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Select Drug Program® Formulary updates

August 28, 2014

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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® XRTM 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 SovaldiTM 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® XRTM 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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