Specialty Clinical Consultation List
August 10, 2023Performance Formulary Step Therapy
August 10, 2023The following medications are excluded from your prescription benefit plan and have lower-cost brand name alternatives available.
| ACANYA | CLIN SINGLE USE KIT | ELETONE TWINPACK |
| ACTICLATE | CLINDACIN ETZ | ENTADFI |
| ACTIMARIS ALL-NATURAL WOU | CLINDACIN ETZ PLEDGETS | FENORTHO |
| ACTIVE-PAC/GABAPENTIN | CLINDACIN PAC | FLECTOR |
| ACTIVE-PREP KIT III | CLINDACIN-P | FLUOCINONIDE |
| ACUICYN ANTIMICROBIAL EY | CONSENSI | FOLAMAX |
| ACUICYN DAILY EYELID & EY | CONZIP | FOLIC-K |
| ADTHYZA | DAYAVITE | FOLVITE-D |
| ALEVEER | DEPRIZINE FUSEPAQ | FORFIVO XL |
| ALEVICYN DERMAL SPRAY | DERMA SILKRX ANODYNEXA PA | FORTAMET |
| ALLZITAL | DERMA SILKRX DICLOPAK | GLUMETZA |
| ALTRENO | DERMA SILKRX SDS PAK | GOCOVRI |
| ALTRENOGEST | DERMACINRX ANALGESIC COMB | GRALISE |
| AMLADEX | DERMACINRX AZENASE PAK | GRALISE STARTER |
| AMRIX | DERMACINRX DUOPATCH PHARM | HORIZANT |
| AQUORAL | DERMACINRX ETHOXY DIGLYCO | HPR |
| ARESTIN | DERMACINRX INFLAMMATRAL P | HPR PLUS |
| ATOPADERM | DERMACINRX LEXITRAL PHARM | HPR PLUS HYDROGEL KIT |
| ATOPICLAIR | DERMACINRX NEUROTRAL PHAR | HPR PLUS/MB HYDROGEL |
| AUVI-Q | DERMACINRX PUREFOLIX | HYLATOPIC PLUS |
| AVENOVA | DERMACINRX SILAPAK | HYSINGLA ER |
| AVENOVA/NEUTROX | DERMACINRX SURGICAL COMBO | INOVA |
| AVIDOXY DK | DERMACINRX SURGICAL PHARM | INOVA 4/1 ACNE CONTROL TH |
| AZESCO | DERMACINRX TICANASE PAK | INOVA 8/2 ACNE CONTROL TH |
| BOCASAL | DERMACINRX TOPICAL SOLUTI | IRENKA |
| BUTALBITAL/ACETAMINOPHEN | DERMACINRX TSS BASE | KEYFOLIC |
| CALICYLIC | DEXERYL | LEVICYN DERMAL SPRAY |