December 2019

Generic Drug Additions

Generic Name Strength Corresponding Brand Name Common Use Clinical Edits Prescription Drug List Tier
Standard Formulary Value Formulary Performance Formulary Advantage Formulary Legacy Formulary
AMINOCAPROIC ACID 250MG/ML AMICAR BLEEDING DISORDERS   1 1 1 1 1
ASPIRIN/OMEPRAZOLE 81 MG-40MG, 325MG-40MG YOSPRALA CLOTTING DISORDERS   NC NC NC NC 3
ERYTHROMYCIN BASE 250, 333, 500MG ERY-TAB ANTIOBIOTIC   1 1 1 1 1
FEBUXOSTAT 40, 80 MG ULORIC GOUT QL 1 1 1 1 1
FOSAPREPITANT DIMEGLUMINE 150 MG EMEND NAUSEA AND VOMITING PA 1 1 1 1 1
HALCINONIDE 0.10% HALOG TOPICAL INFLAMMATORY CONDITIONS   1 1 1 1 1
ICATIBANT ACETATE 30 MG/3 ML FIRAZYR HEREDITARY ANGIOEDEMA PA 1 1 1 1 1
IVERMECTIN 1% SOOLANTRA ROSACEA   1 1 1 1 1
LEVOCARNITINE 100MG/ML CARNITOR SF METABOLIC DEFICIENCIES   1 1 1 1 1
MEMANTINE HCL 10 MG/5 ML MEMANTINE HCL ALZHEIMER'S DISEASE   1 1 1 1 1
NITISINONE 2, 5, 10MG ORFADIN HEREDITARY TYROSINEMIA PA 1 1 1 1 1
ORPHENADRINE/ ASPIRIN/CAFFEINE 50-770-60 NORGESIC FORTE MUSCLE RELAXANT   1 1 1 1 1
PENTAMIDINE ISETHIONATE 300MG NEBUPENT PARASITIC INFECTIONS   1 1 1 1 1
PHENOBARB/HYOSCY/ATROPINE/SCOP 16.2MG/5ML DONNATAL GI DISORDERS   1 1 1 1 1
POSACONAZOLE 100, 200 MG/5ML NOXAFIL FUNGAL INFECTIONS   1 1 1 1 1
PREGABALIN 20, 25, 50, 75, 100, 150, 200, 225, 300 MG/ML LYRICA SEIZURE DISORDERS   1 1 1 1 1
RABEPRAZOLE SODIUM 10 MG ACIPHEX SPRINKLE GERD QL DRT EXCLUDED DRT EXCLUDED 3
RAMELTEON 8 MG ROZEREM INSOMNIA QL 1 1 1 1 1
TRIAMTERENE 50, 100MG DYRENIUM HIGH BLOOD PRESSURE   1 1 1 1 1
VANCOMYCIN HCL 250MG/5ML FIRVANQ ANTIBIOTIC   1 1 1 1 1

PA: Prior authorization
QL: Quantity limit
ST: Step therapy
T1/Tier 1: Generic
T2/Tier 2: Brand
T3/Tier 3: Non-preferred
NC: Not covered: This drug is not covered. However, if the covered alternative is not appropriate for the customer, there is a process where his/her provider can request approval of this drug.

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