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Select Drug Program® Formulary updates

December 2, 2013

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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.

Reminder about the Preventive Medication Program included in our prescription drug plan

Certain preventive medications, as described in the Patient Protection and Affordable Care Act (PPACA), including generic products and those brand products that do not have a generic equivalent, are covered without cost-sharing with a doctor?s prescription when provided by a participating retail or mail-order pharmacy. Coverage includes certain products within the following drug categories: (1) aspirin to prevent cardiovascular disease for men age 45-79 and women age 55-79, (2) breast cancer chemotherapy prevention for women, (3) fluoride supplementation for children 6 months through 6 years, (4) folic acid supplementation for women planning or capable of pregnancy, (5) iron supplementation for children ages 6 to 12 months who are at increased risk for iron deficiency anemia, (6) tobacco interventions for adults who use tobacco products, and (7) vitamin D supplementation for ages 65 and over to prevent falls.

Contraceptives, mandated by the Women?s Preventive Services provision of the PPACA, are covered at 100 percent when provided by a participating provider for generic products and for those brand products that do not have a generic equivalent. Brand contraceptive products with a generic equivalent are covered at the brand cost-sharing level for the member?s plan.

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 acitretin Soriatane? 5. Skin Medications July 25, 2013 alendronate sodium solution Fosamax? solution 10. Female, Hormone Replacement, & Birth Control April 26, 2013 candesartan cilexetil Atacand? 4. Heart, Blood Pressure, & Cholesterol May 23, 2013 chorionic gonadotropin Novarel?/Pregnyl? 15. Diagnostics & Miscellaneous January 1, 2014 dihydrocodeine/aspirin/caffeine Synalgos?-DC 3. Pain, Nervous System, & Psych May 31, 2013 fenofibric acid (choline) Trilipix? 4. Heart, Blood Pressure, & Cholesterol July 19, 2013 metronidazole topical gel Metrogel? 5. Skin Medications July 3, 2013 omeprazole suspension First?-Omeprazole 8. Stomach, Ulcer, & Bowel Meds June 28, 2013 quazepam Doral? 3. Pain, Nervous System, & Psych July 12, 2013 repaglinide Prandin? 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones July 25, 2013 riluzole Rilutek? 3. Pain, Nervous System, & Psych June 7, 2013 zolmitriptan Zomig?, Zomig-ZMT? 3. Pain, Nervous System, & Psych May 17, 2013

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 Advate? 15. Diagnostics & Miscellaneous January 1, 2014 Alphanate? 15. Diagnostics & Miscellaneous January 1, 2014 Alphanine? SD 15. Diagnostics & Miscellaneous January 1, 2014 Bebulin? 15. Diagnostics & Miscellaneous January 1, 2014 BeneFIX? 15. Diagnostics & Miscellaneous January 1, 2014 Cialis? 13. Urinary & Prostate Meds October 1, 2013 Feiba NF? 15. Diagnostics & Miscellaneous January 1, 2014 Helixate? FS 15. Diagnostics & Miscellaneous January 1, 2014 Hemofil? M 15. Diagnostics & Miscellaneous January 1, 2014 Humate-P? 15. Diagnostics & Miscellaneous January 1, 2014 Koate?-DVI 15. Diagnostics & Miscellaneous January 1, 2014 Kogenate? FS 15. Diagnostics & Miscellaneous January 1, 2014 Lialda? 3. Pain, Nervous System, & Psych November 1, 2013 LiptruzetTM 4. Heart, Blood Pressure, & Cholesterol November 1, 2013 Monoclate-P? 15. Diagnostics & Miscellaneous January 1, 2014 Mononine? 15. Diagnostics & Miscellaneous January 1, 2014 NovoSeven? RT 15. Diagnostics & Miscellaneous January 1, 2014 Profilnine? SD 15. Diagnostics & Miscellaneous January 1, 2014 RecombinateTM 15. Diagnostics & Miscellaneous January 1, 2014 Vascepa? 4. Heart, Blood Pressure, & Cholesterol November 1, 2013 Wilate? 15. Diagnostics & Miscellaneous January 1, 2014 Xarelto? 4. Heart, Blood Pressure, & Cholesterol November 1, 2013 Xyntha? 15. Diagnostics & Miscellaneous January 1, 2014

Brand deletions

Effective January 1, 2014, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternatives Formulary chapter Cortef? 5mg, 10mg hydrocortisone 9. Bone, Joint, & Muscle Efudex? fluorouracil 5. Skin Medications Lanoxin? digoxin 4. Heart, Blood Pressure, & Cholesterol Metrogel? metronidazole topical gel 5. Skin Medications Prandin? repaglinide 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones Trilipix? fenofibric acid (choline) 4. Heart, Blood Pressure, & Cholesterol

The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing.

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