Blue Cross and Blue Shield of
Nebraska Prime Perspective April 2017
April 2017
Brand/
Generic
Product
Effective
Date
Description of Change
ADYNOVATE (antihemophilic factor recomb pegylated for inj 1500 unit)
Brand
1/22/2017
Addition
ADYNOVATE (antihemophilic factor recomb pegylated for inj 750 unit)
Brand
1/22/2017
Addition
ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 4000 unit)
Brand
11/6/16
Addition
ARZOL SILVER NITRATE APPLICATORS (silver nitrate-potassium nitrate applicator
75-25%)
Brand
4/1/2017
Addition
AZILECT (rasagiline mesylate tab 0.5 mg (base equiv))
Brand
4/1/2017
Removal, generics available
AZILECT (rasagiline mesylate tab 1 mg (base equiv))
Brand
4/1/2017
Removal, generics available
CONTOUR NEXT ONE BLOOD GLUCOSE MONITORING SYSTEM (*blood glucose
monitoring kit***)
Brand
12/18/2016
Addition
CORLOPAM (fenoldopam mesylate iv inj 10 mg/ml (base equiv))
Brand
4/1/2017
Addition
CORLOPAM (fenoldopam mesylate iv inj 20 mg/2ml (base equiv))
Brand
4/1/2017
Addition
DOPRAM (doxapram hcl inj 20 mg/ml)
Brand
4/1/2017
Addition
EFFIENT (prasugrel hcl tab 10 mg (base equiv))
Brand
4/1/2017
Addition
EFFIENT (prasugrel hcl tab 5 mg (base equiv))
Brand
4/1/2017
Addition
EMEND (aprepitant capsule 80 mg)
Brand
4/1/2017
Removal, generics available
EMEND (aprepitant capsule therapy pack 80 & 125 mg)
Brand
4/1/2017
Removal, generics available
EPINEPHRINE (Mylan Products) (epinephrine solution auto-injector 0.15 mg/0.3ml
(1:2000))
Brand
4/1/2017
Addition
EPINEPHRINE (Mylan Products) (epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000))
Brand
4/1/2017
Addition
EPZICOM (abacavir sulfate-lamivudine tab 600-300 mg)
Brand
4/1/2017
Removal, generics available
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 150-1000 mg)
Brand
4/1/2017
Addition
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 150-500 mg)
Brand
4/1/2017
Addition
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 50-1000 mg)
Brand
4/1/2017
Addition
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 50-500 mg)
Brand
4/1/2017
Addition
IXINITY (coagulation factor ix (recombinant) for inj 2000 unit)
Brand
1/1/2017
Addition
IXINITY (coagulation factor ix (recombinant) for inj 250 unit)
Brand
1/1/2017
Addition
IXINITY (coagulation factor ix (recombinant) for inj 3000 unit)
Brand
1/1/2017
Addition
KALETRA (lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml))
Brand
4/1/2017
Removal, generics available
PREVIDENT 5000 ENAMEL PROTECT (sodium fluoride-potassium nitrate paste 1.1-5%)
Brand
4/1/2017
Addition
PREVIDENT 5000 SENSITIVE (sodium fluoride-potassium nitrate paste 1.1-5%)
Brand
4/1/2017
Addition
SOOLANTRA (ivermectin cream 1%)
Brand
4/1/2017
Addition
TAMIFLU (oseltamivir phosphate cap 30 mg (base equiv))
Brand
4/1/2017
Removal, generics available
TAMIFLU (oseltamivir phosphate cap 45 mg (base equiv))
Brand
4/1/2017
Removal, generics available
TRADE NAME (generic name) or generic name
TAMIFLU (oseltamivir phosphate cap 75 mg (base equiv))
Brand
4/1/2017
Removal, generics available
URAMAXIN (urea lotion 45%)
Brand
4/1/2017
Addition
VAGIFEM (estradiol vaginal tab 10 mcg)
Brand
4/1/2017
Removal, generics available
April 2017 | Nebraska Prime Perspective
2296-A © Prime Therapeutics LLC  04/17