Medications Not Covered List
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Drugs that are Not Covered* (Medicinas que no están cubiertas*) Current (Corriente) 10/1/16 Abilify Absorica Abstral Aciphex Aciphex Sprinkle Acticlate Aczone 735% Adoxa Adrenaclick Adrenalin Adzenys XR Aldara Allegra Children’s Allergy Allegra/D Alltizal Alodox Ambien Ambien CR Amerge Amrix Antara Apidra Aplenzin Arestin Ativan Atralin Auryxia Auvi-Q Axiron Beconase AQ, Belbuca Belsomra Benzoyl peroxide foams Benzoyl peroxide pledgets Benzoyl peroxide washes Benzoyl peroxide kits Brovana Cambia Cardizem Cardizem CD Cardizem LA Celexa Ciclodan Cream Kit Ciclodan Kit Clarinex/D Clindacin Pac Clindagel Clodan kit CNL8 Nail Kit Conzip Cordran Crinone Cuprimine Cyclobenzaprine Comfort Pac Cyclobenzaprine Kit Cymbalta Demerol Demser Dermapak Plus Dermasorb kits (all) Detrol Detrol LA Dexilant Dilaudid Ditropan XL Doryx Doxycycline (brands) Duexis Duragesic Durlaza Dymista Dynacin Ecoza foam Edluar Effexor XR Elavil Enstilar Esgic Esomeprazole strontium Fabior Femara Fenoglide fenofibrate 40mg, 120mg Fentora Fexmid fexofenadine (Rx) fexofenadine combinations (Rx) Fioricet Fiorinal Flector Flonase Flowtuss flunisolide 29 mcg Fortamet Fortesta Gelnique Geodon Glumetza Grastek Halog Humalog Humalog Mix 50/50 Humalog Mix 75/25 Humulin 70/30 Humulin N Humulin R Hycofenix Hysingla ER Ibudone Ibuprofen Comfort Pac Imitrex Intermezzo Intuniv Ionsys Irenka Isordil Jardiance Jublia Karbinal ER Kenalog Kerydin Klonopin Lazanda Levorphanol Lexapro Librax Lidocaine HC kit Lidocaine 5% Lidocaine HCl 3% lotion Lidocaine/Prilocaine kit Lipitor Locoid Locoid lipocream Loestrin 1.5/30-21 Loestrin 1/20-21 Loprox shampoo Lorcet Lortab Lorzone Lunesta Luzu Maxalt Maxalt MLT Maxidone Meloxicam Comfort Pac Mesalamine Kit Mestinon tablet metformin ER (osmotic) methylphenidate ER (osmotic) Metozolv Minocin/Kit Miralax Mircette Mirvaso Mobic Monodox Morgidox/Kit MS Contin Mysoline Naftin Naprelan Naproxen Comfort Pac Nasacort AQ Nasonex Natesto Neo-Synalar/kit Neuac Kit Nexium capsules Niravam Norco Noritate cream Northera Nuvessa Obredon Ocudox Omega-3/ D-3 kit omeprazole-sodium bicarb. (generic Zegerid) Omnaris Onexton Onmel *Please check member benefit documentation to determine inclusion in the Drugs Not Covered program. † Alternatives may be covered or available for purchase Over The Counter (OTC). (*Consulte con la póliza de miembro individual para la inclusión dentro del programa de medicinas no cubiertas) (†Los ingredientes disponibles que no necesitan receta médica) Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 2 Drugs that are Not Covered* (Medicinas que no están cubiertas*) Continued (Continuado) Onzetra Xsail Oracea Oralair Orbivan Ovace Plus Ovcon-35 Ovcon-50 Oxaydo Oxistat Oxytrol Pandel Panoxyl Paxil Paxil CR Pediaderm Kit Pennsaid 2% Pepcid Percocet brand Plavix Pliaglis Prestalia Prevacid Rx Prevacid Solutab Prilosec Rx Primlev Protonix Provigil Prozac Prozac Weekly Qnasl Qnasl Children’s Qutenza Kit Ragwitek Rayos Remeron Remeron Soltab Reprexain Restoril Retin-A Micro Gel/Pump Revatio Rhinocort AQ Risperdal Risperdal M tab Rosadan Kit Rowasa Kit Roxicodone Rybix ODT Rytary Ryzolt Sanctura Semprex-D Sernivo Seroquel Silenor Singulair Sitavig Solodyn Soma Spritam Sprix Stiolto Respimat Striant Subsys Sumavel Dosepro Synalar Kit Synalar TS Kit Synera Synjardy Taclonex ointment Taclonex suspension Targiniq Targadox Targiniq ER Tenormin Testim Testone CIK Kit testosterone topical 1% Testred Tiazac Tivorbex Tizanidine Comfort Pac Tofranil Tofranil PM Tranxene T Treximet Trianex TussiCaps Tuxarin Tuzistra XR Ultracet Ultram Ultram ER Ultravate Ultravate Kit/PAC Uroxatral Valcyte Valium Valtrex Vanatol LQ Vanos cream Vaseretic Vasotec Veltin gel Veramyst Vibramycin Vicodin Vicoprofen Vimovo Vivlodex Vogelxo Vusion Wellbutrin Wellbutrin SR Wellbutrin XL WhyteDerm TDPak Xanax Xanax XR Xartemis XR Xerese cream Xodol Xolegel Xtampza ER Xyzal Zantac Zecuity Zegerid Zelapar Zembrace Zestril Zestoretic Zetonna Ziana gel Zipsor Zohydro ER Zolpimist Zoloft Zomig Zorvolex Zovirax Zuplenz Zyclara Zyflo Zyflo CR Zyprexa Zyprexa Zydis Zyrtec/D *Please check member benefit documentation to determine inclusion in the Drugs Not Covered program. † Alternatives may be covered or available for purchase Over The Counter (OTC). Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association Page 2 of 2