Audience: Providers of impacted patients
We have identified several medications on our formularies that are non-FDA approved products. As a result, beginning April 1, 2021, we will remove these medications from the respective formularies and exclude coverage for the following medications:
-
Hydrocortisone acetate-pramoxine hcl 2.5%-1% cream
-
Analpram HC 2.5%-1% cream
-
Pramosone 2.5%-1% cream
-
Pramosone 2.5%-1% ointment
-
Hydrocortisone 25 mg suppositories
-
Hydrocortisone 30 mg suppositories
-
Anucort HC 25 mg suppositories
-
Anusol HC 25 mg suppositories
-
Proctocort 30 mg suppositories
-
Lidocaine 3% cream
-
Lido-Sorb external 3% lotion
-
Lidocaine-hydrocortisone external cream 3-0.5 %
-
Lidocaine-hydrocortisone rectal gel 2.8-0.55 %
-
Lidocaine-hydrocortisone rectal kit 2-2 %
-
Lidocaine-hydrocortisone rectal kit 3-0.5 %
-
Lidocaine-hydrocortisone rectal kit 3-1 %
-
Lidocaine-hydrocortisone rectal kit 3-2.5 %
This exclusion is applicable to Commercial, Exchange, Essential Plan and Child Health Plus lines of business. Members who have filled one or more of these medications have been notified and directed to speak with you about possible alternatives. A list of recommended over-the-counter (OTC) and prescription alternatives for the excluded products is provided below.
|
Non-FDA Approved Drug |
Common Indications |
Alternative Recommendations |
|
Hydrocortisone acetate /pramoxine hcl 2.5%-1% cream Analpram HC 2.5%-1% cream Pramosone 2.5%-1% cream Pramosone 2.5%-1% ointment |
Hemorrhoids |
OTC:
(i.e. Preparation H)
- pramoxine 1% cream (i.e. Tronolane)
Note: OTC products may contain other active ingredients and vary by product
Rx: hydrocortisone acetate/pramoxine hcl 1%-1% cream |
|
Hydrocortisone 25 mg suppositories Hydrocortisone 30 mg suppositories Anucort HC 25 mg suppositories Anusol HC 25 mg suppositories Proctocort 30 mg suppositories |
Hemorrhoids |
OTC:
(i.e. Preparation H)
Note: OTC products may contain other active ingredients and vary by product
Rx:
|
|
Adjunct treatment of chronic ulcerative colitis |
Rx: hydrocortisone enema |
|
|
Lidocaine 3% cream Lido-Sorb external 3% lotion |
Hemorrhoids |
OTC:
(i.e. Preparation H, Nupercainal, Americaine)
Note: OTC products may contain other active ingredients and vary by product |
|
Topical anesthetic |
OTC: Lidocaine cream (i.e. Aspercreme)
Note: OTC products may contain other active ingredients and vary by product |
|
|
Lidocaine-hydrocortisone external cream 3-0.5% Lidocaine-hydrocortisone rectal gel 2.8-0.55% Lidocaine-hydrocortisone rectal kit 2-2% Lidocaine-hydrocortisone rectal kit 3-0.5% Lidocaine-hydrocortisone rectal kit 3-1% Lidocaine-hydrocortisone rectal kit 3-2.5% |
Hemorrhoids |
OTC:
(i.e. Preparation H, Nupercainal, Americaine)
(i.e. Preparation H, Nupercainal, Americaine)
Note: OTC products may contain other active ingredients and vary by product |
