June 2019

Generic Drug Additions

Generic Name

Strength

Corresponding Brand Name

Common Use

Clinical Edits

PDL Tier

Standard Formulary

Value Formulary

Performance Formulary

Advantage Formulary

Legacy Formulary

ACYCLOVIR CREAM

5%

ZOVIRAX

Herpes simplex infection

QL

NC

NC

NC

NC

1

ALBUTEROL SULFATE

90 MCG

PROAIR HFA

Asthma, COPD

2

NC

2

NC

2

ALBUTEROL SULFATE

90 MCG

VENTOLIN HFA

Asthma, COPD

2

3

2

3

2

ALISKIREN HEMIFUMARATE

150, 300 MG

TEKTURNA

Hypertension

1

1

1

1

1

AMBRISENTAN

5, 10 MG

LETAIRIS

Pulomonary arterial hypertension

PA

1

1

1

1

1

BUPRENORPHINE HCL/NALOXONE HCL

2 MG-0.5MG, 4MG-1MG, 12 MG-3 MG

SUBOXONE

Substance abuse disorder

1

1

1

1

1

BENZHYDROCODONE/ ACETAMINOPHEN

4.08-325, 6.12-325, 8.16-325MG

APADAZ

Short-term treatment of moderate-to-severe acute pain

PA

1

1

1

1

1

CHLORZOXAZONE

375,750 MG

LORZONE

Muscle relaxant

NC

NC

NC

NC

1

CINACALCET HCL

30, 60, 90 MG

SENSIPAR

Hyperparathyroidism

1

1

1

1

1

DEFERASIROX

125, 250, 500 MG

EXJADE

Chronic iron overload

1

1

1

1

1

DESFLURANE

100%

SUPRANE

Anesthetic

1

1

1

1

1

DICLOFENAC EPOLAMINE

1.30%

FLECTOR

Inflammatory conditions

QL

1

1

1

1

1

DOXYCYCLINE HYCLATE

80 MG

 DOXYCYCLINE

Bacterial infection

ST

NC

NC

NC

NC

1

ERYTHROMYCIN ETHYLSUCCINATE

400MG/5ML

ERYPED 400

Bacterial infection

1

1

1

1

1

ESCITALOPRAM OXALATE

10 MG/10ML

ESCITALOPRAM OXALATE

Depression

QL

1

1

1

1

1

FLUTICASONE/ SALMETEROL

100-50, 250-50, 500-50 MCG

ADVAIR DISKUS

Asthma, COPD

1

1

1

1

1

GELATIN SPONGE,ABSORB/PORCINE

100CM, 12-7MM

GELFOAM COMPRESSED

Surgical bleeding

1

1

1

1

1

HALOBETASOL PROPIONATE FOAM

0.05%

LEXETTE

Inflammatory conditions

1

1

1

1

1

HEPARIN SODIUM,PORCINE/PF

5000/0.5ML

HEPARIN SODIUM

Anticoagulant

1

1

1

1

1

LEVORPHANOL TARTRATE

3 MG

LEVORPHANOL TARTRATE

Short-term treatment of moderate-to-severe acute pain

PA

NC

NC

NC

NC

1

MINOCYCLINE HCL

80, 105 MG

SOLODYN

Bacterial infection

1

1

1

1

1

PROMETHAZINE/DEXTROMETHORPHAN

6.25-15/5

PROMETHAZINE-DM

Cough supressant

1

1

1

1

1

PYRIDOSTIGMINE BROMIDE

60 mg/5 mL

MESTINON

Myasthenia gravis

1

1

1

1

1

RANOLAZINE

500, 1000 MG

RANEXA

Chronic angina

QL

1

1

1

1

1

SEVELAMER HCL

800 MG

RENAGEL

Chronix kidney disease

1

1

1

1

1

SIROLIMUS

1 MG/ML

RAPAMUNE

Prevent organ rejection after transplant

1

1

1

1

1

THEOPHYLLINE ANHYDROUS

80MG/15ML

ELIXOPHYLLIN

Asthma, COPD

1

1

1

1

1

TOREMIFENE CITRATE

60 MG

FARESTON

Breast cancer

QL

1

1

1

1

1

VIGABATRIN

500 MG

SABRIL

Seizure disorders

1

1

1

1

1

THEOPHYLLINE ANHYDROUS

80MG/15ML

ELIXOPHYLLIN

XANTHINES

1

1

1

1

1

TOREMIFENE CITRATE

60 MG

FARESTON

Selective Estrogen Receptor Modulators (SERMS)

QL

1

1

1

1

1

VIGABATRIN

500 MG

SABRIL

Anticonvulsants

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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