Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates

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1 Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates April 2018 TRADE NAME (generic name) or generic name Brand/Generic Description of Change 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 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 clobetasol propionate emollient base cream 0.05% Generic Addition, generic for E clobetasol propionate gel 0.05% Generic Addition, generic for clobetasol propionate shampoo 0.05% Generic Addition, generic for CLOBEX clobetasol propionate soln 0.05% Generic Addition, generic for desonide cream 0.05% Generic Removal desoximetasone gel 0.05% Generic 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 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 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 HUMULIN R U-500 (CONCENTRATED) (insulin regular (human) inj 500 unit/ml) Brand Addition HUMULIN R U-500 KWIKPEN (insulin regular (human) soln pen-injector 500 unit/ml) Brand Addition 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 April 2018 Blue Cross and Blue Shield of MN GenRx Formulary Updates

2 TRADE NAME (generic name) or generic name Brand/Generic Description of Change 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 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 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 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 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 SASH KIT FOR FLUSHING VASCULAR ACCESS DEVICES (heparin sod lock flush & nacl lock flush 10 unt/ml-0.9% kit) Brand Removal 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 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 triamcinolone acetonide cream 0.1% Generic Addition triamcinolone acetonide lotion 0.1% Generic Addition April 2018 Blue Cross and Blue Shield of MN GenRx Formulary Updates 2746-F Prime Therapeutics LLC 04/18

3 TRADE NAME (generic name) or generic name Brand/Generic Description of Change VYXEOS (daunorubicin-cytarabine liposome for iv inj mg) Brand Addition ZIAGEN (abacavir sulfate soln 20 mg/ml (base equiv)) Brand Removal, generics available April 2018 Blue Cross and Blue Shield of MN GenRx Formulary Updates

4 Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association

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