Blue Cross and Blue Shield of Minnesota FlexRx Formulary Updates

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1 Blue Cross and Blue Shield of Minnesota FlexRx Formulary Updates TRADE NAME (generic name) or generic name abacavir sulfate soln 20 mg/ml (base equiv) Generic Addition, generic for ZIAGEN alclometasone dipropionate cream 0.05% Generic Removal ALIQOPA (copanlisib hcl for iv soln 60 mg (base equivalent)) Brand Addition AMCINONIDE (amcinonide cream 0.1%) Brand Removal APRISO (mesalamine cap er 24hr gm) Brand Addition ATROPINE SULFATE (atropine sulfate ophth oint 1%) Brand Removal ATROPINE SULFATE (atropine sulfate ophth soln 1%) Brand Removal BENZIQ WASH (benzoyl peroxide liq 5.25%) Brand Removal benzoyl peroxide foam 5.3% Generic Removal benzoyl peroxide foam 9.8% Generic Removal benzoyl peroxide liq 10% Generic Removal benzoyl peroxide liq 2.5% Generic Removal benzoyl peroxide liq 7% Generic Removal benzoyl peroxide lotion 6% Generic Removal BESPONSA (inotuzumab ozogamicin for iv soln 0.9 mg) Brand Addition betamethasone valerate cream 0.1% (base equivalent) Generic Addition clindamycin phosphate foam 1% Generic Removal clobetasol propionate cream 0.05% Generic Addition, generic for TEMOVATE clobetasol propionate emollient base cream 0.05% Generic Addition, generic for TEMOVATE E clobetasol propionate gel 0.05% Generic Addition, generic for TEMOVATE clobetasol propionate shampoo 0.05% Generic Addition, generic for CLOBEX clobetasol propionate soln 0.05% Generic Addition, generic for TEMOVATE desonide cream 0.05% Generic Removal desoximetasone cream 0.05% Generic Removal desoximetasone gel 0.05% Generic Removal DIFLORASONE DIACETATE (diflorasone diacetate cream 0.05%) Brand Removal DRITHO-CREME HP (anthralin cream 1%) Brand Removal EFFIENT (prasugrel hcl tab 10 mg (base equiv)) Brand Removal, generics available EFFIENT (prasugrel hcl tab 5 mg (base equiv)) Brand Removal, generics available ENSTILAR (calcipotriene-betamethasone dipropionate foam %) Brand Addition ESCAVITE LQ (*pediatric multiple vitamins w/ fl-fe drops mg/ml**) Brand Removal FINACEA (azelaic acid foam 15%) Brand Addition FLORIVA PLUS (*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***) Brand Removal fosamprenavir calcium tab 700 mg (base equiv) Generic Addition, generic for LEXIVA gentamicin sulfate cream 0.1% Generic Addition HELIXATE FS (antihemophilic factor (recombinant) for inj kit 1000 unit) Brand Removal HELIXATE FS (antihemophilic factor (recombinant) for inj kit 2000 unit) Brand Removal HELIXATE FS (antihemophilic factor (recombinant) for inj kit 250 unit) Brand Removal HELIXATE FS (antihemophilic factor (recombinant) for inj kit 3000 unit) Brand Removal HELIXATE FS (antihemophilic factor (recombinant) for inj kit 500 unit) Brand Removal HEPARIN LOCK FLUSH (heparin sodium (porcine) lock flush iv soln 1 unit/ml) Brand Removal April 2018 continued April 2018 Blue Cross and Blue Shield of MN FlexRx Formulary Updates

2 TRADE NAME (generic name) or generic name heparin sod lock flush & nacl lock flush 10 unt/ml-0.9% kit Generic Removal heparin sod lock flush & nacl lock flush 100 unt/ml-0.9% kit Generic Removal heparin sodium (porcine) lock flush iv soln 10 unit/ml Generic Removal heparin sodium (porcine) lock flush iv soln 100 unit/ml Generic Removal hydrocortisone acetate suppos 25 mg Generic Removal hyoscyamine sulfate elixir mg/5ml Generic Removal hyoscyamine sulfate soln mg/ml Generic Removal hyoscyamine sulfate tab mg Generic Removal hyoscyamine sulfate tab disint mg Generic Removal hyoscyamine sulfate tab er 12hr mg Generic Removal hyoscyamine sulfate tab sl mg Generic Removal IDHIFA (enasidenib mesylate tab 100 mg (base equivalent)) Brand Addition IDHIFA (enasidenib mesylate tab 50 mg (base equivalent)) Brand Addition isometheptene-dichloral-acetaminophen cap mg Generic Removal LEXIVA (fosamprenavir calcium tab 700 mg (base equiv)) Brand Removal, generics available LIALDA (mesalamine tab delayed release 1.2 gm) Brand Removal, generics available lidocaine-prilocaine cream kit % Generic Removal LYNPARZA (olaparib tab 100 mg) Brand Addition LYNPARZA (olaparib tab 150 mg) Brand Addition malathion lotion 0.5% Generic Addition, generic for OVIDE mesalamine tab delayed release 1.2 gm Generic Addition, generic for LIALDA moxifloxacin hcl ophth soln 0.5% (base equiv) Generic Addition, generic for VIGAMOX NERLYNX (neratinib maleate tab 40 mg (base equivalent)) Brand Addition NITYR (nitisinone tab 10 mg) Brand Addition NITYR (nitisinone tab 2 mg) Brand Addition NITYR (nitisinone tab 5 mg) Brand Addition NOVAREL (chorionic gonadotropin for im inj 5000 unit) Brand Addition NUWIQ (antihemophilic factor (bdd-rfviii) for inj 2500 unit) Brand Addition NUWIQ (antihemophilic factor (bdd-rfviii) for inj 3000 unit) Brand Addition NUWIQ (antihemophilic factor (bdd-rfviii) for inj 4000 unit) Brand Addition NUWIQ (antihemophilic factor (bdd-rfviii) for inj kit 2500 unit) Brand Addition NUWIQ (antihemophilic factor (bdd-rfviii) for inj kit 3000 unit) Brand Addition NUWIQ (antihemophilic factor (bdd-rfviii) for inj kit 4000 unit) Brand Addition nystatin oral powder Generic Removal PENTASA (mesalamine cap er 250 mg) Brand Removal PENTASA (mesalamine cap er 500 mg) Brand Removal phenazopyridine hcl tab 100 mg Generic Removal phenazopyridine hcl tab 200 mg Generic Removal prasugrel hcl tab 10 mg (base equiv) Generic Addition, generic for EFFIENT prasugrel hcl tab 5 mg (base equiv) Generic Addition, generic for EFFIENT QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride chew tab 0.25 mg***) Brand Removal QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride chew tab 0.5 mg***) Brand Removal QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride chew tab 1 mg***) Brand Removal QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***) Brand Removal QUFLORA PEDIATRIC (*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml***) Brand Removal repaglinide tab 1 mg Generic Addition, generic for PRANDIN repaglinide tab 2 mg Generic Addition, generic for PRANDIN ROSULA (sulfacetamide sodium w/ sulfur cleansing cloth 10-5%) Brand Removal continued April 2018 Blue Cross and Blue Shield of MN FlexRx Formulary Updates

3 TRADE NAME (generic name) or generic name SASH KIT FOR FLUSHING VASCULAR ACCESS DEVICES (heparin sod lock flush & nacl lock flush 10 unt/ml-0.9% kit) Brand Removal scopolamine td patch 72hr 1 mg/3days Generic Addition, generic for TRANSDERM- SCOP sevelamer carbonate tab 800 mg Generic Addition, generic for RENVELA sodium chloride soln nebu 10% Generic Removal sodium chloride soln nebu 3% Generic Removal sodium chloride soln nebu 7% Generic Removal SODIUM SULFACETAMIDE/SULFUR (sulfacetamide sodium w/ sulfur lotion 10-5%) Brand Removal SODIUM SULFACETAMIDE/SULFUR (sulfacetamide sodium w/ sulfur susp 10-5%) Brand Removal SOLIQUA 100/33 (insulin glargine-lixisenatide sol pen-inj unit-mcg/ml) Brand Addition SOLIRIS (eculizumab iv soln 300 mg/30ml (10 mg/ml) (for infusion)) Brand Removal sulfacetamide sodium w/ sulfur cleanser 10-2% Generic Removal sulfacetamide sodium w/ sulfur cleanser % Generic Removal sulfacetamide sodium w/ sulfur cleansing cloth 10-5% Generic Removal sulfacetamide sodium w/ sulfur cleansing pad 10-4% Generic Removal sulfacetamide sodium w/ sulfur cream 10-2% Generic Removal sulfacetamide sodium w/ sulfur cream 10-5% Generic Removal sulfacetamide sodium w/ sulfur cream % Generic Removal sulfacetamide sodium w/ sulfur emulsion 10-1% Generic Removal sulfacetamide sodium w/ sulfur emulsion 10-5% Generic Removal sulfacetamide sodium w/ sulfur lotion 10-5% Generic Removal sulfacetamide sodium w/ sulfur lotion % Generic Removal sulfacetamide sodium w/ sulfur susp 8-4% Generic Removal sulfacetamide sodium w/ sulfur wash 9-4% Generic Removal sulfacetamide sodium w/ sulfur wash 9-4.5% Generic Removal sulfacetamide sod-sulfur wash 9-4.5% & skin cleanser kit Generic Removal sulfacetamide sod-sulfur wash 9-4.5% & sunscreen kit Generic Removal TOTECT (dexrazoxane for inj 500 mg) Brand Addition TRANSDERM-SCOP (scopolamine td patch 72hr 1 mg/3days) Brand Removal, generics available triamcinolone acetonide cream 0.1% Generic Addition triamcinolone acetonide lotion 0.1% Generic Addition TRI-VIT/FLUORIDE/IRON (*pediatric vitamins acd fluoride & fe drops mg/ml***) Brand Removal VIGAMOX (moxifloxacin hcl ophth soln 0.5% (base equiv)) Brand Removal, generics available VYXEOS (daunorubicin-cytarabine liposome for iv inj mg) Brand Addition XULTOPHY 100/3.6 (insulin degludec-liraglutide sol pen-inj unit-mg/ml) Brand Addition ZIAGEN (abacavir sulfate soln 20 mg/ml (base equiv)) Brand Removal, generics available April 2018 Blue Cross and Blue Shield of MN FlexRx Formulary Updates 2746-C Prime Therapeutics LLC 04/18

NOTICE OF NONDISCRIMINATION PRACTICES Effective July 18, 2016 Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) complies with applicable Federal civil rights laws and does not

4 NOTICE OF NONDISCRIMINATION PRACTICES Effective July 18, 2016 Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or gender. Blue Cross does not exclude people or treat them differently because of race, color, national origin, age, disability, or gender. Blue Cross provides resources to access information in alternative formats and languages: Auxiliary aids and services, such as qualified interpreters and written information available in other formats, are available free of charge to people with disabilities to assist in communicating with us. Language services, such as qualified interpreters and information written in other languages, are available free of charge to people whose primary language is not English. If you need these services, contact us at or by using the telephone number on the back of your member identification card. TTY users call 711. If you believe that Blue Cross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can file a grievance with the Nondiscrimination Civil Rights Coordinator by at: Civil.Rights.Coord@bluecrossmn.com by mail at: Nondiscrimination Civil Rights Coordinator Blue Cross and Blue Shield of Minnesota and Blue Plus M495 PO Box Eagan, MN or by phone at: Grievance forms are available by contacting us at the contacts listed above, by calling or by using the telephone number on the back of your member identification card. TTY users call 711. If you need help filing a grievance, assistance is available by contacting us at the numbers listed above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at: by phone at: or (TDD) or by mail at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington, DC Complaint forms are available at image_0006_ndl_portrait (09/16) Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. F10773R01 (1/17)

5 This information is available in other languages. Free language assistance services are available by calling the toll free number below. For TTY, call 711. Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al Para TTY, llame al 711. Yog tias koj hais lus Hmoob, muaj kev pab txhais lus pub dawb rau koj. Hu rau Rau TTY, hu rau 711. Haddii aad ku hadasho Soomaali, adigu waxaad heli kartaa caawimo luqad lacag la'aan ah. Wac Markay tahay dad maqalku ku adag yahay (TTY), wac 711. erh>uwdrundusdm'd;< Aw>u[h.eRusdmw>rRpXRuvDwz.M.vDRIAud; vx ATTY t*d><aud; 711 wuh>i إذا كنت تتحدث العربية تتوفر لك خدمات المساعدة اللغوية المجانية. اتصل بالرقم للھاتف النصي اتصل بالرقم. 711 Nếu quý vị nói Tiếng Việt, có sẵn các dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Gọi số Người dùng TTY xin gọi 711. Afaan Oromoo dubbattu yoo ta e, tajaajila gargaarsa afaan hiikuu kaffaltii malee. Argachuuf bilbilaa. TTY dhaaf, 711 bilbilaa. 如果您說中文, 我們可以為您提供免費的語言協助服務請撥打聽語障專 (TTY), 請撥打 711 Если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Звоните Для использования телефонного аппарата с текстовым выходом звоните 711. Si vous parlez français, des services d assistance linguistique sont disponibles gratuitement. Appelez le Pour les personnes malentendantes, appelez le 711. አማርኛ የሚናገሩ ከሆነ ነጻ የቋንቋ አገልግሎት እርዳ አለሎት በ ይደውሉ ለ TTY በ 711 한국어를사용하시는경우, 무료언어지원서비스가제공됩니다 으로전화하십시오. TTY 사용자는 711 로전화하십시오. ຖ າເຈ າເວ າພາສາລາວໄດ, ມການບລການຊວຍເຫ ອພາສາໃຫເຈ າຟຣ. ໃຫໂທຫາ ສາລ ບ. TTY, ໃຫ ໂທຫາ 711. Kung nagsasalita kayo ng Tagalog, mayroon kayong magagamit na libreng tulong na mga serbisyo sa wika. Tumawag sa Para sa TTY, tumawag sa 711. Wenn Sie Deutsch sprechen, steht Ihnen fremdsprachliche Unterstützung zur Verfügung. Wählen Sie Für TTY wählen Sie 711. របស ន បអកនយ យភ ស ខរមន ន ម អកអ ចរកប ន សវ ជនយភ ស ឥតគត ថ ន ល ទរសពមក លខ ទ សរម ប TTY សមទរសពមក លខ ទ 711 Din4 k'ehj7 y1n7[t'i'go saad bee y1t'i' 47 t'11j77k'e bee n7k1'a'doowo[go 47 n1'ahoot'i'. Koj8 47 b44sh bee hod77lnih TTY biniiy4go j8 b44sh bee hod77lnih. image_0002r02_general_portrait (01/17)

BlueLink TPA FlexRx Updates

BlueLink TPA FlexRx Updates April 2018 TRADE NAME (generic name) or generic name abacavir sulfate soln 20 mg/ml (base equiv) Generic Addition, generic for ZIAGEN alclometasone dipropionate cream 0.05%