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); and
• Tranxene^® and generics (clorazepate).

The following drugs will be excluded from the 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
2248722	ALL	ACULAR LS 0.4% OPHTHALMIC SOLUTION
2259052	AST	AMEVIVE 15MG/0.5ML POWDER FOR SOLUTION
2247916	BAY	CIPRO XL  500MG TABLET
2251787	BAY	CIPRO XL 1000MG TABLET
2268507	BPC	GLUMETZA 1000MG EXTENDED RELEASE TABLET
2268493	BPC	GLUMETZA 500MG EXTENDED RELEASE TABLET
2248417	FEI	GYNAZOLE-1 VAG CREAM 2%
2244521	AZC	NEXIUM 20MG SR TABLET
2244522	AZC	NEXIUM 40MG SR TABLET
2241804	SPH	PANTOLOC 20MG EC TABLET
2248503	GSK	PAXIL CR 12.5MG EXTENDED RELEASE TABLET
2248504	GSK	PAXIL CR 25MG EXTENDED RELEASE TABLET
2229437	NAB	PHOSLO 667MG TABLET
2256290	PFI	RELPAX 20MG TABLET
2256304	PFI	RELPAX 40MG TABLET