Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates
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- Norman Holland
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1 Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates July 2018 TRADE NAME (generic name) or generic name ADVAIR DISKUS (fluticasone-salmeterol aer powder ba mcg/dose) Brand Addition ADVAIR DISKUS (fluticasone-salmeterol aer powder ba mcg/dose) Brand Addition ADVAIR DISKUS (fluticasone-salmeterol aer powder ba mcg/dose) Brand Addition ADVAIR HFA (fluticasone-salmeterol inhal aerosol mcg/act) Brand Addition ADVAIR HFA (fluticasone-salmeterol inhal aerosol mcg/act) Brand Addition ADVAIR HFA (fluticasone-salmeterol inhal aerosol mcg/act) Brand Addition ALUNBRIG (brigatinib tab 180 mg) Brand Addition ALUNBRIG (brigatinib tab 90 mg) Brand Addition ALUNBRIG (brigatinib tab initiation therapy pack 90 mg & 180 mg) Brand Addition aprepitant capsule 125 mg Addition, generic for EMEND aprepitant capsule 40 mg Addition, generic for EMEND armodafinil tab 150 mg Addition, generic for NUVIGIL armodafinil tab 200 mg Addition, generic for NUVIGIL armodafinil tab 250 mg Addition, generic for NUVIGIL armodafinil tab 50 mg Addition, generic for NUVIGIL atazanavir sulfate cap 150 mg (base equiv) Addition, generic for REYATAZ atazanavir sulfate cap 200 mg (base equiv) Addition, generic for REYATAZ atazanavir sulfate cap 300 mg (base equiv) Addition, generic for REYATAZ BENZNIDAZOLE (benznidazole tab 100 mg) Brand Addition BENZNIDAZOLE (benznidazole tab 12.5 mg) Brand Addition BERINERT (c1 esterase inhibitor (human) for iv inj kit 500 unit) Brand Addition BORTEZOMIB (bortezomib for iv inj 3.5 mg) Brand Addition BOSULIF (bosutinib tab 400 mg) Brand Addition BREO ELLIPTA (fluticasone furoate-vilanterol aero powd ba mcg/inh) Brand Addition BREO ELLIPTA (fluticasone furoate-vilanterol aero powd ba mcg/inh) Brand Addition CALQUENCE (acalabrutinib cap 100 mg) Brand Addition clorazepate dipotassium tab 15 mg Removal clorazepate dipotassium tab 3.75 mg Removal clorazepate dipotassium tab 7.5 mg Removal DROXIA (hydroxyurea cap 200 mg) Brand Addition DROXIA (hydroxyurea cap 300 mg) Brand Addition DROXIA (hydroxyurea cap 400 mg) Brand Addition efavirenz cap 200 mg Addition, generic for SUSTIVA efavirenz cap 50 mg Addition, generic for SUSTIVA efavirenz tab 600 mg Addition, generic for SUSTIVA EMEND (aprepitant capsule 125 mg) Brand Removal, generics available EMEND (aprepitant capsule 40 mg) Brand Removal, generics available ENBREL MINI (etanercept subcutaneous solution cartridge 50 mg/ml) Brand Addition ERLEADA (apalutamide tab 60 mg) Brand Addition estradiol vaginal cream 0.1 mg/gm Addition, generic for ESTRACE etodolac cap 200 mg Addition etodolac cap 300 mg Addition etodolac tab 400 mg Addition, generic for LODINE etodolac tab 500 mg Addition fentanyl citrate lozenge on a handle 1200 mcg Addition, generic for ACTIQ fentanyl citrate lozenge on a handle 1600 mcg Addition, generic for ACTIQ
2 TRADE NAME (generic name) or generic name fentanyl citrate lozenge on a handle 200 mcg Addition, generic for ACTIQ fentanyl citrate lozenge on a handle 400 mcg Addition, generic for ACTIQ fentanyl citrate lozenge on a handle 600 mcg Addition, generic for ACTIQ fentanyl citrate lozenge on a handle 800 mcg Addition, generic for ACTIQ FIASP (insulin aspart inj 100 unit/ml) Brand Addition FIASP FLEXTOUCH (insulin aspart soln pen-injector 100 unit/ml) Brand Addition GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 1 gm/10ml (100 mg/ml) (base equiv)) Brand Addition GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 1.5 gm/15ml (100 mg/ml) (base equiv)) Brand Addition GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 2 gm/20ml (100 mg/ml) (base equiv)) Brand Addition GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 200 mg/2ml (100 mg/ml) (base equiv)) Brand Addition glatiramer acetate soln prefilled syringe 40 mg/ml Addition, generic for COPAXONE HAEGARDA (c1 esterase inhibitor (human) for subcutaneous inj 2000 unit) Brand Addition HAEGARDA (c1 esterase inhibitor (human) for subcutaneous inj 3000 unit) Brand Addition KALBITOR (ecallantide inj 10 mg/ml) Brand Addition K-PHOS (potassium phosphate monobasic tab 500 mg) Brand Addition LUTATHERA (lutetium lu 177 dotatate iv soln 370 mbq/ml (10 mci/ml)) Brand Addition MORPHINE SULFATE (morphine sulfate suppos 10 mg) Brand Addition MORPHINE SULFATE (morphine sulfate suppos 20 mg) Brand Addition MORPHINE SULFATE (morphine sulfate suppos 30 mg) Brand Addition MORPHINE SULFATE (morphine sulfate suppos 5 mg) Brand Addition naproxen sodium tab 275 mg Removal naproxen sodium tab 550 mg Removal naproxen tab ec 375 mg Addition, generic for EC-NAPROSYN naproxen tab ec 500 mg Addition, generic for EC-NAPROSYN naratriptan hcl tab 1 mg (base equiv) Addition, generic for AMERGE naratriptan hcl tab 2.5 mg (base equiv) Addition, generic for AMERGE OPDIVO (nivolumab iv soln 240 mg/24ml) Brand Addition oseltamivir phosphate for susp 6 mg/ml (base equiv) Addition, generic for TAMIFLU OZEMPIC (semaglutide soln pen-inj 0.25 or 0.5 mg/dose (2 mg/1.5ml)) Brand Addition OZEMPIC (semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml)) Brand Addition piroxicam cap 10 mg Addition, generic for FELDENE piroxicam cap 20 mg Addition, generic for FELDENE QVAR REDIHALER (beclomethasone diprop hfa breath act inh aer 40 mcg/act) Brand Addition QVAR REDIHALER (beclomethasone diprop hfa breath act inh aer 80 mcg/act) Brand Addition REYATAZ (atazanavir sulfate cap 150 mg (base equiv)) Brand Removal, generics available REYATAZ (atazanavir sulfate cap 200 mg (base equiv)) Brand Removal, generics available REYATAZ (atazanavir sulfate cap 300 mg (base equiv)) Brand Removal, generics available rivastigmine tartrate cap 1.5 mg Addition, generic for EXELON rivastigmine tartrate cap 3 mg Addition, generic for EXELON rivastigmine tartrate cap 4.5 mg Addition, generic for EXELON rivastigmine tartrate cap 6 mg Addition, generic for EXELON RUCONEST (c1 esterase inhibitor (recombinant) for iv inj 2100 unit) Brand Addition SHINGRIX (zoster vaccine recombinant adjuvanted for im inj 50 mcg) Brand Addition sildenafil citrate tab 100 mg Addition, generic for VIAGRA sildenafil citrate tab 25 mg Addition, generic for VIAGRA sildenafil citrate tab 50 mg Addition, generic for VIAGRA sumatriptan succinate solution auto-injector 4 mg/0.5ml Addition, generic for IMITREX STATDOSE sumatriptan succinate solution auto-injector 6 mg/0.5ml Addition, generic for IMITREX STATDOSE SUSTIVA (efavirenz cap 200 mg) Brand Removal, generics available SUSTIVA (efavirenz cap 50 mg) Brand Removal, generics available
3 TRADE NAME (generic name) or generic name TAMIFLU (oseltamivir phosphate for susp 6 mg/ml (base equiv)) Brand Removal, generics available tenofovir disoproxil fumarate tab 300 mg Addition, generic for VIREAD tetrabenazine tab 12.5 mg Addition, generic for XENAZINE tetrabenazine tab 25 mg Addition, generic for XENAZINE TOUJEO MAX SOLOSTAR (insulin glargine soln pen-injector 300 unit/ml) Brand Addition TRACLEER (bosentan tab for oral susp 32 mg) Brand Addition TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol aepb mcg/inh) Brand Addition TRISENOX (arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)) Brand Addition VERZENIO (abemaciclib tab 100 mg) Brand Addition VERZENIO (abemaciclib tab 150 mg) Brand Addition VERZENIO (abemaciclib tab 200 mg) Brand Addition VERZENIO (abemaciclib tab 50 mg) Brand Addition VIAGRA (sildenafil citrate tab 100 mg) Brand Removal, generics available VIAGRA (sildenafil citrate tab 25 mg) Brand Removal, generics available VIAGRA (sildenafil citrate tab 50 mg) Brand Removal, generics available VIDEX EC (didanosine delayed release capsule 125 mg) Brand Addition VIREAD (tenofovir disoproxil fumarate tab 300 mg) Brand Removal, generics available ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) Brand Addition ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) Brand Addition ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) Brand Addition ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) Brand Addition zolmitriptan orally disintegrating tab 2.5 mg Addition, generic for ZOMIG ZMT zolmitriptan orally disintegrating tab 5 mg Addition, generic for ZOMIG ZMT zolmitriptan tab 2.5 mg Addition, generic for ZOMIG zolmitriptan tab 5 mg Addition, generic for ZOMIG Special note: The following drugs are excluded from coverage ENDARI (glutamine sickle cell powder pack) - Effective 4/15/18 GOCOVRI (amantadine ext-release) - Effective 4/1/18 OSMOLEX ER (amantadine ext-release) - Effective 5/3/18 Special note: These drugs are excluded from pharmacy benefit coverage, but may be available for medical benefit coverage CRYSVITA (burosumab) - Effective 4/3/18 FASENRA (benralizumab) - Effective 3/1/ F Prime Therapeutics LLC 07/18
4 Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association
5
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