The following drugs will be excluded from the Non-Insured Health Benefits (NIHB) Program as recommended by the Common Drug Review (CDR) and the Federal Pharmacy and Therapeutics Committee (FPT) because published evidence does not support the clinical value or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage.
Of Note: The Appeal Process and the Emergency Supply Policy will not apply for the following drug products.
| DIN | MFR | BRAND NAME |
|---|---|---|
| 02248722 | ALL | ACULAR LS 0.4% OPHTHALMIC SOLUTION |
| 02259052 | AST | AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION |
| 02247916 | BAY | CIPRO XL 500MG TABLET |
| 02251787 | BAY | CIPRO XL 1000MG TABLET |
| 02268507 | BPC | GLUMETZA 1000MG EXTENDED RELEASE TABLET |
| 02268493 | BPC | GLUMETZA 500MG EXTENDED RELEASE TABLET |
| 02248417 | FEI | GYNAZOLE-1 VAG CREAM 2% |
| 02244521 | AZC | NEXIUM 20MG SR TABLET |
| 02244522 | AZC | NEXIUM 40MG SR TABLET |
| 02241804 | SPH | PANTOLOC 20MG EC TABLET |
| 02248503 | GSK | PAXIL CR 12.5MG EXTENDED RELEASE TABLET |
| 02248504 | GSK | PAXIL CR 25MG EXTENDED RELEASE TABLET |
| 02229437 | NAB | PHOSLO 667MG TABLET |
| 02256290 | PFI | RELPAX 20MG TABLET |
| 02256304 | PFI | RELPAX 40MG TABLET |