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Enhanced and Essential Formulary Exclusions and OTC Alternatives
Commercial Policy
Version Date: March 2023
Histamine H2 Receptor Antagonists
| Prescription Formulations | OTC Alternative (s) |
|---|---|
| Cimetidine 200mg, 300mg, 400mg, 800mg tablets | Cimetidine 200 mg tablets |
| Pepcid (Famotidine) 20mg, 40mg tablets | Famotidine 10mg, 20mg tablets |
Proton Pump Inhibitors
| Prescription Formulations | OTC Alternative (s) |
|---|---|
| Esomeprazole Strontium 49.3 mg capsules | Esomeprazole 20mg capsules |
| Konvomep (omeprazole- sodium bicarbonate) 2mg84mg/mL oral suspension | Zegerid OTC (omeprazole- sodium bicarbonate) 20mg/1100mg capsules |
| Nexium (esomeprazole) 20mg, 40 mg capsules | Esomeprazole 20mg capsules |
| Prevacid (lansoprazole) 15mg, 30mg capsules | Lansoprazole 15mg capsules |
| Prilosec (omeprazole) 10mg, 20mg, 40mg capsules | Omeprazole 20mg tablets |
| Zegerid (omeprazole- sodium bicarbonate) 20mg/1100mg, 40mg/1100mg capsules | Zegerid OTC (omeprazole- sodium bicarbonate) 20mg/1100mg capsules |
Allergy Medications
| Prescription Formulations | OTC Alternative (s) |
|---|---|
| Brompheniramine/Pseudoephedrine/Dextromethorphan 4mg/60mg/30mg syrup | Brompheniramine/Pseudoephedrine/Dextromethorphan (various strengths) |
| Clarinex (desloratadine) 5mg tab | Loratadine 10 mg tab/cap |
| Clarinex-D (desloratadine/pseudoephedrine) 2.5mg/120mg tablet | Loratadine 5mg tab and pseudoephedrine 120mg tablet as separate products |
| Diphenhydramine 12.5mg / 5ml Elixir | Diphenhydramine 12.5mg /5ml liquid |
| Flonase (fluticasone) 50mcg nasal spray | Flonase Sensimist (fluticasone furoate) 27.5mcg Fluticasone nasal propionate 50mcg |
| Pataday (olopatadine) 0.1% Ophth solution | Pataday (olopatadine) 0.1% Ophth solution |
| Pataday (olopatadine) 0.2% Ophth solution | Pataday (olopatadine) 0.2% Ophth solution |
| Xyzal (levocetirizine) 5 mg tab | Xyzal Allergy 24hr (Levocetirizine) 5mg tablet |
Topical Products
| Prescription Formulations | OTC Alternative (s) |
|---|---|
| Ammonium Lactate 12% Cream, Lotion | Geri-Hydrolac (Ammonium Lactate 12%) |
| Clotrimazole 1% cream, solution | Clotrimazole 1% cream (various brands) |
| Differin (Adapalene) 0.1% Lotion, Solution, Gel, Cream | Differin (adapalene) 0.1% Gel |
| Epsolay (benzoyl peroxide) 5% cream | benzoyl peroxide 5% cream (various brands) |
| Hydrocortisone 1% cream, lotion, ointment | Hydrocortisone 1% cream, lotion, gel, ointment (various brands) |
| Lidocaine 5% ointment | Lidocaine 5% ointment |
| Mentax (butenafine hcl) 1% cream | Butenafine hydrochloride hcl 1% (various brands) |
| Voltaren (Diclofenac sodium) 1% gel | Voltaren (Diclofenac sodium) 1% gel |
Various
| Prescription Formulations | OTC Alternative (s) |
|---|---|
| Bonjesta (doxylamine 20mg -pyridoxine 20mg) | Doxylamine 25mg and Pyridoxine 25mg as separate products |
| Calcium Acetate 667mg tablets, capsules | Calcium Acetate 667mg tablets |
| Diclegis (doxylamine 10mg -pyridoxine 10mg) | Doxylamine 25mg and Pyridoxine 25mg |
| Duexis (ibuprofen- famotidine) 800mg/26.6 mg | Ibuprofen 200mg and Famotidine 10mg, 20mg tablets as separate products |
| Ibuprofen 100mg/5mL suspension | Ibuprofen 100mg/5mL suspension |
| Loperamide 2mg capsules | Loperamide 2mg tablet |
| Meclizine 12.5mg, 25mg, 50mg tablets | Meclizine 25mg tablets (various brands) |
| Naprelan CR (naproxen sodium ER) 375mg, 500mg, 750mg | Naproxen sodium 220mg |
| Niacor 500mg tablet | Niacin 500mg, Niacin ER 250mg, 500mg, 750mg, 1000mg |
| Oxytrol (oxybutynin) 3.9mg/24H Transdermal Patch | Oxytrol (oxybutynin) 3.9mg/24H Transdermal Patch |
| Vimovo (naproxen delayed release- esomeprazole) 375mg/20mg | Naproxen sodium 220mg and esomeprazole 20mg as separate products |
| Yosprala (aspirin -omeprazole 81mg/40mg) | Aspirin 81mg and Omeprazole 40mg as separate products |
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