September 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
BOSENTAN 62.5, 125 MG TRACLEER Pulmonary arterial hypertension (PAH) PA 1 1 1 1 1
CEFIXIME 400 MG SUPRAX Bacterial infections   1 1 1 1 1
DOXYLAMINE SUCCINATE/VIT B6 10 MG-10MG DICLEGIS Nausea and vomiting   1 1 1 1 1
ERLOTINIB HCL 25, 100, 150 MG TARCEVA Lung or pancreatic cancer PA 1 1 1 1 1
LOTEPREDNOL ETABONATE 0.50% LOTEMAX Eye inflammation or pain   1 1 1 1 1
MESALAMINE 400 MG DELZICOL Inflammatory bowel disease (IBD)   1 1 1 1 1
NAFTIFINE HCL 1% NAFTIN Fungal infections   1 1 1 1 1
PENICILLAMINE 250 MG CUPRIMINE Wilson's disease PA 1 1 1 1 1
SCOPOLAMINE 1 MG/3 DAY TRANSDERM-SCOP Motion sickness   1 1 1 1 1
SILDENAFIL CITRATE 10 MG/ML REVATIO  Pulmonary arterial hypertension (PAH) PA 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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