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Select Drug Program® Formulary updates

September 1, 2015

The Select Drug Program Formulary, which is available for commercial members, is a list of medications approved by the U.S. Food and Drug Administration that were chosen for formulary coverage based on their medical effectiveness, safety, and value. The list changes periodically as the Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. The most recent changes are listed below.

Generic additions

These generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drug Formulary chapterEffective date
adapalene lotion Differin® Lotion 5. Skin Medications April 6, 2015
cefixime susp 100 mg/5 ml and 200 mg/5 ml Suprax® Susp 100 mg/5 ml and 200 mg/5 ml 1. Antibiotics & Other Drugs Used for InfectionApril 27, 2015
dexmethylphenidate hcl er 10 mgFocalin® XR 10 mg 3. Pain, Nervous System, & Psych February 9, 2015
doxycycline ir-dr Oracea® 1. Antibiotics & Other Drugs Used for InfectionApril 6, 2015
esomeprazole magnesium*Nexium®8. Stomach, Ulcer, & Bowel MedsFebruary 23, 2015
lamotrigine odtLamictal® ODT3. Pain, Nervous System, & Psych February 2, 2015
metaxalone 400 mgN/A 9. Bone, Joint, & MuscleApril 6, 2015
methylphenidate hcl chewable tabs Methylin® Chewable Tabs3. Pain, Nervous System, & PsychMarch 16, 2015
metoclopramide hclMetozolv® ODT8. Stomach, Ulcer, & Bowel MedsApril 13, 2015
naproxen cr Naprelan® CR 9. Bone, Joint, & Muscle March 16, 2015
noreth-ethinyl estradiol/ironGeneress® FE 10. Female, Hormone Replacement, & Birth ControlApril 6, 2015
pramipexole er 0.375 mg Mirapex® ER 0.375 mg3. Pain, Nervous System, & PsychApril 27, 2015
pramipexole er 0.75 mg and 1.5 mgMirapex® ER 0.75 mg and 1.5 mg 3. Pain, Nervous System, & PsychFebruary 16, 2015
trandolapril-verapamil erTarka®4. Heart, Blood Pressure, & Cholesterol March 2, 2015
triamcinolone acetonide spray Kenalog® Spray5. Skin MedicationsApril 27, 2015
*Generic requires prior authorization.

Brand deletions

Effective October 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drugGeneric drugFormulary chapter
Generess® FE noreth-ethinyl estradiol/iron10. Female, Hormone Replacement, & Birth Control
Mirapex® ERpramipexole er 3. Pain, Nervous System, & Psych
Oracea® doxycycline ir-dr1. Antibiotics & Other Drugs Used for Infection
The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing.

Effective October 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternative Formulary chapter
Alkeran® cyclophosphamide 2. Cancer & Organ Transplant Drugs
Epivir® HBV Soladefovir, entecavir, lamivudine 1. Antibiotics & Other Drugs Used for Infection
Fareston® exemestane, letrozole, tamoxifen 2. Cancer & Organ Transplant Drugs
Hexalen® etoposide, letrozole, tamoxifen2. Cancer & Organ Transplant Drugs
Kristalose® lactulose solution 8. Stomach, Ulcer, & Bowel Meds
Myleran® cyclophosphamide, Gleevec® 2. Cancer & Organ Transplant Drugs
Novoseven® RT Advate®, Feiba® NF, Hexilate® FS, Recombinate®4. Heart, Blood Pressure, & Cholesterol
Rixubis®AlphaNine® SD, BeneFix®, Humate-P® 4. Heart, Blood Pressure, & Cholesterol
Viramune® XR 100 mg Atripla®, Complera®, nevirapine 200 mg, Sustiva®1. Antibiotics & Other Drugs Used for Infection
Wilate® AlphaNine® SD, BeneFix®, Humate-P®4. Heart, Blood Pressure, & Cholesterol
There are no generic equivalents for the above brand drugs; however, there are formulary therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary level of cost-sharing. We encourage you to discuss formulary alternatives with your patients.


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