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							TitleWeb Select Drug Program® Formulary updates  
							 
							Professional; Facility; Ancillary
						 
						June 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 drug | Brand drug | Formulary chapter | Effective 
date | 
|---|
 | amlodipine-valsartan-HCTZ | Exforge HCT® | 4. Heart, Blood Pressure, & Cholesterol | December 8, 2014 |  | celecoxib | Celebrex® | 3. Pain, Nervous 
System, & Psych | December 15, 2014 |  | clobetasol propionate spray | Clobex® Spray | 5. Skin Medications | January 5, 2015 |  | colchicine | Colcrys® | 9. Bone, Joint, & 
Muscle | January 19, 2015 |  | colchicine | Mitigare? | 9. Bone, Joint, & Muscle | January 19, 2015 |  | dexmethylphenidate ER | Focalin XR® | 3. 
Pain, Nervous System, & Psych | November 17, 2015 |  | estradiol | Vivelle-Dot® | 10. Female, 
Hormone Replacement, & Birth Control | December 29, 2014 |  | guanfacine ER* | Intuniv? | 3. Pain, Nervous System, & 
Psych | December 8, 2014 |  | ivermectin | Stromectol® | 1. Antibiotics 
& Other Drugs Used for Infection | November 17, 2014 |  | lamivudine sol | Epivir® Sol | 1. 
Antibiotics & Other Drugs Used for Infection | January 12, 2015 |  | MB hydrogel | Aurstat® | 5. Skin 
Medications | December 8, 2014 |  | mycophenolate mofetil susp | Cellcept® Susp | 2. Cancer & Organ Transplant Drugs | November 24, 2014 |  | prednisolone sodium phosphate | Orapred ODT® | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | December 15, 2014 |  | sirolimus 1 mg, 2 mg tabs | Rapamune® 1 mg, 2 mg 
tabs | 2. Cancer & Organ Transplant Drugs | November 3, 
2014 |  | tacrolimus | Protopic® | 2. Cancer & Organ 
Transplant Drugs | December 1, 2014 |  | testosterone 1% packet* | Androgel® 1% Packet | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones | January 5, 2015 |  | Urea 47% cream | Keralac® 47% Cream | 5. 
Skin Medications | December 1, 2014 |  | Uro-L | Urelle® | 1. Antibiotics & Other 
Drugs Used for Infection | December 29, 2014 |  | Uro-MP | Uribel | 1. Antibiotics & Other Drugs Used for 
Infection | December 22, 2014 |  | valganciclovir | Valcyte® | 1. Antibiotics 
& Other Drugs Used for Infection | December 8, 2014 |  |  |  |  |  |  *Generic requires prior 
authorization.  Brand additions  
These brand drugs were added to the formulary as of the date indicated below 
and are covered at the appropriate brand formulary level of cost-sharing:  
| Brand drug | Generic drug | Formulary chapter | Effective date | 
|---|
 | Harvoni® | Not available | 1. Antibiotics 
& Other Drugs Used for Infection | April 1, 2015 |  | Invokamet® | Not available | 7. Diabetes, 
Thyroid, Steroids, & Other Miscellaneous Hormones | June 1, 2015 |  | Invokana® | Not available | 7. Diabetes, 
Thyroid, Steroids, & Other Miscellaneous Hormones | June 1, 2015 |  | Suboxone® Film* | Not available | 3. Pain, 
Nervous System, & Psych | June 1, 2015 |  *Covered at the appropriate 
generic formulary level of cost-sharing.  Brand deletions 
 Effective July 1, 2015, these brand drugs will be covered 
at the appropriate non-formulary level of cost-sharing:  
| Brand drug | Generic drug | Formulary chapter | 
|---|
 | Androgel® 1% Packet | testosterone 1% packet | 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones |  | Celebrex® | celecoxib | 3. Pain, Nervous 
System, & Psych |  | Cellcept® Susp | mycophenolate mofetil susp | 2. Cancer & Organ Transplant Drugs |  | Clobex® Spray | clobetasol propionate spray | 5. Skin Medications |  | Colcrys® | colchicine | 9. Bone, Joint, & 
Muscle |  | Rapamune® 1 mg, 2 mg tabs | sirolimus 1 mg, 2 mg 
tabs | 2. Cancer & Organ Transplant Drugs |  | Valcyte® | valganciclovir | 1. Antibiotics 
& Other Drugs Used for Infection |  | Vivelle-Dot® | estradiol | 10. Female, 
Hormone Replacement, & Birth Control |  The generic drugs for the above brand drugs are on our formulary and 
available at the generic formulary level of cost-sharing.  Effective July 1, 2015, Effective July 1, 2015, this brand 
drug will be covered at the appropriate non-formulary level of cost-sharing: 
| Brand drug | Generic drug | Formulary chapter | 
|---|
 | Blephamide® Susp | sulfacetamide/prednisolone 
susp | 11. Eye Medications |  There is no generic equivalent for the above brand drug; however, there is a 
formulary therapeutic alternative drug. This therapeutic alternative drug is 
available at the appropriate formulary level of cost-sharing. We encourage you 
to discuss formulary alternatives with your patients.  |  |