HCSC
5 Tier Basic Formulary Updates
April 2017
TRADE NAME (generic name) or generic name
Brand/
Generic
Product
ADYNOVATE (antihemophilic factor recomb pegylated for inj 1500 unit)
Brand
Addition
ADYNOVATE (antihemophilic factor recomb pegylated for inj 750 unit)
Brand
Addition
Description of Change
ALPROLIX (coagulation factor ix (recomb) (rfixfc) for inj 4000 unit)
Brand
Addition
CHLOROQUINE PHOSPHATE (chloroquine phosphate tab 250 mg)
Brand
Removal
CLEMASTINE FUMARATE (clemastine fumarate tab 2.68 mg)
Brand
Removal
FLORIVA PLUS (*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***)
Brand
Removal
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 150-1000 mg)
Brand
Addition
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 150-500 mg)
Brand
Addition
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 50-1000 mg)
Brand
Addition
INVOKAMET XR (canagliflozin-metformin hcl tab sr 24hr 50-500 mg)
Brand
Addition
KOATE (antihemophilic factor (human) for inj 1000 unit)
Brand
Addition
KOATE (antihemophilic factor (human) for inj 250 unit)
Brand
Addition
KOATE (antihemophilic factor (human) for inj 500 unit)
Brand
Addition
MULTI-VIT/FLUORIDE (*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***)
Brand
Removal
SOOLANTRA (ivermectin cream 1%)
Brand
Addition
Blue Cross and Blue Shield of Illinois (BCBSIL), Blue Cross and Blue Shield of Montana (BCBSMT), Blue Cross and Blue Shield of New Mexico (BCBSNM),
Blue Cross and Blue Shield of Oklahoma (BCBSOK), and Blue Cross and Blue Shield of Texas (BCBSTX) are Divisions of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BCBSIL, BCBSMT, BCBSNM, BCBSOK, and BCBSTX
contract with Prime Therapeutics to provide pharmacy benefit management, home delivery pharmacy and specialty pharmacy services. BCBSIL, BCBSMT,
BCBSNM, BCBSOK, and BCBSTX, as well as several other independent Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics LLC.
April 2017 | HCSC 5 Tier Basic Formulary Updates
4621-G HCSC © Prime Therapeutics LLC 04/17