTORS ADRENACLICK EPIPEN, EPIPEN JR, AUVI-Q LEVITRA ERECTILE DYSFUNCTION TREATMENTS STENDRA STAXYN CIALIS, VIAGRA ESTROGENS DIVIGEL estradiol, VIVELLE-DOT, ALORA, EVAMIST FERTILITY TREATMENTS GROWTH HORMONES GONAL-F MENOPUR GENOTROPIN HUMATROPE OMNITROPE SAIZEN TEV-TROPIN FOLLISTIM AQ, BRAVELLE NUTROPIN, NUTROPIN AQ, NORDITROPIN

4 HEMATOPOIETICS HEPATITIS C TREATMENTS INFLAMMATORY BOWEL DISEASE TREATMENTS ARANESP EPOGEN OLYSIO VICTRELIS VIEKIRA PAK GIAZO APRISO PROCRIT HARVONI, SOVALDI balsalazide DELZICOL, PENTASA IMMUNOMODULATING AGENTS ZYCLARA imiquimod INHALED STEROID COMBOS INHALED STEROIDS ADVAIR DISKUS/HFA BREO ELLIPTA AEROSPAN ALVESCO FLOVENT DISKUS/HFA DULERA, SYMBICORT ASMANEX, PULMICORT FLEXHALER, QVAR LAXATIVES KRISTALOSE lactulose MULTIPLE SCLEROSIS TREATMENTS EXTAVIA BETASERON BECONASE AQ NASAL STEROIDS/ STEROID COMBOS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ORAL OMNARIS QNASL VERAMYST ZETONNA DUEXIS VIMOVO CAMBIA ZIPSOR flunisolide, fluticasone, triamcinolone acetonide, NASONEX ibuprofen AND famotidine omeprazole, pantoprazole, lansoprazole AND naproxen diclofenac NONSTEROIDAL ANTI-INFLAMMATORY DRUGS TOPICAL FLECTOR REXAPHENAC diclofenac, VOLTAREN gel

5 OPHTHALMIC/OTIC AGENTS OPIATE AGONISTS BETOPTIC S RESCULA ZIOPTAN AZASITE DUREZOL LASTACAFT CETRAXAL ABSTRAL FENTORA SUBSYS EXALGO KADIAN ZOHYDRO ER CONZIP betaxolol latanoprost, TRAVATAN Z erythromycin oint dexamethasone, prednisolone, ALREX, LOTEMAX azelastine, PATADAY, PATANOL ofloxacin otic fentanyl patch, fentanyl citrate oral transmucosal morphine sulfate ext-release, oxymorphone ext-release, NUCYNTA ER, OPANA ER, OXYCONTIN tramadol ER OPIOID DEPENDENCE TREATMENTS BUNAVAIL buprenorphine/naloxone BINOSTO OSTEOPOROSIS TREATMENTS PROTON-PUMP INHIBITORS RHEUMATOID ARTHRITIS TREATMENTS ACTONEL ATELVIA DEXILANT PREVACID SOLUTAB ZEGERID SUSPENSION ACTEMRA ENBREL KINERET ORENCIA OTEZLA REMICADE SIMPONI STELARA XELJANZ alendronate, ibandronate, FOSAMAX PLUS D omeprazole, lansoprazole, pantoprazole, NEXIUM HUMIRA, CIMZIA

6 BELSOMRA EDLUAR SEDATIVE HYPNOTICS INTERMEZZO SILENOR ZOLPIMIST zaleplon, zolpidem/cr SKELETAL MUSCLE RELAXANTS AMRIX cyclobenzaprine EUFLEXXA VISCOSUPPLEMENTS GEL-ONE HYALGAN SUPARTZ MONOVISC, ORTHOVISC, SYNVISC, SYNVISC ONE

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