Securerx pdp 2014 formulary update

2014 Formulary Update
Listed below are major updates to the formulary, including additions to Prior Authorization and
Quantity Level Limits, that will be made effective January 1, 2014:
Preferred Generics
alendronate tabs
paroxetine (non-ER) tabs
baclofen tabs
perindopril tabs
carteolol ophthalmic
sertraline tabs
carvedilol tabs
spironolactone tabs
flurbiprofen tabs, eye drops
trandolapril tabs
ketoprofen (non-ER) caps
verapamil ER tabs
Non-Preferred Generics
cephalexin susupension
prochlorperazine suppository
procto-pak
estradiol tabs
promethazine syrup, suppository
estropipate
propranolol solution
gavilyte-c, -g
propylthiouracil
gentamicin cream, ointment
silver sulfadiazine cream
ibuprofen suspension
thermazene cream
thiothixene caps
lithium carbonate ER tabs
triamcinolone ointment 0.5%
Preferred Brands
Common Uses/Indications
KEY: Generic names of medications are noted in lower case print and bolded. Brand names of medications are noted in UPPER CASE PRINT. PA—Prior Authorization Required; ST—Step Therapy Required; QLL—Quantity Level Limits Apply Non-Preferred Brands
Common Uses/Indications
Preferred Alternatives
rabeprazole (QLL)
pioglitazone (QLL), ­
/metformin (QLL), ­
/glimepiride (QLL)
moxifloxacin
valsartan/-hct (QLL)
niacin ER
acyclovir cream, ointment
High Cost/Non-Formulary Tier
NOT COVERED
Preferred Alternatives
TRADJENTA/JENTADUETO JANUVIA/JANUMET/JANUMET XR, Additions to Prior Authorization*
KEY: Generic names of medications are noted in lower case print and bolded. Brand names of medications are noted in UPPER CASE PRINT. PA—Prior Authorization Required; ST—Step Therapy Required; QLL—Quantity Level Limits Apply Additions to Quantity Level Limits*
GLUCOVANCE (glyburide/ metformin)
(pioglitazone, -/metformin, -/glimepiride)
(QLL)
AMARYL (glimepiride) (QLL)
PRANDIN (replaglinide) (QLL)
DIABETA (glyburide), GLYNASE (glyburide, PRANDIMET (QLL)
micronized) (QLL)
EDARBI (QLL)
SOMA (carisoprodol) (QLL)
GLUCOPHAGE (metformin)/-XR (ER),
STARLIX (nateglinide) (QLL)
FORTAMET, GLUMETZA (QLL)
GLUCOTROL (glipizide)/-XL (ER) (QLL)
XANAX (alprazolam) (QLL)
Note: Quantity limits vary depending upon strengths of drugs. Please refer to the *Physicians or pharmacists may call 1-888-486-3326 or fax prior authorization requests to 1-888-836-0730. If you are a SecureRx PDP member and have questions concerning your prescription drug benefits, please call 1-888-486-3326 (TTY: 1-866-236-1069), 24 hours a day, seven days a week. As an added convenience, you may also visit for a listing of the formulary along with other helpful pharmacy information. SecureRx® PDP is offered by Avalon® Insurance Company, a Federally-Qualified Medicare Contracting Prescription Drug Plan. Enrollment in SecureRx® PDP depends on contract renewal. KEY: Generic names of medications are noted in lower case print and bolded. Brand names of medications are noted in UPPER CASE PRINT. PA—Prior Authorization Required; ST—Step Therapy Required; QLL—Quantity Level Limits Apply

Source: https://www.securerxpdp.com/NR/rdonlyres/6D5C10F0-80D8-41F3-9431-ED8ABD4932B3/0/securerxpdpformularyupdate2014final.pdf