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
dimethyl fumarate 120mg & 240mg Tecfidera Multiple Sclerosis PA T1 T1 T1 T1 T1
emtricitabine 200mg Emtriva HIV PA T1 T1 T1 T1 T1
PEG3350/sod/sul/nacl/kcl/asb/c powder Moviprep Bowel Prep   T1 T1 T1 T1 T1
sapropterin dihydrochloride 100mg Kuvan Phenylketonuria PA T1 T1 T1 T1 T1
tobramycin 300mg/4ml Bethkis Cystic Fibrosis PA, QL T1 T1 T1 T1 T1
diclofenac submicronized 35mg Zorvolex Anti-inflammatory NC T3 T3 T3 T3 T3
efavirenz/lamivu/tenofov disop 400/300/300mg Symfi Lo HIV   T1 T1 T1 T1 T1
efavirenz/lamivu/tenofov disop 600/300/300mg Symfi HIV   T1 T1 T1 T1 T1
deferiprone 500mg Ferriprox Iron chelator  PA T1 T1 T1 T1 T1
lapatinib ditosylate 250mg Tykerb Breast Cancer PA T1 T1 T1 T1 T1
emtricitabine/tenofovir 200/300mg Truvada HIV   T1 T1 T1 T1 T1
efavirenz/emtricit/tenofovr df 600/200/300mg Atripla HIV PA T1 T1 T1 T1 T1
fosfomycin 3gm Monurol Antibiotic   T1 T1 T1 T1 T1
tavaborole 5% Kerydin Antifungal NC T1 T1 T1 T1 T1
rufinamide 40mg/ml Banzel Anticonvulsant PA, QL  T1 T1 T1 T1 T1
icosapent ethyl 1 gm Vascepa Hypertriglyceridemia   T1 T1 T1 T1 T1
timolol maleate/PF 0.50% Timoptic Ocudose Glaucoma   T1 T1 T1 T1 T1
norethindrone-e.estradiol-iron 1mg-20mcg/75mg Taytulla Contraception   T1 T1 T1 T1 T1
levothyroxine sodium all Tirosint Thyroid PA(Val/Adv) T3 T3 T3 T3 T3
ivermectin 0.50% Sklice Head Lice   T1 T1 T1 T1 T1

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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