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Coverage Exclusion of Non-FDA Approved Medications for Commercial, Exchange, Essential Plan, and Child Health Plus Members

Audience: Providers of impacted patients

We have identified several medications on our formularies that are non-FDA approved products. As a result, beginning April 1, 2021, we will remove these medications from the respective formularies and exclude coverage for the following medications:

  • Hydrocortisone acetate-pramoxine hcl 2.5%-1% cream

  • Analpram HC 2.5%-1% cream

  • Pramosone 2.5%-1% cream

  • Pramosone 2.5%-1% ointment

  • Hydrocortisone 25 mg suppositories

  • Hydrocortisone 30 mg suppositories

  • Anucort HC 25 mg suppositories

  • Anusol HC 25 mg suppositories

  • Proctocort 30 mg suppositories

  • Lidocaine 3% cream

  • Lido-Sorb external 3% lotion

  • Lidocaine-hydrocortisone external cream 3-0.5 %

  • Lidocaine-hydrocortisone rectal gel 2.8-0.55 %

  • Lidocaine-hydrocortisone rectal kit 2-2 %

  • Lidocaine-hydrocortisone rectal kit 3-0.5 %

  • Lidocaine-hydrocortisone rectal kit 3-1 %

  • Lidocaine-hydrocortisone rectal kit 3-2.5 %

This exclusion is applicable to Commercial, Exchange, Essential Plan and Child Health Plus lines of business. Members who have filled one or more of these medications have been notified and directed to speak with you about possible alternatives. A list of recommended over-the-counter (OTC) and prescription alternatives for the excluded products is provided below.

Non-FDA Approved Drug

Common Indications

Alternative Recommendations

Hydrocortisone acetate /pramoxine hcl 2.5%-1% cream

Analpram HC 2.5%-1% cream

Pramosone 2.5%-1% cream

Pramosone 2.5%-1% ointment

Hemorrhoids

OTC:

  • hydrocortisone 1% rectal cream

(i.e. Preparation H)

  • hydrocortisone 1% ointment

- pramoxine 1% cream (i.e. Tronolane)

 

Note: OTC products may contain other active ingredients and vary by product

 

Rx: hydrocortisone acetate/pramoxine hcl 1%-1% cream

Hydrocortisone 25 mg suppositories

Hydrocortisone 30 mg suppositories

Anucort HC 25 mg suppositories

Anusol HC 25 mg suppositories

Proctocort 30 mg suppositories

Hemorrhoids

OTC:

  • hydrocortisone 1% rectal cream

(i.e. Preparation H)

  • hydrocortisone 1% ointment

 

Note: OTC products may contain other active ingredients and vary by product

 

Rx:

  • hydrocortisone 2.5% rectal cream

  • Procto-Med HC 2.5% external cream

  • Proctosol HC 2.5% external cream

  • Proctozone-HC 2.5% external cream

Adjunct treatment of chronic ulcerative colitis

Rx: hydrocortisone enema

Lidocaine 3% cream

Lido-Sorb external 3% lotion

Hemorrhoids

OTC:

  • lidocaine 5% rectal cream

  • dibucaine 1% rectal ointment

  • benzocaine 20% rectal ointment

(i.e. Preparation H, Nupercainal, Americaine)

 

Note: OTC products may contain other active ingredients and vary by product

Topical anesthetic

OTC: Lidocaine cream (i.e. Aspercreme)

 

Note: OTC products may contain other active ingredients and vary by product

Lidocaine-hydrocortisone external cream 3-0.5%

Lidocaine-hydrocortisone rectal gel 2.8-0.55%

Lidocaine-hydrocortisone rectal kit 2-2%

Lidocaine-hydrocortisone rectal kit 3-0.5%

Lidocaine-hydrocortisone rectal kit 3-1%

Lidocaine-hydrocortisone rectal kit 3-2.5%

Hemorrhoids

OTC:

  • lidocaine 5% rectal cream

  • dibucaine 1% rectal ointment

  • benzocaine 20% rectal ointment

(i.e. Preparation H, Nupercainal, Americaine)

  • hydrocortisone 1% rectal cream

(i.e. Preparation H, Nupercainal, Americaine)

 

Note: OTC products may contain other active ingredients and vary by product

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