CRP1386903A 204612 EXCL-NPF-26 (08/08/2025) Page 7 Drug Class Excluded Medications Preferred Alternatives DORYX DR 80MG, DORYX MPC, DOXYCYCLINE HYCLATE DR 80MG MINOCYCLINE BIPHASIC TABLETS, MINOCYCLINE ER CAPSULES, XIMINO doxycycline hyclate, doxycycline monohydrate DERMATOLOGICAL Oral Agents for Acne (continued) minocycline 24 hour er tablets Oral: minocycline Topical: azelaic acid, ivermectin, metronidazole azelaic acid, ivermectin topical, metronidazole topical, sodium sulfacetamide/sulfur, FINACEA FOAM Rosacea Agents (Oral) EMROSI EPSOLAY, ZILXI Rosacea Agents (Topical) NORITATE metronidazole topical adapalene, adapalene/benzoyl peroxide, benzoyl peroxide gel, clindamycin topical, clindamycin/ benzoyl peroxide, tretinoin, tretinoin micro CABTREO, TWYNEO CLENIA PLUS, SULFACETAMIDE/SULFUR 8%-4% CLEANSER, SULFACETAMIDE/SULFUR 9%-4.25% SUSPENSION, ZMA CLEAR sulfacetamide/sulfur 9%-4% cleanser, sulfacetamide/sulfur 8%-4% suspension Topical Agents for Acne azelaic acid, dapsone 5% (tube) or 7.5% gel (pump), clindamycin topical, erythromycin topical, FINACEA FOAM DAPSONE 7.5% GEL (TUBE) FABIOR, TAZAROTENE FOAM tazarotene cream or gel, tretinoin azelaic acid, clindamycin phosphate gel, clindamycin/tretinoin, dapsone, erythromycin gel, tretinoin diclofenac 3% gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod WINLEVI CARAC, FLUOROURACIL 0.5% CREAM, KLISYRI, ZYCLARA Topical Agents for Actinic Keratosis ciclopirox 8% topical solution, tavaborole topical solution ciclopirox 8% treatment kit MICONAZOLE/ZINC OXIDE/PETROLATUM, VUSION naftifine, oxiconazole, ECOZA, ERTACZO, LULICONAZOLE, LUZU, NAFTIN, OXISTAT LOTION, SULCONAZOLE, XOLEGEL clocortolone, diflorasone, diflorasone/emollient, flurandrenolide, halcinonide, CLOBETASOL 0.025%, IMPOYZ, SERNIVO, ULTRAVATE, VERDESO clotrimazole, ketoconazole, miconazole, nystatin Topical Antifungals ciclopirox, clotrimazole, econazole, ketoconazole generic topical corticosteroids except those listed in the exclusion column Topical Corticosteroids Vitamin D Analogs (Topical) CALCIPOTRIENE FOAM, SORILUX calcipotriene cream, ointment or solution generic topical corticosteroids except those listed in the exclusion column for Topical Corticosteroids plus mupirocin ALCORTIN A crotamiton permethrin Miscellaneous Topical Dermatological Agents alclometasone cream and ointment
Henjum S, Manger M, Hampel D, et al
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Modifier use with J8499 Modifiers matter when billing oral drug codes
