The Select Drug Program Formulary 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
abacavir/lamivudine/zidovudine
Trizivir
®
1. Antibiotics & Other Drugs Used for
Infection
December 23, 2013
dexmethylphenidate hcl xr
Focalin
TM XR
3. Pain, Nervous System, & Psych
November 25, 2013
diclofenac sodium
Solaraze
®
9. Bone, Joint, & Muscle
December 2, 2013
duloxetine
Cymbalta
®
3. Pain, Nervous System, & Psych
December 16, 2013
fluocinonide
Vanos
®
5. Skin Medications
January 20, 2014
hydrocod-cpm-pseudoephedrine
Zutripro
TM
12. Allergy, Cough & Cold, Lung Meds
January 20, 2014
lamivudine
Epivir HBV
®
1. Antibiotics & Other Drugs Used for Infection
January 13, 2014
lomedia 24 fe
Not available
10. Female, Hormone Replacement, &
Birth Control
January 6, 2014
moderiba*
Ribapak
®
1. Antibiotics & Other Drugs Used for Infection
January 13, 2014
mycophenolic acid
Myfortic
®
2. Cancer & Organ Transplant Drugs
January 13, 2014
Not available
Klor-Con
® 25 meq Packets
14. Vitamins & Electrolytes
May 1, 2014
potassium citrate er
Urocit
®-K
13. Urinary & Prostate Meds
January 13, 2014
rabeprazole
Aciphex
®
8. Stomach, Ulcer, & Bowel Meds
November 18, 2013
sirolimus
Rapamune
®
2. Cancer & Organ Transplant Drugs
January 20, 2014
telmisartan
Micardis
®
4. Heart, Blood Pressure, & Cholesterol
January 13, 2014
telmisartan-amlodipine
Twynsta
®
4. Heart, Blood Pressure, & Cholesterol
January 13, 2014
tobramycin
Tobi
®
1. Antibiotics & Other Drugs Used for Infection
November 25, 2013
tolterodine tartrate er
Detrol
® LA
13. Urinary & Prostate Meds
January 13, 2014
*Generic drug requires prior authorization.
Brand additions
Effective May 1, 2014, these brand drugs were added to the formulary and are
covered at the appropriate brand
formulary level of cost-sharing:
Brand drug
Formulary chapter
Asmanex
®
12. Allergy, Cough & Cold, Lung Meds
Ciprodex
®
6. Ear, Nose, Throat Medications
Estring
®
10. Female, Hormone Replacement, & Birth Control
Tecfidera
®
3. Pain, Nervous System, & Psych
Brand deletions
Effective July 1, 2014, these brand drugs will be covered at the appropriate
non-formulary level of cost-sharing:
Brand drug
Generic drug
Formulary chapter
Cymbalta
®
duloxetine
3. Pain, Nervous System, & Psych
Epivir HBV
®
lamivudine
1. Antibiotics & Other Drugs Used for Infection
Rapamune
® 0.5 mg tab
sirolimus
2. Cancer & Organ Transplant Drugs
Tobi
®
tobramycin
1. Antibiotics & Other Drugs Used for Infection
Trizivir
®
abacavir/lamivudine/zidovudine
1. Antibiotics & Other Drugs Used for Infection
The generic drugs for the above brand drugs are available at the generic
formulary level of cost-sharing.
Brand deletions
Effective July 1, 2014, these brand drugs will be covered at the appropriate
non-formulary level of cost-sharing:
Brand drug
Formulary therapeutic alternatives
Formulary chapter
Advair
®
Dulera
®, Symbicort
®
12. Allergy, Cough & Cold, Lung Meds
Ciloxan
®
Vigamox
TM, ciprofloxacin
11. Eye Medications
Cipro
® HC
Ciprodex
®
6. Ear, Nose, Throat Medications
Flovent
®
Qvar
®, Asmanex
®
12. Allergy, Cough & Cold, Lung Meds
Pulmicort Flexhaler
®
Qvar
®, Asmanex
®
12. Allergy, Cough & Cold, Lung 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.