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Select Drug Program® Formulary updates

February 29, 2016

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 aripiprazole 1 mg/ml Abilify® 1 mg/ml 3. Pain, Nervous System, & Psych August 24, 2015 aripiprazole odt 10 mg and 15 mg Not available 3. Pain, Nervous System, & Psych October 12, 2015 budesonide 1 mg/2 ml Pulmicort® 1 mg/2 ml 12. Allergy, Cough & Cold, Lung Meds August 3, 2015 dihydrocodein-acetaminoph-caff Trezix? 3. Pain, Nervous System, & Psych August 17, 2015 dutasteride Avodart® 13. Urinary & Prostate Meds October 19, 2015 fenofibrate 40 mg Fenoglide® 40 mg 4. Heart, Blood Pressure, & Cholesterol September 28, 2015 fluvastatin er Lescol® XL 4. Heart, Blood Pressure, & Cholesterol September 21, 2015 megestrol acetate Megace® ES 2. Cancer & Organ Transplant Drugs August 3, 2015 memantine hcl 2 mg/ml Namenda® 2 mg/ml 3. Pain, Nervous System, & Psych October 19, 2015 naproxen sodium cr 375 mg Naprelan® 375 mg 3. Pain, Nervous System, & Psych August 31, 2015 paliperidone er Invega® 3. Pain, Nervous System, & Psych September 28, 2015 phenoxybenzamine hcl Dibenzyline® 4. Heart, Blood Pressure, & Cholesterol August 17, 2015 pimozide Orap® 3. Pain, Nervous System, & Psych October 5, 2015 pramipexole di-hcl 4.5 mg Mirapex ER® 4.5 mg 3. Pain, Nervous System, & Psych August 17, 2015 rivastigmine 9.5 mg/24 hr, 13.3 mg/24 hr, and 4.6 mg/24 hr Exelon® 9.5 mg/24 hr, 13.3 mg/24 hr, and 4.6 mg/24 hr 3. Pain, Nervous System, & Psych September 7, 2015 tetrabenazine* Xenazine® 3. Pain, Nervous System, & Psych August 31, 2015 tretinoin Atralin® 5. Skin Medications September 7, 2015

*Generic requires prior authorization.

Brand deletions

Effective April 1, 2016, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing: Brand drug Generic drug Formulary chapter Abilify® 1 mg/ml aripiprazole 1 mg/ml 3. Pain, Nervous System, & Psych Mirapex ER® 4.5 mg pramipexole di-hcl 4.5 mg 3. Pain, Nervous System, & Psych Namenda® 2 mg/ml memantine hcl 2 mg/ml 3. Pain, Nervous System, & Psych

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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