Drugs that are withdrawn from the market may be removed from the formulary immediately. If a manufacturer withdraws a product or the FDA determines a drug is withdrawn for safety or effectiveness reasons, the plan may remove it without delay and later notify affected members. For other formulary changes made during the year (for example adding a generic or biosimilar, moving a product to a different tier, or adding utilization controls), the plan will provide notice at least 30 days before the change becomes effective or provide a one-time 31‑day supply with notice at the time of refill. Members or prescribers may request an exception to continue covering the prior drug; exception procedures and timelines (standard and expedited) are described elsewhere in the formulary materials.

The table annotation EX denotes drugs that are not normally covered in a Medicare Prescription Drug Plan. Charges for EX‑listed drugs do not count toward a member's total drug costs (they do not help qualify for catastrophic coverage) and may not qualify for extra help programs.

Products annotated with EX in the Requirements/Limits column are excluded as indicated on the formulary row. For example, individual product lines such as topical entries or specified strengths that show Requirements/Limits = EX are not covered per the formulary listing and must be treated as excluded when adjudicating claims.

Within the excerpt provided there are no additional explicit exclusion policy statements beyond the table annotations and legend references. Exclusion status is shown on a per‑product basis through the formulary Requirements/Limits column and the introduction/legend pages explain the annotations.

An example of a product listed as excluded in the table is SANTYL OINTMENT 250UNIT/GM which appears with formulary row annotations and quantity limits; certain kit and topical product lines are also shown with Requirements/Limits = EX in nearby entries (see table rows for exact items and annotations).

Examples of items marked EX in the formulary include weight‑loss/anorectic agents such as ADIPEX‑P 37.5MG, various formulations of diethylpropion, and phentermine 37.5MG, which are shown with Requirements/Limits = EX in the table.

Additional example products flagged EX in the table include select topical and kit products (for example, entries like HYDROCORTISONE ACETATE/PRAMOXINE CREAM 2.5%, PRAMOSONE CREAM, and PROCORT CREAM are shown with Requirements/Limits = EX), indicating exclusion for those specific formulations.

The formulary shows multiple flagged exclusions. Examples include DRISDOL CAPSULE 50000UNIT listed with Requirements/Limits = EX and other products (for example certain benign prostatic hyperplasia or genitourinary rows) where specific items are indicated as excluded in the Requirements/Limits column.

Across the table several products are explicitly marked EX. These include erectile dysfunction and genitourinary products where some strengths/formulations show Requirements/Limits = EX (for instance CAVERJECT entries, sildenafil/tadalafil/vardenafil lines) and certain fertility or specialty injectables noted elsewhere with exclusion annotations.

No items in this excerpt are labeled as Not Medically Necessary (NMN). The formulary excerpt uses annotations such as PA, QL, ST, and EX to indicate utilization controls and exclusions; NMN designations do not appear in the provided segments.

This formulary groups drugs by medical condition and uses a standard set of annotations to explain coverage rules. Key formulary terms are defined in the introduction: PA (prior authorization required before fill), QL (quantity limits expressed as units per time period), ST (step therapy), EX (excluded/not normally covered), NDS (non‑extended day supply restrictions), and OVM (Oncology Value Management for antineoplastics). Coverage for a listed drug is contingent on the product's formulary row — tier assignment and any listed Requirements/Limits — and prescribers must follow PA, QL, ST, or exception processes as indicated.