CRP1386903A 204612 EXCL-NPF-26 (08/08/2025) Page 6 Drug Class Excluded Medications Preferred Alternatives CARDIOVASCULAR Angiotensin Receptor Blockers (ARBs) & Combinations (continued) telmisartan/amlodipine amlodipine/olmesartan, amlodipine/valsartan VALSARTAN SOLUTION valsartan tablets Anticoagulants PRADAXA, SAVAYSA dabigatran, ELIQUIS, XARELTO BISOPROLOL FUMARATE 2.5MG TABLETS bisoprolol 5mg or 10mg INDERAL XL, INNOPRAN XL KAPSPARGO SPRINKLE LABETALOL 400MG TABLETS CONJUPRI, LEVAMLODIPINE propranolol er Beta Blockers & Combinations metoprolol succinate labetalol 100mg, 200mg or 300mg tablets amlodipine, felodipine er, nifedipine er, nisoldipine Calcium Channel Blockers KATERZIA, NORLIQVA FUROSCIX, SOAANZ HEMICLOR, THALITONE amlodipine bumetanide, furosemide, torsemide chlorthalidone Diuretics INZIRQO hydrochlorothiazide capsules or tablets amiloride hcl, eplerenone, spironolactone triamterene, DYRENIUM Generic Anti-Hypertensive Agents (Categories include: ACE Inhibitors, Alpha-Adrenergic Blockers, Angiotensin Receptor Blockers [ARBs], Beta Blockers, Calcium Channel Blockers, Central Alpha-Adrenergic Agonists, Direct Renin Inhibitors, Direct Vasodilators and Diuretics) fenofibrate capsules (43mg, 67mg, 130mg, 134mg, 200mg), fenofibrate tablets, fenofibric acid atorvastatin, fluvastatin er, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin ezetimibe plus atorvastatin or rosuvastatin Endothelin Receptor Antagonists TRYVIO FENOFIBRATE CAPSULES (30MG, 50MG, 90MG, 150MG), LIPOFEN Fenofibrates ALTOPREV, ATORVALIQ, EZALLOR SPRINKLE HMG & Cholesterol Inhibitor Combinations ROSUVASTATIN/EZETIMIBE PCSK9 & siRNA Inhibitors LEQVIO, PRALUENT REPATHA Pulmonary Arterial Hypertension (PAH) Agents Sodium Glucose Co-Transporter-1 & 2 Inhibitors sildenafil oral suspension, sildenafil 20mg tablets, tadalafil 20mg tablets LIQREV, TADLIQ INPEFA FARXIGA, JARDIANCE ASPRUZYO SPRINKLE ER ranolazine er ivabradine tablets, atenolol, bisoprolol 5mg or 10mg, carvedilol, metoprolol succinate, metoprolol tartrate, propranolol CORLANOR SOLUTION, CORLANOR TABLETS Miscellaneous Cardiovascular Agents LODOCO colchicine NORPACE CR amiodarone, quinidine sulfate, sotalol Over-the-Counter aluminum chloride containing products DERMATOLOGICAL Agents for Hyperhidrosis DRYSOL, QBREXZA, SOFDRA Coverage may be approved for the treatment of molluscum contagiosum
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