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Drug Class Excluded Medications Preferred Alternatives vancomycin capsules, vancomycin 50mg/ml oral solution FIRVANQ, VANCOMYCIN 25MG/ML SOLUTION ANTIINFECTIVES Antibiotic Agents (Oral) FULVICIN P/G griseofulvin ultra 125mg or 250mg tablets LIKMEZ, METRONIDAZOLE 125MG TABLETS metronidazole 250mg or 500mg tablets SIVEXTRO linezolid tablets or suspension nitrofurantoin macro, nitrofurantoin mono/macro, sulfamethoxazole/trimethoprim, trimethoprim fosfomycin Antibiotic Agents for Urinary Tract Infections NITROFURANTOIN 50MG/5ML SUSPENSION nitrofurantoin 25mg/5ml suspension Antifungal Agents (Oral) TOLSURA itraconazole Antivirals penciclovir cream, DENAVIR, XERESE acyclovir oral or cream, famciclovir, valacyclovir Chagas Disease Agents LAMPIT BENZNIDAZOLE KISUNLA, LEQEMBI No alternatives recommended AUTONOMIC & CENTRAL NERVOUS SYSTEM Alzheimer’s Agents Amyotrophic Lateral Sclerosis (ALS) Agents donepezil, galantamine tablets, galantamine er, rivastigmine ZUNVEYL QALSODY No alternatives recommended EPRONTIA, TOPIRAMATE 50MG SPRINKLE CAPSULES topiramate 25mg sprinkle capsules FINTEPLA GABARONE LIBERVANT MOTPOLY XR DIACOMIT, EPIDIOLEX gabapentin diazepam rectal gel, NAYZILAM, VALTOCO Anticonvulsants lacosamide PRIMIDONE 125MG TABLETS primidone 50mg or 250mg tablets VIGAFYDE ZONISADE vigabatrin powder packets zonisamide ONZETRA XSAIL sumatriptan nasal spray, zolmitriptan nasal spray etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen or oxaprozin plus almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan or zolmitriptan sumatriptan/naproxen sodium, SYMBRAVO, TREXIMET Antimigraine Agents TRUDHESA dihydroergotamine nasal spray (continued) © 2025 Evernorth Health Services

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Color:A5 Flat Cup White

Targets skin and connective tissue regeneration