CRP1386903A 204612 EXCL-NPF-26 (08/08/2025) Page 8 Drug Class Excluded Medications Preferred Alternatives DERMATOLOGICAL Miscellaneous Topical Dermatological Agents (continued) TRI-LUMA fluocinolone, hydroquinone, tretinoin VEREGEN imiquimod 5% cream, podofilox gel or solution DIABETES Biguanidine Agents METFORMIN 625MG TABLETS metformin 500mg, 850mg or 1,000mg tablets ABBOTT FREESTYLE KITS/METERS (FREESTYLE FREEDOM, FREESTYLE FREEDOM LITE, FREESTYLE INSULINX, FREESTYLE LITE) ABBOTT FREESTYLE TEST STRIPS (FREESTYLE, FREESTYLE INSULINX, FREESTYLE LITE, FREESTYLE PRECISION NEO) ABBOTT PRECISION XTRA METERS, TEST STRIPS TRIVIDIA METERS (TRUE METRIX AIR, TRUE METRIX, TRUE METRIX GO) TRIVIDIA TEST STRIPS (TRUE METRIX, TRUETRACK) ASCENSIA (CONTOUR) ELI LILLY (TEMPO) LIFESCAN (ONETOUCH SOLUTIONS STARTER, ULTRA, ULTRA2, VERIO, VERIO FLEX) ROCHE (ACCU-CHEK) ALL OTHER METERS & TEST STRIPS THAT ARE NOT LISTED AS PREFERRED Blood Glucose Meters & Test Strips DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR Continuous Glucose Monitoring Systems EVERSENSE 365: SENSOR, TRANSMITTER PEN NEEDLES & SYRINGES BY: ARKRAY HOME AIDE DIAGNOSTICS HTL-STREFA NOVO NORDISK OWEN MUMFORD PRODIGY DIABETES CARE SIMPLE DIAGNOSTICS TRIVIDIA (NIPRO DIAGNOSTICS) ULTIMED ALL OTHER DIABETIC PEN NEEDLES & SYRINGES THAT ARE NOT LISTED AS PREFERRED EMBECTA PEN NEEDLES EMBECTA SYRINGES Diabetic Pen Needles & Syringes DEXCOM G6: RECEIVER, SENSOR, TRANSMITTER DEXCOM G7: RECEIVER, SENSOR FREESTYLE LIBRE: READER, SENSOR Diabetic Supply Kits BIGFOOT UNITY PROGRAM KIT ALOGLIPTIN, NESINA, SITAGLIPTIN, TRADJENTA, ZITUVIO ALOGLIPTIN/METFORMIN, JENTADUETO, JENTADUETO XR, KAZANO, SITAGLIPTIN/METFORMIN, SITAGLIPTIN/METFORMIN ER, ZITUVIMET, ZITUVIMET XR saxagliptin, JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitors & Combinations saxagliptin/metformin, JANUMET, JANUMET XR ALOGLIPTIN/PIOGLITAZONE pioglitazone plus saxagliptin or JANUVIA Dipeptidyl Peptidase-4 (DPP-4) Inhibitors/Sodium Glucose Co-Transporter-2 (SGLT-2) Inhibitors Combinations QTERN, STEGLUJAN GLYXAMBI (continued) 2025 Evernorth Health Services
Burgeson, R
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4) Sodium cromoglicate (cromolyn) Oral cromolyn, which is the only formulation available in Canada, may be considered for individuals with persistent GI symptoms associated with MCAS episodes despite the use of anti-H1 and anti-H2 [78]
Kidney disease and renal impairment represent significant concerns
