Audience: Providers of impacted SafetyNet members
Coverage Exclusion of DESI and Termed Drugs
We have identified medications on our formularies that are DESI (Drug Efficacy Study Implementation) products or have no National Drug Rebate Agreement (NDRA). These medications have been removed from the respective formularies and are not covered. Please see the full list of excluded drugs on the next page.
This exclusion is applicable to Medicaid Managed Care line of business. Members who have filled one or more of these medications have been notified and directed to speak with you about possible alternatives and are listed below.
Please note that only certain NDCs of the listed medications are excluded.
Thank you for your continued participation and for the quality of care and service you provide to your patients, our valued members.
Termed Drugs: |
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NDC |
Drug Name |
NDC |
Drug Name |
00135020001 |
ABREVA 10% CREAM |
42291007715 |
CLOBETASOL 0.05% OINTMENT |
00316012601 |
ALA-CORT 1% CREAM |
10135070801 |
CLONIDINE HCL 0.1 MG TABLET |
72508022114 |
AMOX-CLAV 875-125 MG TABLET |
10135071001 |
CLONIDINE HCL 0.3 MG TABLET |
72508020505 |
AMOXICILLIN 500 MG CAPSULE |
57896087503 |
CO Q-10 100 MG SOFTGEL |
24357070115 |
ANECREAM 4% CREAM |
16110058780 |
CORDRAN 4 MCG/SQ CM TAPE LARGE |
24357070130 |
ANECREAM 4% CREAM |
49100036404 |
CULTURELLE HLTH-WELL 15B CELL |
60505476505 |
APO-VARENICLINE 0.5 MG TABLET |
80681005000 |
DAILY-VITE TABLET |
60505476606 |
APO-VARENICLINE 1 MG TABLET |
42037010478 |
DEBROX 6.5% EAR DROPS |
72865018230 |
ARIPIPRAZOLE 10 MG TABLET |
68176000015 |
DEKAS PLUS CHEWABLE TABLET |
72865018205 |
ARIPIPRAZOLE 10 MG TABLET |
68176000010 |
DEKAS PLUS LIQUID |
72865018305 |
ARIPIPRAZOLE 15 MG TABLET |
68176000011 |
DEKAS PLUS SOFTGEL |
72865018030 |
ARIPIPRAZOLE 2 MG TABLET |
24470092060 |
DESONIDE 0.05% GEL |
72865018130 |
ARIPIPRAZOLE 5 MG TABLET |
42582021605 |
DOXYCYCLINE HYCLATE 100 MG CAP |
72865018105 |
ARIPIPRAZOLE 5 MG TABLET |
42582021618 |
DOXYCYCLINE HYCLATE 100 MG CAP |
11917009588 |
ARTHRITIS PAIN RELIEF 0.1% CRM |
00096070760 |
DRYSOL DAB-O-MATIC SOLUTION |
41167005820 |
ASPERCREME LIDOCAINE 4% CRM |
00096070735 |
DRYSOL DAB-O-MATIC SOLUTION |
69618004610 |
ASPIRIN EC 81 MG TABLET |
49735018262 |
DUOCAL POWDER |
60842002101 |
AUVI-Q 0.1 MG AUTO-INJECTOR |
57896033905 |
EAR DROPS 6.5% |
60842002201 |
AUVI-Q 0.15 MG AUTO-INJECTOR |
51991020311 |
FERREX 150 CAPSULE |
16110086950 |
AZELEX 20% CREAM |
51991020301 |
FERREX 150 CAPSULE |
10135053201 |
BACLOFEN 10 MG TABLET |
20555001900 |
FERROUS GLUCONATE 324 MG TAB |
10135053210 |
BACLOFEN 10 MG TABLET |
65628008003 |
FIRST-LANSOPRAZOLE 3 MG/ML |
10135053310 |
BACLOFEN 20 MG TABLET |
65628008010 |
FIRST-LANSOPRAZOLE 3 MG/ML |
10135053301 |
BACLOFEN 20 MG TABLET |
65628008005 |
FIRST-LANSOPRAZOLE 3 MG/ML |
69336012615 |
BENZONATATE 150 MG CAPSULE |
65628005004 |
FIRST-MOUTHWASH BLM SUSP |
40985027116 |
BIOTIN 5,000 MCG CAPSULE |
65628005001 |
FIRST-MOUTHWASH BLM SUSP |
74312013430 |
BIOTIN 5,000 MCG SOFTGEL |
65628007003 |
FIRST-OMEPRAZOLE 2 MG/ML SUSP |
24470090960 |
BP 5% GEL |
65628007005 |
FIRST-OMEPRAZOLE 2 MG/ML SUSP |
80681013700 |
CALCIUM 500-VIT D3 10 MCG CHEW |
65628007010 |
FIRST-OMEPRAZOLE 2 MG/ML SUSP |
80681000500 |
CALCIUM 600 MG TABLET |
00135057617 |
FLONASE ALLERGY RLF 50 MCG SPR |
20555000500 |
CALCIUM 600 MG TABLET |
54629065002 |
FOLIC ACID 0.4 MG TABLET |
80681002900 |
CALCIUM 600 MG-VIT D3 10MCG TB |
73152014110 |
FOLIC ACID 1 MG TABLET |
80681013901 |
CALCIUM 600 MG-VIT D3 10MCG TB |
80681009900 |
FOLIC ACID 400 MCG TABLET |
80681013900 |
CALCIUM 600 MG-VIT D3 10MCG TB |
57896045401 |
GERI-KOT 8.6 MG TABLET |
20555001700 |
CALCIUM 600 MG-VIT D3 10MCG TB |
80681010000 |
GLUCOSE 3.75 GRAM TABLET CHEW |
80681013801 |
CALCIUM 600 MG-VIT D3 5 MCG TB |
11917016741 |
GLUCOSE 4 GRAM TABLET CHEW |
41167075142 |
CAPZASIN-HP 0.1% CREAM |
11917006844 |
GLUCOSE 4 GRAM TABLET CHEW |
80681014101 |
CERTAVITE SENIOR TABLET |
11917004682 |
GLUCOSE 4 GRAM TABLET CHEW |
80681014202 |
CERTAVITE-ANTIOXIDANT TABLET |
38396054232 |
GLUCOSE 4 GRAM TABLET CHEW |
80681011600 |
CHILDREN MULTIVIT CHEW TAB |
11917016740 |
GLUCOSE 4 GRAM TABLET CHEW |
80681004900 |
CHILDREN MULTIVIT CHEW TAB |
00574006930 |
GLUTOSE-15 GEL |
00178089430 |
CITRANATAL DHA PACK |
00574006915 |
GLUTOSE-15 GEL |
11523716201 |
CLARITIN-D 12 HOUR TABLET |
00574007030 |
GLUTOSE-15 GEL |
11523433203 |
CLARITIN-D 24 HOUR TABLET |
00574006945 |
GLUTOSE-45 GEL |
11523433202 |
CLARITIN-D 24 HOUR TABLET |
24359035307 |
GLYTACTIN BUILD 10-10 POWD PKT |
10135069161 |
CLINDAMYCIN PH 1% SOLUTION |
24359054403 |
GLYTACTIN RTD 15 PE LIQUID |
48878312004 |
CLINPRO 5000 1.1% TOOTHPASTE |
87701040729 |
GNP VITAMIN B-1 100 MG TABLET |
42291007660 |
CLOBETASOL 0.05% CREAM |
34362030201 |
GYNOL II 3% GEL |
42291007730 |
CLOBETASOL 0.05% OINTMENT |
63807050055 |
HEPARIN 50 UNITS/5 ML (10/ML) |
42291007760 |
CLOBETASOL 0.05% OINTMENT |
08290306424 |
HEPARIN 500 UNIT/5 ML (100/ML) |
70795241202 |
HYDROCORTISONE AC 25 MG SUPP |
69528030116 |
OZOBAX 5 MG/5 ML SOLUTION |
43199001401 |
HYOSCYAMINE ER 0.375 MG TAB |
11112003048 |
PEPTIDE 1.0 LIQUID |
11788000905 |
IBUPROFEN 600 MG TABLET |
49735018305 |
PERIFLEX ADVANCE PKU POWDER |
11788000901 |
IBUPROFEN 600 MG TABLET |
00126027216 |
PERIOGARD 0.12% ORAL RINSE |
11788001005 |
IBUPROFEN 800 MG TABLET |
11917010670 |
PETROLEUM JELLY |
41167000881 |
ICY HOT 10-30% CREAM |
70000048701 |
PETROLEUM JELLY |
41167000883 |
ICY HOT 10-30% CREAM |
11917010673 |
PETROLEUM JELLY |
41167000885 |
ICY HOT 10-30% CREAM |
11917004964 |
PETROLEUM JELLY 100% PURE |
41167000843 |
ICY HOT MEDICATED 5% PATCH |
70074051123 |
PHENEX-2 POWDER |
41167000841 |
ICY HOT MEDICATED PATCH |
70074067055 |
PHENEX-2 POWDER |
63044020301 |
IFEREX 150 CAPSULE |
49735010058 |
PHENYLADE GMP ULTRA POWDER PKT |
63044020361 |
IFEREX 150 CAPSULE |
52343005530 |
PIOGLITAZONE HCL 45 MG TABLET |
59781066678 |
JUVEN PACKET |
49735010164 |
PKU PERIFLEX EARLY YEARS POWD |
59212065860 |
KAPVAY ER 0.1 MG TABLET |
50600021124 |
PKU SPHERE20 POWDER PACKET |
49735017155 |
KETOCAL 3:1 POWDER |
59212056210 |
PLAQUENIL 200 MG TABLET |
24359050203 |
KETOVIE 4:1 LIQUID |
60258018501 |
POLY-IRON 150 MG CAPSULE |
00496088215 |
LMX 4 4% CREAM |
59390019613 |
POLYVINYL ALCOHL 1.4% EYEDROP |
00496088230 |
LMX 4 4% CREAM |
54288012530 |
POTASSIUM CL 20 MEQ PACKET |
68585000575 |
MAG64 DR 64 MG TABLET |
50265039830 |
PRENA1 CHEW TABLET |
10135058362 |
MAGNESIUM OXIDE 400 MG TABLET |
60258019001 |
PRENATABS FA TABLET |
00394013012 |
MERIBIN 5 MG CAPSULE |
60258019309 |
PRENATABS RX TABLET |
11788003860 |
METFORMIN ER 1,000 MG OSM-TAB |
42937070710 |
PRENATAL 19 CHEWABLE TABLET |
50816002502 |
METOPROLOL SUCC ER 25 MG TAB |
42937070510 |
PRENATAL PLUS IRON TABLET |
50816005003 |
METOPROLOL SUCC ER 50 MG TAB |
42937070518 |
PRENATAL PLUS IRON TABLET |
11523723402 |
MIRALAX POWDER |
60258017901 |
PRENATAL-U CAPSULE |
80681002000 |
MULTIVITAMIN TABLET |
37000045504 |
PRILOSEC OTC 20.6 MG TABLET |
78112073623 |
MURINE 6.5% EAR DROPS |
70408014634 |
PROMETHAZINE 6.25 MG/5 ML SOLN |
78112073621 |
MURINE EAR WAX REMOVAL SYS |
94688001525 |
PROSOURCE NO CARB PROTEIN LIQ |
58204000411 |
MVW COMPL FORMUL D3000 CHEW |
94688001535 |
PROSOURCE NO CARB PROTEIN LIQ |
57771000104 |
NANOVM T-F POWDER |
11822511260 |
RA FISH OIL 1,000 MG SOFTGEL |
41167580005 |
NASACORT ALLERGY 24HR SPRAY |
11822067511 |
RA TRUEPLUS GLUCOSE 15 GM GEL |
00525031590 |
NEEVODHA CAPSULE |
56151161211 |
RA TRUEPLUS GLUCOSE 4 G TB CHW |
70074064799 |
NEPRO CARB STEADY LIQUID |
10956061801 |
REESE'S PINWORM 144 MG/ML SUSP |
80681001900 |
NIACINAMIDE 500 MG TABLET |
23513061821 |
REESE'S PINWORM 144 MG/ML SUSP |
00135019502 |
NICODERM CQ 14 MG/24HR PATCH |
80681009600 |
REGULOID POWDER |
00135046702 |
NICORETTE 4 MG CHEWING GUM |
12539002484 |
RENA STEP LIQUID |
70408023932 |
NITROFURANTOIN 25 MG/5 ML SUSP |
43900022510 |
RESOURCE THICKENUP POWDER |
00316022130 |
NYSTATIN 100,000 UNIT/GM CREAM |
52187052610 |
SALICYLIC ACID 26% LIQUID |
00316022115 |
NYSTATIN 100,000 UNIT/GM CREAM |
32953068965 |
SALINE 0.65% NASAL SPRAY |
00316022330 |
NYSTATIN-TRIAMCINOLONE CREAM |
45802035758 |
SALINE MIST 0.65% NOSE SPRY |
00316022360 |
NYSTATIN-TRIAMCINOLONE CREAM |
50484001030 |
SANTYL OINTMENT |
00316022315 |
NYSTATIN-TRIAMCINOLONE CREAM |
50484001090 |
SANTYL OINTMENT |
00187526003 |
OCEAN 0.65% NASAL SPRAY |
16477042306 |
SELENIUM SULFIDE 2.3% SHAMPOO |
52709170103 |
ODACTRA 12 SQ-HDM SL TABLET |
69618006401 |
SENNA 8.6 MG TABLET |
58602000640 |
OLOPATADINE HCL 0.1% EYE DROPS |
16110024730 |
SEYSARA 150 MG TABLET |
58602000739 |
OLOPATADINE HCL 0.2% EYE DROP |
69618003206 |
SIMETHICONE 125 MG TAB CHEW |
42291065712 |
OMEGA-3 ETHYL ESTERS 1 GM CAP |
20513007001 |
SIMPLYTHICK 6 GM PACKET |
80681005800 |
OYSTER SHELL CALCIUM 500 MG TB |
10939005044 |
SM PETROLEUM JELLY |
20555000300 |
OYSTER SHELL CALCIUM 500 MG TB |
00395277516 |
STRONG IODINE SOLUTION |
80681000400 |
OYSTER SHELL CALCIUM 500 MG TB |
67871011104 |
SUCRAID 8,500 UNITS/ML SOLN |
42291078142 |
SUCRALFATE 1 GM/10 ML SUSP |
51645091301 |
VITAMIN B-12 500 MCG TABLET |
70074062089 |
SUPLENA CARB STEADY LIQUID |
54629058501 |
VITAMIN B-12 500 MCG TABLET |
80681012400 |
TAB-A-VITE MULTIVIT WITH IRON |
80681012800 |
VITAMIN B-12 500 MCG TABLET |
80681006301 |
TAB-A-VITE MULTIVIT WITH IRON |
20555003200 |
VITAMIN B-12 500 MCG TABLET |
80681006300 |
TAB-A-VITE MULTIVIT WITH IRON |
74312000650 |
VITAMIN B-6 100 MG TABLET |
20555002700 |
TAB-A-VITE TABLET |
80681002500 |
VITAMIN B-6 100 MG TABLET |
16110091530 |
TAZORAC 0.05% CREAM |
51645091001 |
VITAMIN B-6 100 MG TABLET |
16110004230 |
TAZORAC 0.1% GEL |
00536440601 |
VITAMIN B-6 25 MG TABLET |
16110004210 |
TAZORAC 0.1% GEL |
10006073017 |
VITAMIN B-6 50 MG TABLET |
58790000115 |
THERA TEARS 0.25% EYE DROPS |
10006073016 |
VITAMIN B-6 50 MG TABLET |
80681006400 |
THEREMS MULTIVITAMIN TABLET |
20555000100 |
VITAMIN C 250 MG TABLET |
80681000300 |
THEREMS MULTIVITAMIN TABLET |
80681012900 |
VITAMIN C 250 MG TABLET CHEW |
72058061081 |
THICK-IT #2 POWDER |
54629041120 |
VITAMIN D3 2,000 UNIT TABLET |
72058061079 |
THICK-IT POWDER |
80681016900 |
VITAMIN D3 25 MCG TABLET |
72058061078 |
THICK-IT POWDER |
80681016801 |
VITAMIN D3 25 MCG TABLET |
10135070760 |
TOLTERODINE TARTRATE 2 MG TAB |
80681016800 |
VITAMIN D3 25 MCG TABLET |
11701003132 |
TRIAD WOUND DRESSING PASTE |
20555003300 |
VITAMIN D3 25 MCG TABLET |
11701003133 |
TRIAD WOUND DRESSING PASTE |
74312019377 |
VITAMIN D3 5,000 UNIT SOFTGEL |
56151161051 |
TRUEPLUS GLUCOSE 4 GM TAB CHEW |
80681000900 |
VITAMIN D3 50 MCG (2,000 UNIT) |
56151161011 |
TRUEPLUS GLUCOSE 4 GM TAB CHEW |
80681017000 |
VITAMIN D3 50 MCG TABLET |
56151161111 |
TRUEPLUS GLUCOSE 4 GM TAB CHEW |
80681013200 |
VITAMIN D3 50 MCG TABLET |
56151161151 |
TRUEPLUS GLUCOSE 4 GM TAB CHEW |
00904573182 |
WHITE PETROLEUM JELLY |
00536478701 |
VITAMIN B COMPLEX CAPSULE |
16110008045 |
XOLEGEL 2% GEL |
80681012600 |
VITAMIN B COMPLEX-VIT C CAPLET |
00525097160 |
ZELNORM 6 MG TABLET |
80681009800 |
VITAMIN B-1 100 MG TABLET |
59212068010 |
ZONEGRAN 100 MG CAPSULE |
10006073021 |
VITAMIN B-1 100 MG TABLET |
61787044302 |
ZOSTRIX HP 0.1% CREAM |
10006070011 |
VITAMIN B-1 100 MG TABLET |
50580072824 |
ZYRTEC-D TABLET |
10006070022 |
VITAMIN B-12 1,000 MCG TABLET |
||
54629058605 |
VITAMIN B-12 1,000 MCG TABLET |
||
20555001600 |
VITAMIN B-12 1,000 MCG TABLET |
||
20555000600 |
VITAMIN B-12 1,000 MCG TABLET |
||
80681007100 |
VITAMIN B-12 100 MCG TABLET |
||
80681007200 |
VITAMIN B-12 500 MCG TABLET |
DESI Products:
CHLORDIAZEPOXIDE-CLIDINIUM CAP
ESTROGEN-METHYLTESTOS F.S. TAB
HYDROCORTISONE AC 25 MG SUPP
HYDROCORTISONE AC 30 MG SUPP
HYDROCORT-PRAMOXINE 1%-1% CRM
HYOSYNE 0.125 MG/ML DROP
HYOSYNE 125 MCG/5 ML ELIXIR
PV UNIFINE PENTIP PLUS 31GX6MM