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Coverage Exclusion for DESI and Termed Drugs

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:

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

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