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Select Drug Program® Formulary updates

December 1, 2016

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The Select Drug Program Formulary, which is available for commercial members, is a list of medications approved bythe 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 formularyto 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, webegan covering them at the appropriate generic formulary level of cost-sharing:

Generic drug Brand drugFormulary chapter Effective date
armodafinil* Nuvigil® 3. Pain, Nervous System, & PsychJune 6, 2016
clindamycin phos-tretinoin
1.2% - 0.025% gel
Veltin® 1.2% - 0.025% gel or
Ziana 1.2% - 0.025% gel
5. Skin MedicationsJuly 11, 2016
clindamycin-benzoyl peroxide
1% - 5% gel w/ pump
benzaclin pump5. Skin MedicationsMay 9, 2016
dofetilideTikosyn®4. Heart, Blood Pressure, & CholesterolJune 13, 2016
doxycycline hyclate 50 mgDoryx® 50 mg and200 mg dr tablet1. Antibiotics & Other Drugs Used for InfectionMay 30, 2016
ethacrynic acidEdecrin® 4. Heart, Blood Pressure, & CholesterolJuly 11, 2016
miglitol Glyset® 7. Diabetes, Thyroid, Steroids, & OtherMiscellaneous HormonesMay 23, 2016
nilutamide Nilandron®2. Cancer & Organ Transplant Drugs July 25, 2016
omeprazole-sodium
bicarbonate 20 mg - 1,680 mg
and 40 mg - 1,680 mg packet*
Zegerid® 20 mg - 1,680mg and 40 mg - 1,680 mgpacket8. Stomach, Ulcer, & Bowel MedsJuly 25, 2016
pramipexole er 3.75 mgMirapex ER 3.75 mg3. Pain, Nervous System, & PsychJuly 18, 2016

*Generic requires prior authorization.

Brand additions

Effective October 1, 2016, these brand drugs were added to the formulary and covered at the appropriate brandformulary level of cost-sharing:

Brand drugFormulary chapter
Simponi®9. Bone, Joint, & Muscle
Stelara®9. Bone, Joint, & Muscle

Covered under pharmacy and medical benefit.

Brand deletions

Effective January 1, 2017, these brand drugs will be covered at the appropriate non-formulary level of cost-sharing:

Brand drugGeneric drugFormulary chapter
Edecrin®ethacrynic acid4. Heart, Blood Pressure, & Cholesterol
Mirapex ER 3.75 mgpramipexole er 3.75 mg3. Pain, Nervous System, & Psych

The generic drugs for the above brand drugs are on our formulary and available at the generic formulary level ofcost-sharing.

Generic deletions

Effective January 1, 2017, these drugs will be covered at the appropriate non-preferred level of cost-sharing:

Non-preferred drugFormulary therapeutic alternativeFormulary chapter
Apexicon® Ebetamethasone dipropionate, fluocinolone acetonidem,triamcinolone acetonide5. Skin Medications
Clodan®clobetasol propionate5. Skin Medications
frovatriptan almotriptan malate, sumatriptan, zolmitriptan 3. Pain, Nervous System, & Psych
metformin ER
(generic Glumetza®)
metformin ER (generic Glucophage® XR and Fortamet®)7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones
omeprazole-sodiumbicarbonate omeprazaole, lansoprazole, pantoprazole sodium8. Stomach, Ulcer, & Bowel Meds
oxiconazoleeconazole nitrate, ketoconazole5. Skin Medications
Trianex® betamethasone dipropionate, fluocinolone acetonide,triamcinolone acetonide3. Pain, Nervous System, & Psych

For additional information on pharmacy policies and programs, go to our website.

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