TitleWeb Select Drug Program® Formulary updates
Professional; Facility; Ancillary
December 1, 2015
Page Content 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 chapter | Effective
date |
almotriptan maleate | Axert® | 3. Pain,
Nervous System, & Psych | July 13, 2015 |
alosetron hcl | Lotronex® | 8. Stomach,
Ulcer, & Bowel Meds | June 1, 2015 |
aripiprazole | Abilify® | 3. Pain, Nervous
System, & Psych | May 4, 2015 |
aspirin-dipyridamole er 25 mg ? 200 mg | Aggrenox
® 25 mg ? 200 mg | 4. Heart, Blood Pressure, &
Cholesterol | July 6, 2015 |
bexarotene 75 mg | Targretin® | 5. Skin
Medications | July 13, 2015 |
bimatoprost | Not available | 11. Eye
Medications | May 4, 2015 |
clozapine odt 150 mg and 200 mg | Fazaclo® 150 mg
and 200 mg | 3. Pain, Nervous System, & Psych | May 11, 2015
|
dexmethylphenidate hcl 20 mg | Focalin® XR 20 mg
| 3. Pain, Nervous System, & Psych | June 29, 2015 |
duloxetine hcl | Irenka? | 3. Pain, Nervous System, &
Psych | June 15, 2015 |
fenofibrate 120 mg | Fenoglide® 120 mg |
4. Heart, Blood Pressure, & Cholesterol | June 29, 2015 |
glatopa 20 mg/ml syringe | Copaxone® 20 mg/ml
Syringe | 3. Pain, Nervous System, & Psych | June 29, 2015
|
linezolid 600 mg* | Zyvox® 600 mg | 1.
Antibiotics & Other Drugs Used for Infection | June 29, 2015 |
memantine hcl | Namenda® | 3. Pain,
Nervous System, & Psych | July 20, 2015 |
naftifine hcl cream 1% | Naftin® Cream
1% | 5. Skin Medications | June 8, 2015 |
norethindrone ethinyl estradiol | FemHRT®
| 10. Female, Hormone Replacement, & Birth Control | May 18, 2015
|
pramipexole di-hcl 3 mg | Mirapex® ER 3 mg
| 3. Pain, Nervous System, & Psych | July 27, 2015 |
pyridostigmine bromide er 180 mg | Mestinon® 180
mg | 8. Stomach, Ulcer, & Bowel Meds | July 6, 2015 |
risedronate sodium 5 mg, 30 mg, and 35 mg | Actonel
® 5 mg, 30 mg, and 35 mg | 9. Bone, Joint, &
Muscle | June 8, 2015 |
risedronate sodium dr | Atelvia® | 9.
Bone, Joint, & Muscle | May 25, 2015 |
tolcapone | Tasmar® | 3. Pain, Nervous
System, & Psych | May 18, 2015 |
tramadol hcl er | Conzip? | 3. Pain, Nervous System, &
Psych | June 15, 2015 |
*Generic requires prior authorization.
Brand additions
These brand drugs were added to the formulary and covered at the appropriate
brand formulary level of cost-sharing as of the date indicated below:
Brand drug | Generic drug | Formulary chapter | Effective
date |
Caverject® | Not available | 13. Urinary &
Prostate Meds | September 1, 2015 |
Eliquis® | Not available | 4. Heart,
Blood Pressure, & Cholesterol | September 1, 2015 |
Nutropin AQ® | Not available | 7.
Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | September
1, 2015 |
Restasis® | Not available | 11. Eye
Medications | December 1, 2015 |
Brand deletions
Effective January 1, 2016, these brand drugs will be
covered at the appropriate non-formulary level of cost-sharing:
Brand drug | Generic drug | Formulary chapter |
Abilify® | aripiprazole | 3. Pain, Nervous
System, & Psych |
Actonel® 5 mg, 30 mg, and 35 mg | risedronate
sodium 5 mg, 30 mg, and 35 mg | 9. Bone, Joint, & Muscle |
Mestinon® 180 mg | pyridostigmine bromide er 180
mg | 8. Stomach, Ulcer, & Bowel Meds |
Mirapex® ER 3 mg | pramipexole di-hcl 3 mg
| 3. Pain, Nervous System, & Psych |
Namenda® | memantine hcl | 3. Pain,
Nervous System, & Psych |
Targretin® | bexarotene 75 mg | 5. Skin
Medications |
The generic drugs for the above brand drugs are on our formulary and available
at the generic formulary level of cost-sharing.
Effective January 1, 2016, this brand drug will be covered
at the appropriate non-formulary level of cost-sharing:
Brand drug | Generic drug | Formulary chapter |
Replax® | sumatriptan, rizatriptan,
zolmitriptan | 3. Pain, Nervous System, & Psych |
There is no generic equivalent for the above brand drug; 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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