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Johns Hopkins Health Plans

Non-Covered Medications

Prescription medications removed from the TRICARE pharmacy benefit program.

Drug Class Products not covered/removed from TRICARE Formulary Formulary Alternatives Effective Date of Change
Acne Agents: Topical Acne and Rosacea
 clindamycin 1.2%, adapalene 0.15%, and benzoyl peroxide 3.1% topical gel (Cabtreo)
  • clindamycin/benzoyl peroxide gel
  • adapalene gel
  • tretinoin cream
 08/28/2024
Pain Agents: NSAIDs
 oxaprozin 300 mg capsules (Coxanto)
  • meloxicam
  • oxaprozin 600 mg tabletsnaproxen ER (Naprelan ER)
 08/28/2024
Cardiovascular Agents Miscellaneous colchicine low dose (LODOCO 0.5 mg tablets
  • colchicine 0.6 mg tablets (generic Colcrys)
  • colchicine 0.6 mg caps (generic Mitigare
 6/12/2024
PAH: PDE-5 Inhibitors sildenafil 10 mg/mL oral
suspension (Liqrev)
  • sildenafil tabs
  • sildenafil 10 mg/mL oral suspension
    (generic Revatio)
  • tadalafil oral suspension (Tadliq)
 02/28/2024
Binders
Chelators
Antidotes 		trientine
tetrahydrochloride tabs
(Cuvrior)
  • trientine hydrochloride caps
  • penicillamine
 02/28/2024
Sleep Disorders: Insomnia Agents zolpidem 7.5 mg caps
  • zolpidem IR 5 mg, 10 mg tabs
  • zolpidem ER 6.25 mg, 12.5 mg tabs
  • zaleplon 5 mg and 10 mg caps
  • eszopiclone 1 mg, 2 mg and 3 mg tabs
 02/28/2024
Ophthalmic Dry Eye Agentsloteprednol etabonate 0.25% ophthalmic suspension (Eysuvis)
  • cyclosporine 0.05% ophthalmic emulsion unit-dose (generic Restasis)
  • cyclosporine 0.05% ophthalmic emulsion multi-dose (Restasis Multidose)
  • cyclosporine 0.09% ophthalmic solution (Cequa)
  • lifitegrast 5% ophthalmic solution (Xiidra)
  • loteprednol 0.2% ophthalmic suspension (Alrex, generic)
  • loteprednol 0.5% ophthalmic suspension (Lotemax, generic)
 11/22/2023
Diureticsfurosemide SC injection (Fuoscix)
  • furosemide
  • bumetanide
  • ethacrynic acid
  • torsemide
 08/30/2023
Benign Prostatic Hyperplasia Agents; 5-alpha Reductase Inhibitors finasteride/ tadalafil (Entadfi)
  • finasteride tab
  • dutasteride tab
  • tadalafil tab
 05/31/2023
Nasal Allergy Agents: Corticosteroids olopatadine 665 mcg /mometasone 25 mcg nasal spray (Ryaltris Nasal Spray)
  • azelastine (Astelin, Astepro)
  • olopatadine (Patanase)
  • fluticasone/azelastine (Dymista)
  • fluticasone propionate (Flonase)
  • mometasone (Nasonex)
  • ipratropium (Atrovent)
  • budesonide (Rhinocort)
  • triamcinolone (Nasacort)
  • beclomethasone (Beconase AQ, QNASL)
  • ciclesonide (Omnaris, Zetonna)
  • flunisolide (Nasarel)
 05/31/2023
Skeletal Muscle Relaxants baclofen oral solution (Lyvispah)
  • baclofen oral solution (Ozobax)
  • baclofen oral suspension (Fleqsuvy)
  • baclofen tablets
 03/01/2023
Acne Agents: Topical Acne & Rosacea benzoyl peroxide 5% cream (Epsolay)
  • benzoyl peroxide gel OTC and Rx versions
  • azaleic acid 15% gel (Finacea gel)
  • metronidazole 1% gel
  • brimonidine 0.33% gel (Mirvaso)
  • ivermectin 1% cream (Soolantra)
  • minocycline 1.5% topical foam (Zilxi)
  • minocycline 4% foam (Amzeeq)
  • minocycline 50 mg tablets
 03/01/2023
Nephrology Agents Miscellaneous budesonide (Tarpeyo)
  • prednisone
  • methylprednisolone 
  • budesonide delayed release capsules (Entocort EC, generics)
 11/30/2022
Narcotic Analgesics and Combinations celecoxib/tramadol (Seglentis)
  • tramadol
  • celecoxib
 11/30/2022
Anticholinergics-Antispasmodics glycopyrrolate (Dartisla ODT)
  • glycopyrrolate tablets glycopyrrolate oral solution (Cuvposa)
  • omeprazole
  • famotidine
 11/30/2022
Endocrine Agents Miscellaneous levoketoconazole(Recorlev)
  • ketoconazole
  • metyrapone (Metopirone)
  • osilodrostat (Isturisa)
  • pasireotide (Signifor LAR –medical benefit)
 11/30/2022
Diuretics torsemide (Soaanz)
  • torsemide
  • furosemide
  • bumetanide
  • ethacrynic acid
 11/30/2022
Acne Agents: Topical Acne &
Rosacea		 tretinoin 0.1%/benzoyl peroxide3% topical cream(Twyneo)
  • tretinoin cream
  • benzoyl peroxide cream
 11/30/2022
Pain Agents: NSAIDs Celecoxib oral solution (Elyxyb)
  • Celecoxib tablets
  • Ibuprofen
  • Naproxen
  • Diclofenac
  • Numerous other NSAIDs or combo products
 08/24/2022
Antianxiety Agents: Benzodiazepines Lorazepam ER capsule (Loreev XR)
  • Lorazepam IR tablets
  • Alprazolam IR and XR tablets
 06/15/2022
Migraine Agents Dihydroergotamine mesylate nasal spray (Trudhesa)
  • DHE nasal spray
  • Sumatriptan nasal and oral
  • Rizatriptan
  • Zolmitriptan
  • Eletriptan
 06/15/2022
Antilipidemic-1s Rosuvastatin/ ezetimibe (Roszet)
  • Rosuvastatin with ezetimibe
  • Atorvastatin with ezetimibe
  • Simvastatin/ezetimibe (Vytorin)
  • Evolocumab (Repatha)
  • Alirocumab (Praluent)
 06/15/2022
Anticonvulsants-Antimania Agents Levetiracetam (Elepsia XR)
  • Levetiracetam ER
  • Lamotrigine XR
  • Topiramate ER
 06/15/2022
Corticosteroids-Immune Modulators: High Potency Clobetasol propionate 0.05% lotion metered dose pump (Impeklo)
  • Betamethasone/propylene glycol 0.05% lotion
  • Betamethasone dipropionate 0.05% gel
  • Clobetasol propionate/emollient 0.05 % (emulsion) foam
  • Clobetasol propionate 0.05% solution, lotion, gel, foam, spray, and shampoo
  • Fluocinonide 0.05% solution and gel
 06/15/2022
Psoriasis Agents Calcipotriene/ betamethasone dipropionate 0.005% /0.064% topical cream (Wynzora)
  • Vitamin D analog (calcipotriene 0.005% cream, ointment or solution) with a high potency topical corticosteroid (clobetasol propionate 0.05% ointment, cream, solution and gel
  • Fluocinonide 0.05% cream, gel, and solution
  •  Calcipotriene 0.005% / betamethasone 0.064% foam (Enstilar) [Nonformulary]
 06/15/2022
GI-1 Agents Budesonide ER 9 mg capsules (Ortikos)
  • Budesonide ER tablets (Entocort EC, generics
  • Other corticosteroids
 06/02/2021
Corticosteroids Dexamethasone 20 mg tables (Hemady)
  • Dexamethasone generics 0.5, 0.75, 1, 1.5, 2, 4, 6 mg tabs
 06/02/2021
Pulmonary I Agents Inhaled Corticosteroids (ICS) Fluticasone propionate dry powder inhaler oral (ArmonAir Digihaler)
  • Fluticasone (Flovent Diskus)
  • Fluticasone (Flovent HFA)
  • Fluticasone furoate (Arnuity Ellipta) [non formulary]
  • Beclomethasone (QVAR) [non formulary]
  • Budesonide (Pulmicort Flexhaler) [non formulary]
  • Ciclesonide (Alvesco) [non formulary]
  • Flunisolide (Aerospan) [non formulary]
  • Mometasone (Asmanex Twisthaler [non formulary]
 06/02/2021
Pulmonary I Agents ICS/Long-Acting Beta Agonists (LABA) Fluticasone propionate / salmeterol dry powder inhaler oral (AirDuo Digihaler)
  • Fluticasone/salmeterol (Advair Diskus)
  • Fluticasone/salmeterol (Advair HFA)
  • Fluticasone/vilanterol (Breo Ellipta) [non formulary]
  • Mometasone/formoterol (Dulera) [non formulary]
  • Budesonide/formoterol (Symbicort) [non formulary]
  • Fluticasone/salmeterol (AirDuo Respiclick) [non formulary]
 06/02/2021
Calcium Channel Blockers Levamlodipine (Conjupri)
  • Amlodipine
  • Felodipine
  • Nifedipine
  • Diltiazem
  • Verapamil
 06/02/2021
GI-2 Agents Metoclopramide nasal spray (Gimoti)
  • Metoclopramide oral tablet (Reglan generics)
  • Metoclopramide oral solution (Reglan, generics)
  • Metoclopramide orally disintegrating tablet (Reglan ODT)
 06/02/2021
Topical Psoriasis Agents Calcipotriene 0.005%­ Betamethasone 0.064% Suspension (Taclonex, Generic) Scalp Psoriasis:
  • Calcipotriene 0.005% solution
  • Clobetasol 0.05% solution, shampoo
  • Fluocinonide 0.05% solution
  • Calcipotriene 0.005%-betamethasone 0.064% foam (Enstilar) [Nonformulary]
Psoriasis involving areas other than the scalp:
  • Calcipotriene 0.005% ointment, cream, solution
  • Clobetasol 0.05% ointment, cream
  • Fluocinonide 0.05% cream, ointment
 02/24/2021
High-Potency Topical Corticosteroids Halcinonide 0.1% topical solution (Halog)
  • Betamethasone propylene glycol 0.05% cream
  • Clobetasol propionate 0.05% cream and ointment
  • Clobetasol propionate/emollient 0.05% cream
  • Desoximetasone 0.25% cream and ointment
  • Fluocinonide 0.05% cream and ointment
  • Fluocinonide/emollient base 0.05% cream
  • Halobetasol propionate 0.05% ointment
 2/24/2021
Acne Agents: Topical Acne and Rosacea Tazarotene 0.045% lotion (Arazlo)
  • Adapalene 0.1% lotion, gel, cream
  • Adapalene 0.3% gel
  • Clindamycin phosphate 1% gel, cream, lotion, and solution
  • Clindamycin/ benzoyl peroxide 1.2% -5% gel
  • Tazarotene 0.1% cream • tretinoin 0.025%, 0.05%, and 0.1% cream
  • Tetinoin 0.01% and 0.025% gel
 2/24/2021
Pain Agents Class; NSAIDs Subclass Consensi (Amlodipine-celecoxib)
  • Dihydropyridine calcium channel blockers: amlodipine, felodipine, nifedipine, isradipine PLUS
  • NSAIDs: celecoxib, diclofenac, ibuprofen, meloxicam, naproxen, (also includes other NSAIDs)
 8/26/2020
Pain Agents Class; NSAIDs Subclass
  • Zipsor liquid-filled capsules (diclofenac potassium)
  • Zorvolex (diclofenac submicronized)
  • Fenoprofen capsules
  • Tivorbex (indomethacin submicronized)
  • Vivlodex (meloxicam submicronized)
 NSAIDs: celecoxib, diclofenac, indomethacin, meloxicam, naproxen, (also includes other NSAIDs) 8/26/2020
Pain Agents Class; NSAIDs Subclass Duexis tablets (ibuprofen-famotidine)
  • H2 blockers: famotidine, ranitidine, cimetidine, nizatidine PLUS
  • NSAIDs: celecoxib, diclofenac, ibuprofen, meloxicam, naproxen, (also includes other NSAIDs)
 8/26/2020
Pain Agents Class; Pain Topical Subclass
  • Pennsaid 2% (diclofenac 2% solution)
  • Flector, generics (diclofenac 1.3% patch)
  • Oral NSAIDs: celecoxib, diclofenac, indomethacin, meloxicam, naproxen, (also includes other NSAIDs)
  • Diclofenac 1.5% solution
  • Diclofenac 1% gel
 8/26/2020
Pain Agents Class; Pain Topical Subclass ZTlido (lidocaine 1.8% patch) Lidocaine 5% patch 8/26/2020
Pulmonary: Short Acting Beta-2 Agonists (SABA) ProAir Digihaler (albuterol dry powder inhaler)
  • Albuterol MDI (ProAir HFA)
  • Albuterol DPI (ProAir Respiclick)
  • Albuterol MDI (Proventil HFA) [Nonformulary]
  • Albuterol MDI (Ventolin HFA) [Nonformulary]
  • Levalbuterol MDI (Xopenex HFA) [Nonformulary]
 8/26/2020
Acne Agents: Topical Acne and Rosacea Enzoclear (benzoyl peroxide 9.8% foam)
  • Clindamycin/benzoyl peroxide 1.2% -5% gel (Duac, generics)
  • Clindamycin/benzoyl peroxide 1% -5% gel (Benzaclin, generics)
  • Clindamycin/benzoyl peroxide 1% -5% gel kit (Duac CS Kit)
 8/26/2020
Anti-Infectives: Miscellaneous Talicia (omeprazole magnesium-amoxicillin-rifabutin)
  • Omeprazole PLUS amoxicillin PLUS rifabutin (given separately)
  • Omeprazole PLUS clarithromycin PLUS amoxicillin
  • Bismuth subsalicylate OTC PLUS metronidazole PLUS tetracycline PLUS PPI
 8/26/2020
Rapid Acting Insulins Insulin plus niacinamide (Fiasp)
  • Insulin aspart (Novolog)
  • Insulin lispro (Humalog or authorized generic lispro)
  • Insulin lispro (Admelog) [nonformulary]
  • Insulin glulisine (Apidra) [nonformulary]
 07/01/2020
Pulmonary-2 Agents: COPD Formoterol/aclidinium (Duaklir Pressair)
  • Umeclidinium/vilanterol (Anoro Ellipta)
  • Tiotropium/olodaterol (Stiolto Respimat)
  • Glycopyrrolate/formoterol (Bevespi Aerosphere) [nonformulary]
 06/10/2020
Migraine Agents: Triptans Sumatriptan nasal spray (Tosymra)
  • Sumatriptan nasal spray (Imitrex, generics)
  • Sumatriptan nasal powder (Onzetra Xsail)
  • Zolmitriptan nasal spray (Zomig)
 06/10/2020
GI2 Agents: CIC and IBS-C Tegaserod (Zelnorm)
  • Linaclotide (Linzess)
  • Plecanatide (Trulance)
  • Lubiprostone (Amitiza)
  • Pruclaopride (Motegrity) [nonformulary]
 06/10/2020
PDE-5 inhibitor
  • Avanafil tablet (Stendra)
  • Brand Viagra tablet
  • Brand Cialis tablet
  • Vardenafil tablet (Levitra and generics)
  • Vardenafil oral disintegrating tablet (ODT) (Staxyn and generics)
  • Sildenafil tablet (generic Viagra only)
  • Tadalafil tablet (generic Cialis only)
 06/03/2020
ADHD Methylphenidate ER sprinkle capsules (Adhansia XR)
  • Methylphenidate ER (Aptensio XR sprinkle capsule) for patients with swallowing difficulties
  • Methylphenidate ER oral suspension (Quillivant XR suspension) for patients with swallowing difficulties
  • Methylphenidate ER osmotic controlled release oral delivery system (OROS) (Concerta, generics)
  • Methylphenidate long-acting (Ritalin LA, generics)
  • Methylphenidate controlled delivery (CD) (Metadate CD, generics)
  • Dexmethylphenidate ER (Focalin XR, generics)
  • Mixed amphetamine salts ER (Adderall XR, generics)
 03/04/2020
High-Potency Topical Corticosteroids
  • Clobetasol propionate 0.025% cream (Impoyz)
  • Diflorasone diacetate/emollient 0.05% cream (Apexicon-E)
  • Halcinonide 0.1% cream (Halog)
  • Betamethasone/propylene glycol 0.05% cream
  • Clobetasol propionate 0.05% cream
  • Clobetasol propionate/emollient 0.05% cream
  • Desoximetasone 0.25% cream
  • Fluocinonide 0.05% cream
  • Fluocinonide/emollient base 0.05% cream
 03/04/2020
High-Potency Topical Corticosteroids Halcinonide 0.1% ointment (Halog)
  • Betamethasone dipropionate 0.05% ointment
  • Betamethasone/propylene glycol 0.05% ointment
  • Clobetasol propionate 0.05% ointment
  • Desoximetasone 0.25% ointment
  • Fluocinonide 0.05% ointment
  • Halobetasol propionate 0.05% ointment
 03/04/2020
High-Potency Topical Corticosteroids
  • Clobetasol propionate 0.05% shampoo/ cleanser (kit) (Clodan kit)
  • Halobetasol propionate 0.05% lotion (Ultravate)
  • Halobetasol propionate 0.05% foam (authorized generic for Lexette) (see Feb 2019 for brand Lexette recommendation)
  • Betamethasone propylene glycol 0.05% lotion
  • Betamethasone dipropionate 0.05% gel
  • Clobetasol propionate/emollient 0.05 % emulsion foam
  • Clobetasol propionate 0.05% solution, lotion, gel, foam, spray, and shampoo
  • Fluocinonide 0.05% solution and gel
 03/04/2020
PPIs
  • Dexlansoprazole (Dexilant)
  • Esomeprazole strontium
  • Esomeprazole
  • Omeprazole
  • Pantoprazole
  • Rabeprazole
 11/28/2019
High-Potency Topical Corticosteroids Halobetasol propionate 0.05% foam (Lexette brand)
  • Betamethasone/propylene glycol 0.05% lotion
  • Betamethasone dipropionate 0.05% gel
  • Clobetasol propionate/emollient 0.05% emulsion foam
  • Clobetasol propionate 0.05% solution, lotion, gel, foam, spray, and shampoo
 10/01/2019
Diabetes Non- Insulin Drugs – Biguanides Subclass Metformin ER gastric retention 24 hours (Glumetza)
  • Metformin IR (Glucophage generic)
  • Metformin ER (Glucophage XR generic)
 10/01/2019
Pain Agents – Combinations Naproxen / Esomeprazole (Vimovo)
  • PPIs: omeprazole, pantoprazole, esomeprazole, rabeprazole PLUS
  • NSAIDs: celecoxib, diclofenac, indomethacin, meloxicam, naproxen, (also includes other NSAIDs)
 10/01/2019