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The Select Drug Program Formulary 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
acyclovir ointment
Zovirax? ointment
5. Skin Medications
April 5, 2013
buprenorphine hcl/naloxone hcl
Suboxone?
3. Pain, Nervous System, & Psych
March 8, 2013
dihydroergotamine mesylate
Migranal?
3. Pain, Nervous System, & Psych
April 12, 2013
fenofibrate
Antara?
4. Heart, Blood Pressure, & Cholesterol
March 1, 2013
fluvoxamine
Luvox CR?
3. Pain, Nervous System, & Psych
March 15, 2013
mafenide acetate
Sulfamylon?
5. Skin Medications
February 22, 2013
mupirocin calcium cream
Bactroban? cream
5. Skin Medications
February 1, 2013
travoprost
Travatan?
12. Eye Medications
April 19, 2013
tretinoin gel
Retin-A Micro?
5. Skin Medications
March 22, 2013
Brand deletions
These brand drugs will be covered at the appropriate non-formulary level of
cost-sharing: Effective October 1, 2013.
Brand drug
Generic drug
Formulary chapter
Augmentin? suspension
amoxicillin/potassium clavulanate
1. Antibiotics & Other Drugs Used for Infection
Bactroban? cream
mupirocin calcium cream
5. Skin Medications
Suboxone?
buprenorphine hcl/naloxone hcl
3. Pain, Nervous System, & Psych
Zovirax?
ointment acyclovir ointment
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.
Brand deletions
These brand drugs will be covered at the appropriate non-formulary level of
cost-sharing: Effective October 1, 2013.
Brand drug
Formulary therapeutic alternatives
Formulary chapter
Actoplus Met XR?
pioglitazone/metformin
7. Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
Ceftin? suspension
cefprozil suspension, cefaclor suspension
1. Antibiotics & Other Drugs Used for Infection
Mepron?
tinidazole tablets
1. Antibiotics & Other Drugs Used for
Infection
Proventil? HFA
ProAir? HFA
13. Allergy, Cough & Cold, Lung Meds
Rebetol?
solution ribasphere, ribavirin capsules
1. Antibiotics & Other Drugs Used for Infection
There is no generic equivalent for the above brand drugs; however, there are
therapeutic alternative drugs. These therapeutic alternative drugs are
available at the appropriate formulary level of cost-sharing.
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