Drug Benefit List
Exclusions by the Common Drug Review and the Federal Pharmacy
and Therapeutics Committee
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 |
| 02248722 |
ALL |
ACULAR LS 0.4% OPHTHALMIC SOLUTION |
| 02247916 |
BAY |
CIPRO XL 500MG TABLET |
| 02251787 |
BAY |
CIPRO XL 1000MG 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 |
| 02243797 |
JNO |
PARIET EC 20MG TABLET |
| 02248503 |
GSK |
PAXIL CR 12.5MG EXTENDED RELEASE TABLET |
| 02248504 |
GSK |
PAXIL CR 25MG EXTENDED RELEASE TABLET |
| 02256290 |
PFI |
RELPAX 20MG TABLET |
| 02256304 |
PFI |
RELPAX 40MG TABLET |
|
