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 /Generic ALUNBRIG (brigatinib tab 180 mg) ALUNBRIG (brigatinib tab 90 mg) ALUNBRIG (brigatinib tab initiation therapy pack 90 mg & 180 mg) aprepitant capsule 125 mg Generic, generic for EMEND aprepitant capsule 40 mg Generic, generic for EMEND armodafinil tab 150 mg Generic, generic for NUVIGIL armodafinil tab 200 mg Generic, generic for NUVIGIL armodafinil tab 250 mg Generic, generic for NUVIGIL armodafinil tab 50 mg Generic, generic for NUVIGIL atazanavir sulfate cap 150 mg (base equiv) Generic, generic for REYATAZ atazanavir sulfate cap 200 mg (base equiv) Generic, generic for REYATAZ atazanavir sulfate cap 300 mg (base equiv) Generic, generic for REYATAZ BENZNIDAZOLE (benznidazole tab 100 mg) BENZNIDAZOLE (benznidazole tab 12.5 mg) BERINERT (c1 esterase inhibitor (human) for iv inj kit 500 unit) BORTEZOMIB (bortezomib for iv inj 3.5 mg) BOSULIF (bosutinib tab 400 mg) CALQUENCE (acalabrutinib cap 100 mg) clorazepate dipotassium tab 15 mg Generic Removal clorazepate dipotassium tab 3.75 mg Generic Removal clorazepate dipotassium tab 7.5 mg Generic Removal DROXIA (hydroxyurea cap 200 mg) DROXIA (hydroxyurea cap 300 mg) DROXIA (hydroxyurea cap 400 mg) efavirenz cap 200 mg Generic, generic for SUSTIVA efavirenz cap 50 mg Generic, generic for SUSTIVA efavirenz tab 600 mg Generic, generic for SUSTIVA EMEND (aprepitant capsule 125 mg) Removal, generics available EMEND (aprepitant capsule 40 mg) Removal, generics available ENBREL MINI (etanercept subcutaneous solution cartridge 50 mg/ml) ERLEADA (apalutamide tab 60 mg) estradiol vaginal cream 0.1 mg/gm Generic, generic for ESTRACE etodolac cap 200 mg Generic etodolac cap 300 mg Generic etodolac tab 400 mg Generic, generic for LODINE etodolac tab 500 mg Generic fentanyl citrate lozenge on a handle 1200 mcg Generic, generic for ACTIQ fentanyl citrate lozenge on a handle 1600 mcg Generic, generic for ACTIQ fentanyl citrate lozenge on a handle 200 mcg Generic, generic for ACTIQ fentanyl citrate lozenge on a handle 400 mcg Generic, generic for ACTIQ fentanyl citrate lozenge on a handle 600 mcg Generic, generic for ACTIQ fentanyl citrate lozenge on a handle 800 mcg Generic, generic for ACTIQ FIASP (insulin aspart inj 100 unit/ml) July 2018 continued July 2018 Blue Cross and Blue Shield of MN FlexRx Formulary Updates

2 TRADE NAME (generic name) or generic name /Generic FIASP FLEXTOUCH (insulin aspart soln pen-injector 100 unit/ml) GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 1 gm/10ml (100 mg/ml) GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 1.5 gm/15ml (100 mg/ml) GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 2 gm/20ml (100 mg/ml) GEMCITABINE HYDROCHLORIDE (gemcitabine hcl inj 200 mg/2ml (100 mg/ml) glatiramer acetate soln prefilled syringe 40 mg/ml Generic, generic for COPAXONE HAEGARDA (c1 esterase inhibitor (human) for subcutaneous inj 2000 unit) HAEGARDA (c1 esterase inhibitor (human) for subcutaneous inj 3000 unit) KALBITOR (ecallantide inj 10 mg/ml) LUTATHERA (lutetium lu 177 dotatate iv soln 370 mbq/ml (10 mci/ml)) memantine hcl cap er 24hr 14 mg Generic, generic for NAMENDA XR memantine hcl cap er 24hr 21 mg Generic, generic for NAMENDA XR memantine hcl cap er 24hr 28 mg Generic, generic for NAMENDA XR memantine hcl cap er 24hr 7 mg Generic, generic for NAMENDA XR methadone hcl tab for oral susp 40 mg Generic MIGERGOT (ergotamine w/ caffeine suppos mg) Removal MIGRANAL (dihydroergotamine mesylate nasal spray 4 mg/ml) Removal naproxen sodium tab 275 mg Generic Removal naproxen sodium tab 550 mg Generic Removal naproxen susp 125 mg/5ml Generic Removal naproxen tab ec 375 mg Generic, generic for EC-NAPROSYN naproxen tab ec 500 mg Generic, generic for EC-NAPROSYN naratriptan hcl tab 1 mg (base equiv) Generic, generic for AMERGE naratriptan hcl tab 2.5 mg (base equiv) Generic, generic for AMERGE OPDIVO (nivolumab iv soln 240 mg/24ml) oseltamivir phosphate for susp 6 mg/ml (base equiv) Generic, generic for TAMIFLU oxycodone hcl conc 100 mg/5ml (20 mg/ml) Generic Removal OZEMPIC (semaglutide soln pen-inj 0.25 or 0.5 mg/dose (2 mg/1.5ml)) OZEMPIC (semaglutide soln pen-inj 1 mg/dose (2 mg/1.5ml)) piroxicam cap 10 mg Generic, generic for FELDENE piroxicam cap 20 mg Generic, generic for FELDENE PROLASTIN-C (alpha1-proteinase inhibitor (human) inj 1000 mg/20ml) QVAR REDIHALER (beclomethasone diprop hfa breath act inh aer 40 mcg/act) QVAR REDIHALER (beclomethasone diprop hfa breath act inh aer 80 mcg/act) REYATAZ (atazanavir sulfate cap 150 mg Removal, generics available REYATAZ (atazanavir sulfate cap 200 mg Removal, generics available REYATAZ (atazanavir sulfate cap 300 mg Removal, generics available rivastigmine tartrate cap 1.5 mg Generic, generic for EXELON rivastigmine tartrate cap 3 mg Generic, generic for EXELON rivastigmine tartrate cap 4.5 mg Generic, generic for EXELON rivastigmine tartrate cap 6 mg Generic, generic for EXELON RUCONEST (c1 esterase inhibitor (recombinant) for iv inj 2100 unit) SHINGRIX (zoster vaccine recombinant adjuvanted for im inj 50 mcg) sildenafil citrate tab 100 mg Generic, generic for VIAGRA sildenafil citrate tab 25 mg Generic, generic for VIAGRA sildenafil citrate tab 50 mg Generic, generic for VIAGRA sumatriptan succinate solution auto-injector 4 mg/0.5ml Generic, generic for IMITREX STATDOSE continued July 2018 Blue Cross and Blue Shield of MN FlexRx Formulary Updates

3 TRADE NAME (generic name) or generic name /Generic sumatriptan succinate solution auto-injector 6 mg/0.5ml Generic, generic for IMITREX STATDOSE SUSTIVA (efavirenz cap 200 mg) Removal, generics available SUSTIVA (efavirenz cap 50 mg) Removal, generics available TAMIFLU (oseltamivir phosphate for susp 6 mg/ml Removal, generics available tenofovir disoproxil fumarate tab 300 mg Generic, generic for VIREAD tetrabenazine tab 12.5 mg Generic, generic for XENAZINE tetrabenazine tab 25 mg Generic, generic for XENAZINE TOUJEO MAX SOLOSTAR (insulin glargine soln pen-injector 300 unit/ml) TRACLEER (bosentan tab for oral susp 32 mg) TRELEGY ELLIPTA (fluticasone-umeclidinium-vilanterol aepb mcg/inh) TRISENOX (arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)) VERZENIO (abemaciclib tab 100 mg) VERZENIO (abemaciclib tab 150 mg) VERZENIO (abemaciclib tab 200 mg) VERZENIO (abemaciclib tab 50 mg) VIAGRA (sildenafil citrate tab 100 mg) Removal, generics available VIAGRA (sildenafil citrate tab 25 mg) Removal, generics available VIAGRA (sildenafil citrate tab 50 mg) Removal, generics available VIDEX EC (didanosine delayed release capsule 125 mg) VIREAD (tenofovir disoproxil fumarate tab 300 mg) Removal, generics available XENICAL (orlistat cap 120 mg) Removal ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) ZENPEP (pancrelipase (lip-prot-amyl) dr cap unit) zolmitriptan orally disintegrating tab 2.5 mg Generic, generic for ZOMIG ZMT zolmitriptan orally disintegrating tab 5 mg Generic, generic for ZOMIG ZMT zolmitriptan tab 2.5 mg Generic, generic for ZOMIG zolmitriptan tab 5 mg Generic, 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 3/1/18 July 2018 Blue Cross and Blue Shield of MN FlexRx Formulary Updates 2746-C Prime Therapeutics LLC 07/18

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: 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)

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