CVS Caremark® Drug Benefit Alignment Legacy Drug List - Q1 2021 - Self & Clin Admin Active Historical Route of Therapy Class/Indication Name Generic Name HCPCs HCPCs Admin Category Program ACROMEGALY SOMATULINE LANREOTIDE ACETATE J1930 SC Clin-Admin DBA FASENRA PEN BENRALIZUMAB J0517 SC Self-Admin DBA NUCALA (PREFILLED SYRINGE/ AUTO- ASTHMA J2182 SC Self-Admin DBA INJECTOR) CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES ARCALYST J2793 SC Self-Admin DBA CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES ILARIS J0638 SC Clin-Admin DBA CYSTIC FIBROSIS BETHKIS TOBRAMYCIN J7682 IN Self-Admin DBA CYSTIC FIBROSIS KITABIS PAK TOBRAMYCIN SULFATE J7682 IN Self-Admin DBA CYSTIC FIBROSIS PULMOZYME DORNASE ALFA J7639 IN Self-Admin DBA CYSTIC FIBROSIS TOBI TOBRAMYCIN J7682 IN Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS GENOTROPIN SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS HUMATROPE SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS INCRELEX MECASERMIN J2170 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS NORDITROPIN SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS NUTROPIN SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS OMNITROPE SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS SAIZEN SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS SEROSTIM SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS ZOMACTON SOMATROPIN J2941 SC Self-Admin DBA GROWTH HORMONE & RELATED DISORDERS ZORBTIVE SOMATROPIN J2941 SC Self-Admin DBA HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ADVATE ANTIHEMOPHILIC FACTOR RAHF-PFM J7192 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ANTIHEMOPHILIC FACTOR (RECOMBINANT) ADYNOVATE J7207 IV Self-Admin DBA BLEEDING DISORDERS PEGYLATED HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ANTIHEMOPHILIC FACTOR (RECOMBINANT) AFSTYLA J7210 IV Self-Admin DBA BLEEDING DISORDERS SINGLE CHAIN HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ALPHANATE ANTIHEMOPHILIC FACTOR-VWF (HUMAN) J7186 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ALPHANINE SD COAGULATION FACTOR IX J7193 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ALPROLIX COAGULATION FACTOR IX (RFIXFC) J7201 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED BEBULIN FACTOR IX COMPLEX J7194 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED BENEFIX COAGULATION FACTOR IX (RECOMBINANT) J7195 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED COAGADEX COAGULATION FACTOR X (HUMAN) J7175 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED CORIFACT FACTOR XIII CONCENTRATE HUMAN J7180 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ANTIHEMOPHILIC FACTOR (RECOMB) FC ELOCTATE J7205 IV Self-Admin DBA BLEEDING DISORDERS FUSION PROTEIN (RFVIIIFC) HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ANTIHEMOPHILIC FACTOR (RECOMBINANT) ESPEROCT J7204 IV Self-Admin DBA BLEEDING DISORDERS GLYCOPEGYLATED-EXEI HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED FEIBA ANTIINHIBITOR COAGULANT CMPLX J7198 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED HELIXATE FS ANTIHEMOPHILIC FACTOR (RECOMBINANT) J7192 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED HEMLIBRA EMICIZUMAB-KXWH J7170 SC Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED HEMOFIL M ANTIHEMOPHILIC FACTOR (HUMAN) J7190 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED HUMATE-P ANTIHEMOPHILIC FACTOR-VWF (HUMAN) J7187 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED COAGULATION FACTOR IX RECOMB ALBUMIN IDELVION J7202 IV Self-Admin DBA BLEEDING DISORDERS FUSION PROTEIN (RIX-FP) HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED IXINITY COAGULATION FACTOR IX (RECOMBINANT) J7195 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ANTIHEMOPHILIC FACTOR (RECOMBINANT) J7208, JIVI J7207, IV Self-Admin DBA BLEEDING DISORDERS PEGYLATED-AUCL J7192 HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED KOATE ANTIHEMOPHILIC FACTOR (HUMAN) J7190 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED KOGENATE ANTIHEMOPHILIC FACTOR (RECOMBINANT) J7192 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED KOVALTRY ANTIHEMOPHILIC FACTOR (RECOMBINANT) J7211 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED MONOCLATE-P ANTIHEMOPHILIC FACTOR (HUMAN) J7190 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED MONONINE COAGULATION FACTOR IX J7193 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED NOVOEIGHT ANTIHEMOPHILIC FACTOR (RECOMBINANT) J7182 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED NOVOSEVEN RT COAGULATION FACTOR VIIA (RECOMBINANT) J7189 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED ANTIHEMOPHILIC FACTOR (RECOMB B-DOMAIN NUWIQ J7209 IV Self-Admin DBA BLEEDING DISORDERS DELETED) (BDD-RFVIII) HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED PROFILNINE SD FACTOR IX COMPLEX J7194 IV Self-Admin DBA BLEEDING DISORDERS

©2020 CVS Caremark. All rights reserved. 75-MS014 120920 CVS Caremark® Drug Benefit Alignment Legacy Drug List - Q1 2021 - Self & Clin Admin Active Historical Route of Therapy Class/Indication Name Generic Name HCPCs HCPCs Admin Category Program HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED COAGULATION FACTOR IX (RECOMBINANT) J7203, REBINYN IV Self-Admin DBA BLEEDING DISORDERS GLYCOPEGYLATED J7195 HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED RECOMBINATE ANTIHEMOPHILIC FACTOR (RECOMBINANT) J7192 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED RIXUBIS COAGULATION FACTOR IX (RECOMBINANT) J7200 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED COAGULATION FACTOR VIIA (RECOMBINANT)- SEVENFACT J7212 IV Self-Admin DBA BLEEDING DISORDERS JNCW HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED J7181, TRETTEN COAGULATION FACTOR XIII A-SUB IV Self-Admin DBA BLEEDING DISORDERS J7180 HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED VONVENDI VON WILLEBRAND FACTOR (RECOMBINANT) J7179 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED WILATE ANTIHEMOPHILIC FACTOR-VWF (HUMAN) J7183 IV Self-Admin DBA BLEEDING DISORDERS HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED XYNTHA ANTIHEMOPHILIC FACTOR RECOMBINANT PAF J7185 IV Self-Admin DBA BLEEDING DISORDERS HEPATITIS C PEGASYS PEGINTERFERON ALFA-2A S0145 SC Self-Admin DBA HEPATITIS C PEG-INTRON PEGINTERFERON ALFA-2B S0148 SC Self-Admin DBA HEREDITARY ANGIOEDEMA FIRAZYR ICATIBANT ACETATE J1744 SC Self-Admin DBA HEREDITARY ANGIOEDEMA HAEGARDA C1 ESTERASE INHIBITOR (HUMAN) J0599 SC Self-Admin DBA HEREDITARY ANGIOEDEMA TAKHZYRO LADELUMAB-FLYO J0593 SC Self-Admin DBA HIV FUZEON ENFUVIRTIDE J1324 SC Self-Admin DBA HORMONAL THERAPIES SUPPRELIN LA HISTRELIN ACETATE (CPP) J9226 SC Clin-Admin DBA IMMUNE (IDIOPATHIC) THROMBOCYTOPENIA NPLATE ROMIPLOSTIM J2796 SC Clin-Admin DBA PURPURA IMMUNE DEFICIENCIES & RELATED DISORDERS: J1460, GAMASTAN S/D IMMUNE GLOBULIN (HUMAN) J1560, IM Clin-Admin DBA IMMUNE GLOBULINS 90281 IMMUNE DEFICIENCIES & RELATED DISORDERS: J1571, HEPAGAM B (IM) HEPATITIS B IMMUNE GLOBULIN IM Clin-Admin DBA IMMUNE GLOBULINS 90371 IMMUNE DEFICIENCIES & RELATED DISORDERS: HYPERHEP B S/D HEPATITIS B IMMUNE GLOBULIN 90371 IM Clin-Admin DBA IMMUNE GLOBULINS IMMUNE DEFICIENCIES & RELATED DISORDERS: NABI-HB HEPATITIS B IMMUNE GLOBULIN 90371 IM Clin-Admin DBA IMMUNE GLOBULINS INFECTIOUS DISEASE ACTIMMUNE INTERFERON GAMMA-1B J9216 SC Self-Admin DBA INFECTIOUS DISEASE ALFERON N INTERFERON ALFA-N3 J9215 I-LES Clin-Admin DBA INFERTILITY BRAVELLE UROFOLLITROPIN PURIFIED J3355 IM, SC Self-Admin DBA INFERTILITY FOLLISTIM AQ FOLLITROPIN BETA S0128 IM, SC Self-Admin DBA INFERTILITY GANIRELIX ACETATE GANIRELIX ACETATE S0132 SC Self-Admin DBA INFERTILITY GONAL-F FOLLITROPIN ALFA S0126 SC Self-Admin DBA INFERTILITY MENOPUR MENOTROPINS S0122 SC Self-Admin DBA INFERTILITY NOVAREL CHORIONIC GONADOTROPIN J0725 IM Self-Admin DBA INFERTILITY PREGNYL CHORIONIC GONADOTROPIN J0725 IM Self-Admin DBA INFLAMMATORY BOWEL DISEASE CIMZIA (LYOPHILIZED POWDER) J0717 SC Clin-Admin DBA INFLAMMATORY BOWEL DISEASE CIMZIA (PREFILLED SYRINGE) CERTOLIZUMAB PEGOL J0717 SC Self-Admin DBA INFLAMMATORY BOWEL DISEASE HUMIRA J0135 SC Self-Admin DBA INFLAMMATORY BOWEL DISEASE STELARA J3357 SC Self-Admin DBA MOVEMENT DISORDERS APOKYN APOMORPHINE HCL J0364 SC Self-Admin DBA J1826, IM Self-Admin DBA MULTIPLE SCLEROSIS AVONEX INTERFERON BETA-1A Q3027 MULTIPLE SCLEROSIS BETASERON INTERFERON BETA-1B J1830 SC Self-Admin DBA MULTIPLE SCLEROSIS COPAXONE GLATIRAMER ACETATE J1595 SC Self-Admin DBA MULTIPLE SCLEROSIS EXTAVIA INTERFERON BETA-1B J1830 SC Self-Admin DBA MULTIPLE SCLEROSIS GLATOPA GLATIRAMER ACETATE J1595 SC Self-Admin DBA Q3028, SC Self-Admin DBA MULTIPLE SCLEROSIS REBIF INTERFERON BETA-1A J1826 ONCOLOGY-ORAL AFINITOR EVEROLIMUS J7527 OR Self-Admin DBA ONCOLOGY-ORAL GLEEVEC IMATINIB MESYLATE S0088 OR Self-Admin DBA ONCOLOGY-ORAL HYCAMTIN TOPOTECAN HCL J8705 OR Self-Admin DBA ONCOLOGY-ORAL IRESSA GEFITINIB J8565 OR Self-Admin DBA ONCOLOGY-ORAL TEMODAR TEMOZOLOMIDE J8700 OR Self-Admin DBA J8520, OR Self-Admin DBA ONCOLOGY-ORAL XELODA CAPECITABINE J8521 OSTEOPOROSIS FORTEO TERIPARATIDE (RECOMBINANT) J3110 SC Self-Admin DBA PSORIASIS ENBREL ETANERCEPT J1438 SC Self-Admin DBA PSORIASIS HUMIRA ADALIMUMAB J0135 SC Self-Admin DBA PSORIASIS ILUMYA -ASMN J3245 SC Clin-Admin DBA PSORIASIS STELARA USTEKINUMAB J3357 SC Self-Admin DBA PSORIASIS TREMFYA J1628 SC Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION EPOPROSTENOL SODIUM EPOPROSTENOL SODIUM J1325 IV Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION FLOLAN EPOPROSTENOL SODIUM J1325 IV Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION REMODULIN TREPROSTINIL SODIUM J3285 IV, SC Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION REVATIO SILDENAFIL CITRATE S0090 IV, OR Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION TYVASO TREPROSTINIL J7686 IN Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION VELETRI EPOPROSTENOL SODIUM J1325 IV Self-Admin DBA PULMONARY ARTERIAL HYPERTENSION VENTAVIS ILOPROST Q4074 IN Self-Admin DBA RENAL DISEASE SENSIPAR CINACALCET HCL J0604 OR Self-Admin DBA RESPIRATORY SYNCYTIAL VIRUS SYNAGIS PALIVIZUMAB 90378 IM Clin-Admin DBA RHEUMATOID ARTHRITIS CIMZIA (LYOPHILIZED POWDER) CERTOLIZUMAB PEGOL J0717 SC Clin-Admin DBA RHEUMATOID ARTHRITIS CIMZIA (PREFILLED SYRINGE) CERTOLIZUMAB PEGOL J0717 SC Self-Admin DBA RHEUMATOID ARTHRITIS ENBREL ETANERCEPT J1438 SC Self-Admin DBA

©2020 CVS Caremark. All rights reserved. 75-MS014 120920 CVS Caremark® Drug Benefit Alignment Legacy Drug List - Q1 2021 - Self & Clin Admin Active Historical Route of Therapy Class/Indication Name Generic Name HCPCs HCPCs Admin Category Program RHEUMATOID ARTHRITIS HUMIRA ADALIMUMAB J0135 SC Self-Admin DBA ORENCIA (PREFILLED SYRINGE/ RHEUMATOID ARTHRITIS ABATACEPT J0129 SC Self-Admin DBA CLICKJET AUTO-INJECTOR) SEIZURE DISORDERS ACTHAR GEL CORTICOTROPIN J0800 IM, SC Self-Admin DBA HEMOPHILIA CLOTTING FACTOR, NOT HEMOPHILIA CLOTTING FACTOR, NOT UNCLASSIFIED - HEMOPHILIA J7199 IV Self-Admin DBA OTHERWISE CLASSIFIED OTHERWISE CLASSIFIED

LEGEND Program / Category Description Drug Benefit Alignment (DBA) / Self-Admin Self-administered drugs; includes oral oncology Drug Benefit Alignment (DBA) / Clin-Admin Clinician-administered drugs (non-infused)

This document contains confidential and proprietary information of CVS Caremark and may not be reproduced, distributed or printed without written permission from CVS Caremark. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. This list is subject to change.

©2020 CVS Caremark. All rights reserved. 75-MS014 120920