Drug Benefit List 2012

Appendix E - Exclusions

Certain drug products are not within the scope of the program. These products will not be reimbursed as benefits under the NIHB Program:

• Anti-obesity drugs;
• Household products (regular soaps and shampoos);
• Cosmetics;
• Alternative therapies, including glucosamine and evening primrose oil;
• Megavitamins;
• Drugs with investigational/experimental status;
• Vaccinations for travel indications;
• Hair growth stimulants;
• Fertility agents and impotence drugs;
• Selected over-the-counter products;
• Codeine containing cough preparations;
• Dalmane^®, Somnol^® and generics (flurazepam);
• Darvon^® and 642^® (propoxyphene);
• Fiorinal^®, Fiorinal^® C ¼, Fiorinal^® C ½ and generics (Butalbital containing analgesics with and
• without codeine);
• Librium^®, Solium^®, Medilium^® and generics (chlordiazepoxide);
• Stadol TM NS and generics (butorphanol tartrate nasal spray);
• Tranxene^® and generics (clorazepate); and
• Imovane^® and generics (zopiclone).

The following drugs will be excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC) 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.

• 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%
• 02216167 SAC IMOVANE 5MG TABLET
• 01926799 SAC IMOVANE 7.5MG TABLET
• 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