Formulary Updates

The following drug products were reviewed and acted upon by the CDPHP Pharmacy and Therapeutics Committee on June 16, 2010.   Review the full CDPHP Clinical Formulary which includes tier status, prior authorization requirements and quantity limits for select drugs. Also see Medicare Drug Formulary and Medicare Formulary Updates.

Legend

  • Changes will be effective immediately unless noted otherwise
  • E Excluded from the CDPHP two-tier and three-tier formulary
  • P Preferred
  • PA Prior authorization required
  • QL Quantity limits of # 30 every 30 days (cumulative by class)
  • SP Available through Caremark Specialty Pharmacy Services
  • ST Subject to step therapy through cyclobenzaprine
  • ST2 Subject to step therapy through Norditropin effective July 14, 2010
  • ST3 Subject to step therapy for proton pump inhibitor class effective imediately for new starts to therapy
  • ST4 Subject to step therapy for HMG-CoA reductase inhibitors (statins) effective immediately for new starts to therapy
DrugNew Tier / Formulary StatusPrevious Tier / Formulary Status
Aciphex tablets (rabeprazole)E3, E, QL
Amrix capsules (cyclobenzaprine ext-rel)3, ST3
Cayston inhalation solution (aztreonam)3, SPNew to Market
Crestor 40 mg tablets (rosuvastatin)3, ST42, P
Crestor 5 mg, 10 mg, 20 mg tablets (rosuvastatin)E2, P
Dexilant capsules (dexlansoprazole delayed-rel)E3, ST, QL
Effexor XR capsules (venlafaxine HCl ext-rel)32, P
imipramine pamoate capsules (generic for Tofranil-PM)1New to Market
Istodax injection (romidepsin)Medical Benefit, PANew to Market
lansoprazole delayed-rel capsules1, QL, ST31, QL
Lescol capsules (fluvastatin)E3
Lescol XL tablets (fluvastatin ext-rel)E3
Lipitor 10 mg, 20 mg, 40 mg tablets (atorvastatin)E2, P
Lipitor 80 mg tablets (atorvastatin)2, ST42, P
Livalo tablets (pitavastatin)ENew to Market
metaxalone tablets (generic for Skelaxin)3New to Market
Mevacor tablets (lovastatin)E3
Nexium capsules (esomeprazole delayed-rel)E2, QL, P
omeprazole delayed-rel capsules 40mg1, P1, P, QL
Omnitrope injection (somatropin [rDNA origin])3, ST2, PA, SP2, PA, SP
pantoprazole delayed-rel tablet (generic for Protonix)1, QL, ST31, ST, QL
Pravachol tablets (pravastatin)E3
Prevacid capsules/solutab (lansoprazole delayed-rel)E3, QL
Prilosec capsules (omeprazole delayed-rel)E3, QL
Qutenza transdermal patch (capsaicin)Non-Covered TechnologyNew to Market
Revatio injection (sildenafil)Medical Benefit, PANew to Market
Vpriv injection (velaglucerase)Medical Benefit, PA, SPNew to Market
Xiaflex injection (collagenase clostridium histolyticum)Non-Covered TechnologyNew to Market
Xifaxan 550mg tablets (rifaximin)3New to Market
Zegerid capsules/powder for oral suspension (omeprazole/sodium bicarbonate)E3, E, QL
Zirgan ophthalmic gel (ganciclovir)3New to Market
Zocor tablets (simvastatin)E3

The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. These trademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third-party pharmaceutical companies.

Back To Top