[
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
acamprosate calcium
Campral®
3. Pain, Nervous System, & Psych
August 16, 2013
adefovir dipivoxil
Hepsera®
1. Antibiotics & Other Drugs Used for Infection
August 16, 2013
ceftibuten
Cedax®
1. Antibiotics & Other Drugs Used for Infection
August 23, 2013
clonidine HCl ER*
KapvayTM
3. Pain, Nervous System, & Psych
September 6, 2013
gatifloxacin
ZymaxidTM
11. Eye Medications
September 20, 2013
hydrocortisone butyrate/emoll
Locoid Lipocream®
5. Skin Medications
September 20, 2013
lidocaine
Lidoderm®
3. Pain, Nervous System, & Psych
September 27, 2013
lomustine
n/a
2. Cancer & Organ Transplant Drugs
July 25, 2013
niacin ER
Niaspan®
4. Heart, Blood Pressure, & Cholesterol
September 27, 2013
paricalcitol
Zemplar®
7. Diabetes, Thyroid, Steroids, & Other
Miscellaneous Hormones
September 27, 2013
sulfacetamide sodium
Ovace® Plus
5. Skin Medications
October 4, 2013
sulfacetamide sodium/sulfur
AVAR-eTM LS cream
5. Skin Medications
October 4, 2013
temozolomide*
Temodar®
2. Cancer & Organ Transplant Drugs
October 11, 2013
voriconazole susp
Vfend® susp
1. Antibiotics & Other Drugs Used for Infection
October 18, 2013
Brand additions
Effective February 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
Acanya®
5. Skin Medications
Beyaz®
10. Female, Hormone Replacement, & Birth Control
Celebrex®
9. Bone, Joint, & Muscle
Differin® 0.3% topical gel
5. Skin Medications
First®-Progesterone VGS 25,
VGS 400
10. Female, Hormone Replacement, & Birth Control
Generess® FE
10. Female, Hormone Replacement, & Birth Control
Lo Loestrin? FE
10. Female, Hormone Replacement, & Birth Control
Minastrin® 24 FE
10. Female, Hormone Replacement, & Birth Control
Natazia®
10. Female, Hormone Replacement, & Birth Control
Ortho Tri-Cyclen® Lo
10. Female, Hormone Replacement, & Birth Control
Tazorac®
5. Skin Medications
Zovirax® cream
5. Skin Medications
Brand deletions
Effective April 1, 2014, these brand drugs will be covered at the
appropriate non-formulary level of cost-sharing:
Brand drug
Generic drug
Formulary chapter
Campral®
acamprosate calcium
3. Pain, Nervous System, & Psych
Depo-Provera® 150 mg
medroxyprogesterone acetate
10. Female, Hormone Replacement, & Birth Control
Hepsera®
adefovir dipivoxil
1. Antibiotics & Other Drugs Used for Infection
Niaspan®
niacin ER
4. Heart, Blood Pressure, & Cholesterol
Temodar®
temozolomide
2. Cancer & Organ Transplant Drugs
Vfend®
susp voriconazole susp
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 April 1, 2014, these brand drugs will be covered at the appropriate
non-formulary level of cost-sharing:
Brand drug
Formulary therapeutic alternatives
Formulary chapter
Depo-Provera® 104 mg
medroxyprogesterone acetate
10. Female, Hormone Replacement, & Birth Control
Emend®
granisetron, ondansetron
8. Gastroenterology
Estring®
Premarin® Vaginal Cream
10. Female, Hormone Replacement, & Birth Control
Repronex®
Menopur®, chorionic gonadotropin
15. Diagnostics & Miscellaneous Agents
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.]