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Select Drug Program® Formulary updates

December 1, 2014

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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
azelastine Astepro® 6. Ear, Nose, Throat Medications May 16, 2014
budesonide Rhinocort® Aqua 6. Ear, Nose, Throat Medications May 16, 2014
diclofenac sodium Pennsaid® 9. Bone, Joint, & Muscle June 6, 2014
fenofibrate Lipofen® 4. Heart, Blood Pressure, & Cholesterol May 9, 2014
hydromorphone ER* Exalgo® 3. Pain, Nervous System, & Psych May 22, 2014
methoxsalen Oxsoralen-ultra® 5. Skin Medications June 27, 2014
oxycodone ER Oxycontin® 3. Pain, Nervous System, & Psych October 6, 2014
risedronate Actonel® 150 mg 9. Bone, Joint, & Muscle June 13, 2014
testosterone* Testim®, Vogelxo? 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones June 20, 2014
topiramate ER Qudexy? XR 3. Pain, Nervous System, & Psych July 11, 2014
valsartan Diovan® 4. Heart, Blood Pressure, & Cholesterol July 8, 2014
*Generic requires prior authorization.

Brand addition

This brand drug was added to the formulary as of the date indicated below and is covered at the appropriate brand formulary level of cost-sharing:

Brand drug Formulary chapter Effective date
Dilantin® Infatabs® 3. Pain, Nervous System, & Psych November 1, 2014
*Generic requires prior authorization.

Brand addition

This brand drug was added to the formulary as of the date indicated below and is covered at the appropriate brand formulary level of cost-sharing:

Brand drug Formulary chapter Effective date
Dilantin® Infatabs® 3. Pain, Nervous System, & Psych November 1, 2014

Brand deletions

Effective January 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Generic drug Formulary chapter
Actonel® 150 mg risedronate 9. Bone, Joint, & Muscle
Astepro® azelastine 6. Ear, Nose, Throat Medications
Diovan® valsartan 4. Heart, Blood Pressure, & Cholesterol
Levoxyl® levothyroxine 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Mestinon® IR pyridostigmine 3. Pain, Nervous System, & Psych
Oxsoralen-ultra® methoxsalen 5. Skin Medications
Oxycontin® oxycodone ER 3. Pain, Nervous System, & Psych
Unithroid® levothyroxine 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
Vandazole® metronidazole 10. Female, Hormone Replacement, & Birth Control
The generic drugs for the above brand drugs are available at the generic formulary level of cost-sharing.

Effective January 1, 2015, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drug Formulary therapeutic alternatives Formulary chapter
Alphanate® Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol
Bebulin® Rixubis® 4. Heart, Blood Pressure, & Cholesterol
Hemofil-M® Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol
Koate®-DVI Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol
Monoclate-P® Advate®, Helixate® FS 4. Heart, Blood Pressure, & Cholesterol
Nasonex® budesonide, fluticasone propionate 6. Ear, Nose, Throat Medications
Profilnine® Rixubis® 4. Heart, Blood Pressure, & Cholesterol
There is no generic equivalent 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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