Appendix G - Exclusions

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

The following drugs are 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.

08:00 ANTI-INFECTIVE AGENTS

08:12.18 QUINOLONES

CIPROFLOXACIN HYDROCHLORIDE

Table: CIPROFLOXACIN HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
500MG Tablet (Extended Release) 02247916 CIPRO XL BAY
1,000MG Tablet (Extended Release) 02251787 CIPRO XL BAY

28:00 CENTRAL NERVOUS SYSTEM AGENTS

28:16.04 ANTIDEPRESSANTS

PAROXETINE HYDROCHLORIDE

Table: PAROXETINE HYDROCHLORIDE
Drug strength and dosage form DIN Brand name Manufacturer code
12.5MG Tablet (Extended Release) 02248503 PAXIL GSK
25MG Tablet (Extended Release) 02248504 PAXIL GSK

28:24.92 MISCELLANEOUS ANXIOLYTICS, SEDATIVES, AND HYPNOTICS

ZOPICLONE

Table: ZOPICLONE
Drug strength and dosage form DIN Brand name Manufacturer code
5MG Tablet 02216167 IMOVANE SAC
7.5MG Tablet 01926799 IMOVANE SAC

28:32.28 SELECTIVE SEROTONIN AGONISTS

ELETRIPTAN HYDROBROMIDE

Table: ELETRIPTAN HYDROBROMIDE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG Tablet 02256290 RELPAX UNK
40MG Tablet 02256304 RELPAX UNK

40:00 ELECTROLYTIC, CALORIC, AND WATER BALANCE

40:18.19 PHOSPHATE - REMOVING AGENTS

CALCIUM ACETATE

Table: CALCIUM ACETATE
Drug strength and dosage form DIN Brand name Manufacturer code
667MG Tablet 02229437 PHOSLO FMC

52:00 EYE, EAR, NOSE AND THROAT (EENT) PREPARATIONS

52:08.20 EENT - NONSTEROIDAL ANTI-INFLAMMATORY AGENTS

KETOROLAC TROMETHAMINE

Table: KETOROLAC TROMETHAMINE
Drug strength and dosage form DIN Brand name Manufacturer code
0.4% Solution 02248722 ACULAR LS ALL

56:00 GASTROINTESTINAL DRUGS

56:28.36 PROTON-PUMP INHIBITORS

ESOMEPRAZOLE

Table: ESOMEPRAZOLE
Drug strength and dosage form DIN Brand name Manufacturer code
20MG Tablet (Delayed Release) 02244521 NEXIUM AZC
40MG Tablet (Delayed Release) 02244522 NEXIUM AZC

PANTOPRAZOLE SODIUM

Table: PANTOPRAZOLE SODIUM
Drug strength and dosage form DIN Brand name Manufacturer code
20MG Tablet (Enteric Coated) 02241804 PANTOLOC TAK

84:00 SKIN AND MUCOUS MEMBRANE AGENTS (SMMA)

84:04.08 SMMA - ANTIFUNGALS

BUTOCONAZOLE NITRATE

Table: BUTOCONAZOLE NITRATE
Drug strength and dosage form DIN Brand name Manufacturer code
2% Cream 02248417 GYNAZOLE FEI

84:92.00 MISCELLANEOUS SKIN AND MUCOUS MEMBRANE AGENTS

ALEFACEPT

Table: ALEFACEPT
Drug strength and dosage form DIN Brand name Manufacturer code
15MG/ML Powder For Solution 02259052 AMEVIVE AST
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