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Effective January 1, 2014, these medications will be excluded from benefit coverage. You may continue taking an excluded medication but you will pay the
full price for the medication. We encourage you to use one of the lower-cost options shown in the flyer.
Medication
Lower-cost option(s)
Medication
Lower-cost option(s)
Amnesteem, Claravis, Myorisan, Sotret, Zenatane Fluticasone, Omnaris, Zetonna, Qnasl, Nasonex fentanyl citrate (generic Actiq), Lazanda, Onsolis, Subsys Benzac, Desquam, Panoxyl, Brevoxyl OTC benzoyl peroxide doxycycline hyclate, doxycycline monohydrate tablets Levocetirizine, OTC Allegra, OTC Claritin, OTC Zyrtec levocetirizine + OTC pseudoephedrine; OTC Al egra D, Amnesteem, Claravis, Myorisan, Sotret, Zenatane fentanyl citrate (generic Actiq), Lazanda, Onsolis, Subsys mupirocin fenofibrate 54 mg, 160 mg, fenofibrate 43 mg, 130 mg, amphetamine/ dextroamphetamine immediate-release doxycycline hyclate, doxycycline monohydrate tablets levocetirizine, OTC Allegra, OTC Claritin, OTC ZyrtecLevocetirizine + OTC pseudoephedrine; OTC Al egra D, Levocetirizine, OTC Allegra, OTC Claritin, OTC Zyrtec levocetirizine + OTC pseudoephedrine; OTC Al egra D, amphetamine/ dextroamphetamine Adderall XR amlodipine plus lisinopril/hydrochlorothiazide, valsartan/hydrochlorothiazide, Benicar HCT or Micardis HCT tizanadine methylphenidate, methylphenidate extended-release, tramadol immediate-release, tramadol extended-release sulfasalazine, balsalazide , Apriso, Lialda balsalazide, sulfasalazine, Apriso, Lialda venlafaxine extended-release capsule, Pristiq oxybutynin, oxybutynin extended-release, Toviazoxybutynin, oxybutynin exteneded-release, trospium, trospium extended-release, Enalblex, Gelnique, Vesicare doxycycline hyclate, doxycycline monohydrate tablets eprosartan, losartan, Benicar, or Micardis + amlodipine Medication
Lower-cost option(s)
Medication
Lower-cost option(s)
doxycycline hyclate, doxycycline monohydrate doxycycline hyclate, doxycycline monohydrate tabletsmorphine sulfate sustained-action tablet, Opana morphine sulfate extended-release ER, Oxycontin Motrin Suspension, Pedia-Profen OTC Motrin oxybutynin, oxybutynin extended-release, Toviaz oxybutynin, oxybutynin extended-release, Toviaz clonidine omeprazole, pantoprazole, Aciphex, Dexilant; OTC amlodipine plus losartan, Benicar, Diovan or amlodipine plus lisinopril/hydrochlorothiazide, losartan/hydrochlorothiazide, valsartan/hydrochlorothiazide, Benicar HCT or Micardis HCT fenofibrate 54 mg, 160 mg, fenofibrate 43 mg, 130, fentanyl citrate, Abstral, Lazanda, Onsolis Omeprazole + clarithromycin + amoxicillin omeprazole sodium bicarbonate omeprazole, pantoprazole, Aciphex, Dexilant; OTC oxybutynin, oxybutynin extended-release, Toviaz oxybutynin, oxybutynin extended-release, Toviaz balsalazide, sulfasalazine , Apriso, Lialda omeprazole, pantoprazole, Aciphex, Dexilant; OTC morphine sulfate extended-release, Avinza omeprazole, pantoprazole, Aciphex, Dexilant; OTC rizatriptan, rizatriptan orally disintegrating tablet methylphenidate, methylphenidate extended- oxybutynin, oxybutynin extended-release, Toviaz oxybutynin, oxybutynin extended-release, Toviaz Medication
Lower-cost option(s)
montelukast cyclobenzaprine, chlorzoxazone, metaxalone, sodium sulfacetamide/sulfur 9%- sodium sulfacetamide/sulfur OTC Tavistamlodipine plus lisinoprilm losartan, eprosartan , oxybutynin , oxybutynin extended-release, Toviaz Amlodipine plus losartan/hydrochlorothiazide, fenofibrate, Antara, Fenoglide, Lipofen, Triglide oxybutynin, oxybutynin extended-release, Toviaz oxybutynin, oxybutynin extended-release, Toviaz amlodipine plus losartan, Benicar, or Micardis Ultravate X Combination Package halobetasol cream oxybutynin, oxybutynin extended-release, Toviaz naproxen plus omeprazole or pantoprazole omeprazole, pantoprazole, Aciphex, Dexilant; OTC olanzapine , olanzapine orally disintegrating tablet

Source: http://mlrcrs.welcometouhc.com/files/mlrcrs/content/millercoorsexclusions.pdf