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Select Drug Program® Formulary updates

December 1, 2015

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 drugBrand drug Formulary chapter Effective date
almotriptan maleate Axert® 3. Pain, Nervous System, & Psych July 13, 2015
alosetron hcl Lotronex® 8. Stomach, Ulcer, & Bowel Meds June 1, 2015
aripiprazole Abilify® 3. Pain, Nervous System, & Psych May 4, 2015
aspirin-dipyridamole er 25 mg ? 200 mg Aggrenox ® 25 mg ? 200 mg 4. Heart, Blood Pressure, & Cholesterol July 6, 2015
bexarotene 75 mg Targretin® 5. Skin Medications July 13, 2015
bimatoprost Not available 11. Eye MedicationsMay 4, 2015
clozapine odt 150 mg and 200 mgFazaclo® 150 mg and 200 mg 3. Pain, Nervous System, & Psych May 11, 2015
dexmethylphenidate hcl 20 mg Focalin® XR 20 mg 3. Pain, Nervous System, & Psych June 29, 2015
duloxetine hcl Irenka? 3. Pain, Nervous System, & PsychJune 15, 2015
fenofibrate 120 mg Fenoglide® 120 mg 4. Heart, Blood Pressure, & CholesterolJune 29, 2015
glatopa 20 mg/ml syringe Copaxone® 20 mg/ml Syringe 3. Pain, Nervous System, & PsychJune 29, 2015
linezolid 600 mg* Zyvox® 600 mg 1. Antibiotics & Other Drugs Used for Infection June 29, 2015
memantine hcl Namenda® 3. Pain, Nervous System, & Psych July 20, 2015
naftifine hcl cream 1% Naftin® Cream 1%5. Skin Medications June 8, 2015
norethindrone ethinyl estradiol FemHRT® 10. Female, Hormone Replacement, & Birth Control May 18, 2015
pramipexole di-hcl 3 mg Mirapex® ER 3 mg 3. Pain, Nervous System, & PsychJuly 27, 2015
pyridostigmine bromide er 180 mg Mestinon® 180 mg 8. Stomach, Ulcer, & Bowel MedsJuly 6, 2015
risedronate sodium 5 mg, 30 mg, and 35 mg Actonel ® 5 mg, 30 mg, and 35 mg 9. Bone, Joint, & MuscleJune 8, 2015
risedronate sodium dr Atelvia® 9. Bone, Joint, & Muscle May 25, 2015
tolcapone Tasmar® 3. Pain, Nervous System, & Psych May 18, 2015
tramadol hcl er Conzip? 3. Pain, Nervous System, & PsychJune 15, 2015
*Generic requires prior authorization.

Brand additions

These brand drugs were added to the formulary and covered at the appropriate brand formulary level of cost-sharing as of the date indicated below:

Brand drugGeneric drugFormulary chapter Effective date
Caverject® Not available 13. Urinary & Prostate MedsSeptember 1, 2015
Eliquis® Not available 4. Heart, Blood Pressure, & Cholesterol September 1, 2015
Nutropin AQ® Not available 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous HormonesSeptember 1, 2015
Restasis® Not available 11. Eye Medications December 1, 2015

Brand deletions

Effective January 1, 2016, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drugGeneric drugFormulary chapter
Abilify® aripiprazole3. Pain, Nervous System, & Psych
Actonel® 5 mg, 30 mg, and 35 mg risedronate sodium 5 mg, 30 mg, and 35 mg9. Bone, Joint, & Muscle
Mestinon® 180 mg pyridostigmine bromide er 180 mg 8. Stomach, Ulcer, & Bowel Meds
Mirapex® ER 3 mg pramipexole di-hcl 3 mg 3. Pain, Nervous System, & Psych
Namenda® memantine hcl 3. Pain, Nervous System, & Psych
Targretin® bexarotene 75 mg 5. Skin Medications
The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level of cost-sharing.

Effective January 1, 2016, this brand drug will be covered at the appropriate non-formulary level of cost-sharing:

Brand drugGeneric drugFormulary chapter
Replax® sumatriptan, rizatriptan, zolmitriptan3. Pain, Nervous System, & Psych

There is no generic equivalent for the above brand drug; however, there are formulary therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary level of cost-sharing. We encourage you to discuss formulary alternatives with your patients.


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