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The Select Drug Program Formulary, which is available for commercial
members, is a list for commercial members 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 chapter
Effective date
adapalene 0.3% gel
Differin
® 0.3% gel
5. Skin Medications
April 14, 2014
atovaquone
Mepron
®
1. Antibiotics & Other Drugs Used for Infection
March 24, 2014
calcipotriene-betamethasone dp
Taclonex
®
5. Skin Medications
April 7, 2014
capecitabine
Xeloda
®
2. Cancer & Organ Transplant Drugs
March 17, 2014
carbidopa
Lodosyn
®
3. Pain, Nervous System, & Psych
March 17, 2014
clocortolone pivalate
Cloderm
®
5. Skin Medications
February 24, 2014
desvenlafaxine er
Khedezla
®
3. Pain, Nervous System, & Psych
April 14, 2014
doxercalciferol
Hectorol
®
7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
February 24, 2014
eszopiclone
Lunesta
®
3. Pain, Nervous System, & Psych
April 21, 2014
morphine sulf er
Avinza
®
3. Pain, Nervous System, & Psych
February 10, 2014
moxifloxacin hcl
Avelox
®
1. Antibiotics & Other Drugs Used for Infection
February 24, 2014
nevirapine
Viramune
® XR
TM
1. Antibiotics & Other Drugs Used for Infection
April 21, 2014
omega-3 acid ethyl esters
Lovaza
®
4. Heart, Blood Pressure, & Cholesterol
April 14, 2014
raloxifene hcl
Evista
®
9. Bone, Joint, & Muscle
April 7, 2014
rifabutin
Mycobutin
®
1. Antibiotics & Other Drugs Used for Infection
April 7, 2014
sevelamer carbonate
Renvela
®
15. Diagnostics & Miscellaneous Agents
April 28, 2014
telmisartan/hydrochlorothiazide
Micardis
® HCT
4. Heart, Blood Pressure, & Cholesterol
March 3, 2014
Xulane
Ortho Evra
®
10. Female, Hormone Replacement, & Birth Control
April 28, 2014
Brand additions
These brand drugs were added to the formulary as of the dates indicated
below and are covered at the appropriate
brand formulary level of cost-sharing:
Brand drug
Formulary chapter
Effective date
Axiron
®
7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
August 1, 2014
Creon
®
8. Stomach, Ulcer, & Bowel Meds
August 1, 2014
Sovaldi
TM
1. Antibiotics & Other Drugs Used for Infection
July 1, 2014
Victoza
®
7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
August 1, 2014
Zenpep
®
8. Stomach, Ulcer, & Bowel Meds
August 1, 2014
Brand deletions
Effective October 1, 2014, these brand drugs will be covered at the
appropriate non-formulary level of cost-sharing:
Brand drug
Generic drug
Formulary chapter
Aromasin
®
exemestane
2. Cancer & Organ Transplant Drugs
Avinza
®
morphine sulf er
3. Pain, Nervous System, & Psych
Differin
® 0.3% gel
adapalene 0.3% gel
5. Skin Medications
Evista
®
raloxifene hcl
9. Bone, Joint, & Muscle
Gastrocrom
®
cromolyn sodium solution
8. Stomach, Ulcer, & Bowel Meds
Lovaza
®
omega-3 acid ethyl esters
4. Heart, Blood Pressure, & Cholesterol
Lunesta
®
eszopiclone
3. Pain, Nervous System, & Psych
Mycobutin
®
rifabutin
1. Antibiotics & Other Drugs Used for Infection
Ortho Evra
®
Xulane
10. Female, Hormone Replacement, & Birth Control
Viramune
® XR
TM
nevirapine
1. Antibiotics & Other Drugs Used for Infection
Xeloda
®
capecitabine
2. Cancer & Organ Transplant Drugs
The generic drugs for the above brand drugs are available at the generic
formulary level of cost-sharing.
Brand deletions
Effective October 1, 2014, these brand drugs will be covered at the
appropriate non-formulary level of cost-sharing:
Brand drug
Formulary therapeutic alternatives
Formulary chapter
Fragmin
®
enoxaparin
4. Heart, Blood Pressure, & Cholesterol
Nexium
®
pantoprazole, rabeprazole
8. Stomach, Ulcer, & Bowel Meds
Rescriptor
®
Edurant
®, Sustiva
®
1. Antibiotics & Other Drugs Used for Infection
Videx
® solution
Emtriva
® 10 mg/ml, zidovudine 10 mg/ml
1. Antibiotics & Other Drugs Used for Infection
Vimovo
®
pantoprazole, naproxen
8. Stomach, Ulcer, & Bowel Meds
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.
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