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							TitleWeb Select Drug Program® Formulary updates  
							 
							Professional; Facility; Ancillary
						 
						December 1, 2015
						  
 
						Page Content 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 requires prior authorization.| Generic drug | Brand 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 
Medications | May 4, 2015 |  | clozapine odt 150 mg and 200 mg | Fazaclo® 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, & 
Psych | June 15, 2015 |  | fenofibrate 120 mg | Fenoglide® 120 mg | 4. Heart, Blood Pressure, & Cholesterol | June 29, 2015 |  | glatopa 20 mg/ml syringe | Copaxone® 20 mg/ml 
Syringe | 3. Pain, Nervous System, & Psych | June 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, & Psych | July 27, 2015 |  | pyridostigmine bromide er 180 mg | Mestinon® 180 
mg | 8. Stomach, Ulcer, & Bowel Meds | July 6, 2015 |  | risedronate sodium 5 mg, 30 mg, and 35 mg | Actonel
® 5 mg, 30 mg, and 35 mg | 9. Bone, Joint, & 
Muscle | June 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, & 
Psych | June 15, 2015 |  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 drug | Generic drug | Formulary chapter | Effective 
date | 
|---|
 | Caverject® | Not available | 13. Urinary & 
Prostate Meds | September 1, 2015 |  | Eliquis® | Not available | 4. Heart, 
Blood Pressure, & Cholesterol | September 1, 2015 |  | Nutropin AQ® | Not available | 7. 
Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | September 
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 drug | Generic drug | Formulary chapter | 
|---|
 | Abilify® | aripiprazole | 3. Pain, Nervous 
System, & Psych |  | Actonel® 5 mg, 30 mg, and 35 mg | risedronate 
sodium 5 mg, 30 mg, and 35 mg | 9. 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 drug | Generic drug | Formulary chapter | 
|---|
 | Replax® | sumatriptan, rizatriptan, 
zolmitriptan | 3. 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.  |  |