Coverage Exclusion for DESI and Termed Drugs

Issued April 29, 2022

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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