Drugs that are Not Covered* (Medicinas que no están cubiertas*)
Current (Corriente) 4/1/17
Abilify
Absorica
Abstral
Aciphex
Aciphex Sprinkle
Acticlate
Actoplus Met
Actos
Acuvail
Aczone
adapalene lotion 0.1%
Adlyxin
Adoxa/Adoxa Pak
Adrenaclick
Adrenalin
Adzenys XR
Aldara
Allegra Children’s Allergy
Allegra/D
Alltizal
Ambien
Ambien CR
Amerge
Amrix
Androderm
Antara
Apexicon E
Apidra
Aplenzin
Apriso
Arestin
aspirin/caffeine/dihydrocodeine bitartrate
Ativan
Atralin
Auryxia
Auvi-Q
Azasite
Azopt
Beconase AQ
Belbuca
Belsomra
BenzaClin
benzoyl peroxide foams
benzoyl peroxide pledgets
benzoyl peroxide washes
benzoyl peroxide kits
Betapace
Betoptic S
BromSite
Brovana
Cambia
Capital and Codeine
Cardizem
Cardizem CD
Cardizem LA
carisoprodol 250 mg
Cefaclor ER tablet
Celexa
Cephalexin tablets
Cervidil
Ciclodan Cream Kit
Ciclodan Kit
Clarinex/D
Clindacin Pac
Clindagel
clindamycin foam
clindamycin/tretinoin gel
Cleocin-T
Clobex spray
Clodan kit
CNL8 Nail Kit
Conzip
Cordran
Crinone
Cuprimine
Cutivate cream 0.05%
Cutivate lotion 0.05%
Cutivate ointment 0.005%
Cyclobenzaprine Comfort
Pac
Cyclobenzaprine Kit
Cymbalta
DDAVP nasal spray
Demerol
Demser
Dermapak Plus
Dermasorb kits (all)
Desonate
desoximetasone cream
0.05%
desoximetasone ointment
0.05%
desvenlafaxine ER
(generic Khedezla)
Detrol
Detrol LA
Dexilant
Differin
Differin pump
dihydroergotamine nasal
spray
Dilaudid
Dipentum
Ditropan XL
Doral
Doryx
doxycycline (brands)
doxycycline hyclate DR
tablets
doxycycline monohydrate
75 mg, 150 mg capsules
Duexis
Duragesic
Durlaza
Dymista
Ecoza foam
Edluar
Effexor XR
Elavil
Enstilar
Epaned
EPIsnap
Esgic
esomeprazole strontium
Evoclin
Extina
Fabior
Femara
Fenoglide
fenofibrate 40 mg, 120 mg
fentanyl patch 37.5 mcg,
62.5 mcg, 87.5 mcg
Fentora
Fexmid
fexofenadine (Rx)
fexofenadine combinations
(Rx)
Fioricet
Fiorinal
Flector
Flonase
Flowtuss
fluocinonide 0.1%
fluorouracil cream 0.5%
(authorized generic of
Carac)
fluoxetine 60 mg tablet
flunisolide 29 mcg
fluticasone propionate
lotion 0.05%
Forfivo XL
Fortamet
Fortesta
Gelnique
Geodon
Giazo
Gleevec
Glumetza
GoNitro
Grastek
Halog
Humalog
Humulin 70/30
Humulin N
Humulin R
Hycofenix
Hysingla ER
Ibudone
Ibuprofen Comfort Pac
Imitrex
Innopran XL
Intermezzo
Intuniv
Ionsys
Irenka
Isordil
Istalol
Jublia
Kadian
Karbinal ER
Kenalog
*Please check member benefit documentation to determine inclusion in the Drugs Not Covered program.
†Alternatives may be covered or available for purchase Over The Counter (OTC).
(*Consulte con la póliza de miembro individual para la inclusión dentro del programa de medicinas no cubiertas)
(†Los ingredientes disponibles que no necesitan receta médica)
Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1 of 3
Drugs that are Not Covered* (Medicinas que no están cubiertas*)
Continued (Continuado)
Kerydin
ketoconazole foam
Khedezla
Klonopin
Kristalose
Lamisil AT spray
Lazanda
levorphanol
Lexapro
Librax
Lidocaine HC kit
Lidocaine 5%
Lidocaine HCl 3% lotion
Lidocaine/Prilocaine kit
Lipitor
Locoid
Locoid lipocream
Loestrin 1.5/30-21
Loestrin 1/20-21
Loprox shampoo
Lorcet
Lortab
Lorzone
Lunesta
Luzu
Maxalt
Maxalt MLT
Maxidone
Meloxicam Comfort Pac
Mesalamine Kit
Mestinon tablet
metformin ER (generic
Fortamet)
metformin ER (generic
Glumetza)
methylphenidate ER
(osmotic)
metoclopramide ODT
metoprolol succinate/
hydrochlorothiazide
Metozolv
MiCort-HC
Millipred
Millipred DP
Minocin
Miralax
Mircette
Mirvaso gel
Mirvaso Pump gel
Mobic
Monodox
mometasone nasal spray
Morgidox
MS Contin
Mysoline
Naftin
Nalfon 400 mg capsule
Naprelan
Naprosyn suspension
Naproxen Comfort Pac
Nasacort AQ
Nasonex
Natesto
Neuac Kit
Nevanac
Nexium capsules
Niaspan
Niravam
Norco
Noritate cream
Northera
Nucynta IR
Nuvessa
Nuvigil
Obredon
Ocudox
Olux foam
Olux E foam
Omega-3/D-3 kit
omeprazole-sodium bicarb.
(generic Zegerid)
Omnaris
Onexton
Onmel
Onzetra Xsail
Oracea
Oralair
Orbivan
Ovace Plus
Ovcon-35
Ovcon-50
Oxaydo
Oxytrol
Pancreaze
Pancrelipase
Pandel
Panoxyl
Patanol
Paxil
Paxil CR
Pediaderm Kit
Penlac
Pennsaid 2%
Pepcid
Percocet brand
Pertyze
Pexeva
Physicians EZ Use B-12
Compliance Injection Kit
Plavix
Pliaglis
Ponstel
Pramosone
Prandin
Prestalia
Prevacid Rx
Prevacid Solutab
Prilosec Rx
Primlev
Protonix
Proventil HFA
Provigil
Prozac
Prozac Weekly
quazepam
Qbrelis
Qnasl
Qnasl Children’s
Qutenza Kit
Ragwitek
Rayaldee
Rayos
Remeron
Remeron Soltab
Reprexain
Restoril
Retin-A Micro Gel/Pump
Revatio
Rhinocort AQ
Risperdal
Risperdal M tab
Rosadan Kit
Rowasa Kit
Roxicodone
Rybix ODT
Rytary
Ryzolt
Sanctura
Semprex-D
Sernivo
Seroquel
Silenor
Singulair
Sitavig
Soliqua
Solodyn
Soma
Sorilux
Sotilyze solution
Spritam
Sprix
Striant
Subsys
Sumavel Dosepro
Synalar topical/Kit
Synalar TS Kit
Synalgos-DC
Taclonex ointment
Taclonex suspension
Targiniq
Targiniq ER
Tenormin
Testim
Testone CIK Kit
testosterone topical 1%
Testred
Texacort
Tiazac
Tivorbex
Tizanidine Comfort Pac
Tobi nebulizer solution
Tofranil
Tofranil PM
Topicort cream 0.05%
Topicort ointment 0.05%
Topicort spray
Tranxene T
Tretin-X
Treximet
Trianex
TussiCaps
Tuxarin
Tuzistra XR
Uceris
Ultracet
Ultram
*Please check member benefit documentation to determine inclusion in the Drugs Not Covered program.
†Alternatives may be covered or available for purchase Over The Counter (OTC).
Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association
Page 2 of 3
Drugs that are Not Covered* (Medicinas que no están cubiertas*)
Continued (Continuado)
Ultram ER
Ultravate
Ultravate Kit/PAC
Ultresa
Uroxatral
Valcyte
Valium
Valtrex
Vanatol LQ
Vanos cream
Vaseretic
Vasotec
Veltin
Veramyst
Verdeso
Vibramycin
Vicodin
Vicoprofen
Vimovo
Viokace
Vivlodex
Vogelxo
Vusion
Wellbutrin
Wellbutrin SR
Wellbutrin XL
WhyteDerm TDPak
Xanax
Xanax XR
Xartemis XR
Xenazine
Xerese cream
Xodol
Xolegel
Xopenex
Xopenex HFA
Xopenex concentrate
Xtampza ER
Xyzal
Yosprala
Zantac
Zecuity
Zegerid
Zelapar
Zembrace
Zestril
Zestoretic
Zetonna
Ziana gel
Zipsor
Zohydro ER
Zolpimist
Zoloft
Zomig
Zorvolex
Zovirax
Zuplenz
Zyclara
Zyflo
Zyflo CR
Zylet
Zyprexa
Zyprexa Zydis
Zyrtec
Zyrtec-D
*Please check member benefit documentation to determine inclusion in the Drugs Not Covered program.
†Alternatives may be covered or available for purchase Over The Counter (OTC).
Florida Blue is an Independent Licensee of the Blue Cross and Blue Shield Association
Page 3 of 3