Drug Exclusions List – Effective 7/1/17 1 Drug Exclusions July 1, 2017 These drugs are excluded from coverage as of the date of this list. We will update the list frequently, but it is subject to change at any time. 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. Specialty drugs are listed with a (#). Generic drugs listed with a (^) are excluded from coverage only when produced by certain manufacturers, but may be available from alternate sources — consult your pharmacist for more information. Formulary Exceptions Providers or members may request a formulary exception for any of the excluded drugs listed by following these steps: Providers To request a formulary exception for a drug noted with a (+), call 866-814-5506. To request a formulary exception for all other listed drugs, call the precertification number on the back of the member’s ID card. Members To request a formulary exception for all drugs listed, call the Customer Service number on the back of your ID card. Note: Formulary exceptions cannot be considered without required documentation from the member’s health care provider. Excluded Drug List Absorica Acanya acetic acid/aluminum acetate (^) Aciphex Acnefree Acticlate (and generic) Adlyxin Adzenys XR Aerospan Afstyla (#+) Airduo Alavert albuterol sulfate (^) Alcortin A Aldara (brand) Allegra/Allegra-D Allzital Aloquin Alunbrig (#) Alvesco Alzair Ameluz Android-10 (brand) antipyrine/benzocaine (^) anusol-hc (^) Aplenzin Arestin Arymo ER Ativan (brand) Atopiclair Atralin atropine sulfate (^) Aurstat Anti-Itch Gel Aurstat Kit Hydrogel Austedo (#+) Auvi-Q bacitracin/neomycin/ polymyxin (^) bacitracin/polymyxin b (^) Bavencio (#+) Belbuca Bensal HP Benzaclin (brand) Benzamycin (brand) Betapace/AF tablet Bevespi Biafine brimonidine tartrate (^) Brineura (#+) Briviact Bromsite Byvalson Cafergot tablet Cambia Carac (brand) Cardizem CD/LA (brand) Carnitor/SF carteolol hcl (^) castellani paint (^) Cerave Cinqair (#+) Clarinex/Clarinex-D Claritin/Claritin-D Clindagel cormax scalp application (^) Cortaid Max. Strength cromolyn sodium (^) Cuprimine Cuvitru (#) cyclopentolate hcl (^) Cyfolex D.H.E. (brand) Daklinza (#) Daxbia Defitelio (#) Deflux Dermatop (brand) Descovy Desloratadine dexamethasone sodium phosphate (^) Dexilant Dexpak Diuril dorzolamide hcl (^) dorzolamide hcl/timolol m (^) Doxepin Cream Duexis Dupixent (#) Dutoprol Dyrenium capsule Edecrin (brand) Edex EES granules Efudex (brand)
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Excluded Drug List - July 2017 - South Carolina Blues...Drug Exclusions List – Effective 7/1/17 1 Drug Exclusions July 1, 2017 These drugs are excluded from coverage as of the date
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Drug Exclusions List – Effective 7/1/17 1
Drug Exclusions July 1, 2017
These drugs are excluded from coverage as of the date of this list. We will update the list frequently, but it is subject to change at any time. 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.
Specialty drugs are listed with a (#). Generic drugs listed with a (^) are excluded from coverage only when produced by certain manufacturers, but may be available from alternate sources — consult your pharmacist for more information.
Formulary Exceptions Providers or members may request a formulary exception for any of the excluded drugs listed by following these steps:
Providers To request a formulary exception for a drug noted with a (+), call 866-814-5506. To request a formulary exception for all other listed drugs, call the precertification number on the back of the member’s ID card.
Members To request a formulary exception for all drugs listed, call the Customer Service number on the back of your ID card.
Note: Formulary exceptions cannot be considered without required documentation from the member’s health care provider.