Advanced Control Specialty Formulary® Is a Guide Within Select Therapeutic Categories for Clients, Plan Members and Health Care Providers

October 2021 ® Advanced Control Specialty Formulary

The CVS Caremark® Advanced Control Specialty Formulary® is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a doctor. on this list.

Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in • The member's prescription benefit plan design may alter coverage this document. Products recently approved by the U.S. Food and of certain products or vary copay amounts based on the condition Drug Administration (FDA) may not be covered upon release being treated. to the market. • This drug list represents a summary of prescription coverage. It is • Your prescription benefit plan design may alter coverage of certain not all-inclusive and does not guarantee coverage. The member’s products or vary copay1 amounts based on the condition being specific prescription benefit plan design may not cover certain treated. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are removed from coverage. covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay information, please visit Caremark.com copay for specific products on the list. or contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or • Log in to Caremark.com to check coverage and copay generic equivalent. This may result in your doctor prescribing, information for a specific medicine. when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.

ANALGESICS EVOTAZ § NUCLEOSIDE REVERSE BARACLUDE SOLUTION HORMONAL GENVOYA TRANSCRIPTASE VEMLIDY ANTINEOPLASTIC AGENTS VISCOSUPPLEMENTS ODEFSEY INHIBITORS § ANTIANDROGENS § HEPATITIS C AGENTS DUROLANE PREZCOBIX abacavir abiraterone EUFLEXXA SYMTUZA ribavirin lamivudine ERLEADA GELSYN-3 TEMIXYS EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) stavudine NUBEQA SUPARTZ FX TRIUMEQ HARVONI (genotypes 1, 4, 5, 6) zidovudine XTANDI VOSEVI 2 EMTRIVA ANTI-INFECTIVES FUSION INHIBITORS YONSA

FUZEON § NUCLEOTIDE REVERSE ANTINEOPLASTIC ANTIRETROVIRAL AGENTS § KINASE INHIBITORS TRANSCRIPTASE AGENTS erlotinib § ANTIRETROVIRAL INTEGRASE INHIBITORS INHIBITORS § ALKYLATING AGENTS imatinib mesylate COMBINATIONS ISENTRESS tenofovir disoproxil fumarate lapatinib abacavir-lamivudine TIVICAY temozolomide AFINITOR efavirenz-emtricitabine- § PROTEASE INHIBITORS § NON-NUCLEOSIDE § ANTIMETABOLITES ALECENSA tenofovir disoproxil fumarate atazanavir REVERSE TRANSCRIPTASE capecitabine ALUNBRIG efavirenz-lamivudine- lopinavir-ritonavir INHIBITORS LONSURF BOSULIF tenofovir disoproxil fumarate NORVIR CABOMETYX efavirenz emtricitabine-tenofovir PREZISTA BIOSIMILARS CALQUENCE disoproxil fumarate nevirapine KANJINTI COPIKTRA lamivudine-zidovudine nevirapine ext-rel ANTIVIRALS RUXIENCE IBRANCE BIKTARVY EDURANT § HEPATITIS B AGENTS TRAZIMERA IRESSA CIMDUO INTELENCE entecavir ZIRABEV KISQALI DESCOVY lamivudine KISQALI FEMARA DOVATO tenofovir disoproxil fumarate CO-PACK

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.

KOSELUGO § PROSTAGLANDIN MIRENA THROMBOCYTOPENIA ALL OTHER CONDITIONS RYDAPT VASODILATORS SKYLA AGENTS ENBREL

SPRYCEL treprostinil DOPTELET HUMIRA FERTILITY REGULATORS STIVARGA ORENITRAM MULPLETA SUTENT GNRH / LHRH DISEASE-MODIFYING TAGRISSO SOLUBLE GUANYLATE ANTAGONISTS IMMUNOLOGIC ANTIRHEUMATIC DRUGS VOTRIENT CYCLASE STIMULATORS CETROTIDE AGENTS (DMARDs) XOSPATA ADEMPAS RASUVO OVULATION STIMULANTS, ALLERGENIC EXTRACTS MONOCLONAL ANTIBODIES CENTRAL NERVOUS GONADOTROPINS ORALAIR § HEREDITARY

PERJETA SYSTEM GONAL-F ANGIOEDEMA AUTOIMMUNE AGENTS PHESGO OVIDREL icatibant § ANTICONVULSANTS (PHYSICIAN- RUCONEST MULTIPLE MYELOMA GAUCHER DISEASE ADMINISTERED) vigabatrin TAKHZYRO

IMMUNOMODULATORS CERDELGA REMICADE ANTIPARKINSONIAN IMMUNOMODULATORS REVLIMID CEREZYME SIMPONI ARIA AGENTS THALOMID STELARA INTRAVENOUS IMMUNE GLOBULINS INBRIJA HEREDITARY TYROSINEMIA AUTOIMMUNE AGENTS CUTAQUIG PROTEASOME INHIBITORS KYNMOBI TYPE 1 AGENTS (SELF-ADMINISTERED) NINLARO ORFADIN IMMUNOSUPPRESSANTS § MOVEMENT DISORDERS See Table 1 for Indication Based VELCADE Coverage Details § ANTIMETABOLITES tetrabenazine HUMAN GROWTH mycophenolate mofetil PROSTATE CANCER AUSTEDO HORMONES ANKYLOSING SPONDYLITIS mycophenolate sodium INGREZZA § LUTEINIZING HORMONE- NORDITROPIN COSENTYX RELEASING HORMONE § CALCINEURIN INHIBITORS § MULTIPLE SCLEROSIS § PHENYLKETONURIA ENBREL (LHRH) AGONISTS AGENTS TREATMENT AGENTS HUMIRA cyclosporine leuprolide acetate cyclosporine, modified dimethyl fumarate sapropterin ELIGARD CROHN'S DISEASE tacrolimus delayed-rel HUMIRA glatiramer POLYNEUROPATHY LUTEINIZING HORMONE- STELARA § RAPAMYCIN DERIVATIVES RELEASING HORMONE AUBAGIO TEGSEDI SUBCUTANEOUS # everolimus BETASERON (LHRH) ANTAGONISTS § UREA CYCLE DISORDERS sirolimus COPAXONE # After failure of HUMIRA FIRMAGON

GILENYA sodium phenylbutyrate RESPIRATORY KESIMPTA PSORIASIS § MISCELLANEOUS MISCELLANEOUS MAYZENT ALPHA-1 ANTITRYPSIN bexarotene capsule HUMIRA CYSTAGON OCREVUS OTEZLA DEFICIENCY AGENTS ERIVEDGE REBIF SKYRIZI PROLASTIN-C LYNPARZA HEMATOLOGIC TYSABRI MATULANE STELARA VUMERITY § CYSTIC FIBROSIS ODOMZO § CHELATING AGENTS SUBCUTANEOUS ZEPOSIA tobramycin RUBRACA deferasirox TALTZ inhalation solution VISTOGARD deferiprone TREMFYA ENDOCRINE AND BETHKIS ZEJULA deferoxamine METABOLIC PSORIATIC ARTHRITIS ZOLINZA penicillamine capsule PULMONARY FIBROSIS COSENTYX ACROMEGALY trientine AGENTS CARDIOVASCULAR ENBREL SOMATULINE DEPOT HEMATOPOIETIC GROWTH HUMIRA ESBRIET ANTILIPEMICS § CALCIUM RECEPTOR FACTORS OTEZLA OFEV

PCSK9 INHIBITORS ARANESP ANTAGONISTS RHEUMATOID ARTHRITIS SEVERE ASTHMA AGENTS PRALUENT cinacalcet NIVESTYM ENBREL DUPIXENT RETACRIT PULMONARY ARTERIAL HUMIRA FASENRA CALCIUM REGULATORS ZIEXTENZO HYPERTENSION KEVZARA NUCALA PARATHYROID HORMONES § ENDOTHELIN RECEPTOR HEMOPHILIA A AGENTS ORENCIA CLICKJECT XOLAIR FORTEO ANTAGONISTS ADVATE ORENCIA

TYMLOS SUBCUTANEOUS TOPICAL ambrisentan ADYNOVATE RINVOQ bosentan MISCELLANEOUS AFSTYLA DERMATOLOGY ELOCTATE XELJANZ OPSUMIT PROLIA ATOPIC DERMATITIS ESPEROCT XELJANZ XR DUPIXENT § PHOSPHODIESTERASE CENTRAL PRECOCIOUS JIVI ULCERATIVE COLITIS INHIBITORS PUBERTY KOGENATE FS MOUTH / THROAT / HUMIRA sildenafil SUPPRELIN LA KOVALTRY DENTAL AGENTS STELARA tadalafil TRIPTODUR NOVOEIGHT PROTECTANTS SUBCUTANEOUS # NUWIQ PROSTACYCLIN RECEPTOR CONTRACEPTIVES XELJANZ # MUGARD

AGONISTS HEMOPHILIA B AGENTS XELJANZ XR # PROGESTIN INTRAUTERINE OPHTHALMIC UPTRAVI REBINYN DEVICES # After failure of HUMIRA RETINAL DISORDERS

KYLEENA EYLEA LUCENTIS

QUICK REFERENCE DRUG LIST

A E J ORALAIR T ORENCIA CLICKJECT abacavir EDURANT JIVI tacrolimus ORENCIA abacavir-lamivudine efavirenz tadalafil SUBCUTANEOUS abiraterone efavirenz-emtricitabine- K TAGRISSO ORENITRAM ADEMPAS tenofovir disoproxil fumarate KANJINTI TAKHZYRO ORFADIN ADVATE efavirenz-lamivudine- KESIMPTA TALTZ OTEZLA ADYNOVATE tenofovir disoproxil fumarate KEVZARA TEGSEDI OVIDREL

AFINITOR ELIGARD KISQALI TEMIXYS AFSTYLA ELOCTATE KISQALI FEMARA P temozolomide ALECENSA emtricitabine-tenofovir CO-PACK tenofovir disoproxil fumarate penicillamine capsule ALUNBRIG disoproxil fumarate KOGENATE FS tetrabenazine PERJETA ambrisentan EMTRIVA KOSELUGO THALOMID PHESGO ARANESP ENBREL KOVALTRY TIVICAY PRALUENT atazanavir entecavir KYLEENA tobramycin PREZCOBIX AUBAGIO EPCLUSA KYNMOBI inhalation solution PREZISTA AUSTEDO ERIVEDGE TRAZIMERA PROLASTIN-C ERLEADA L TREMFYA PROLIA B erlotinib treprostinil lamivudine ESBRIET trientine BARACLUDE SOLUTION lamivudine-zidovudine R BETASERON ESPEROCT lapatinib TRIPTODUR RASUVO BETHKIS EUFLEXXA leuprolide acetate TRIUMEQ REBIF bexarotene capsule everolimus LONSURF TYMLOS REBINYN BIKTARVY EVOTAZ lopinavir-ritonavir TYSABRI REMICADE bosentan EYLEA LUCENTIS RETACRIT U BOSULIF LYNPARZA REVLIMID F UPTRAVI ribavirin C FASENRA M RINVOQ V CABOMETYX FIRMAGON MATULANE RUBRACA CALQUENCE FORTEO MAYZENT VELCADE RUCONEST capecitabine FUZEON MIRENA VEMLIDY RUXIENCE CERDELGA MUGARD vigabatrin RYDAPT G CEREZYME MULPLETA VISTOGARD 2 CETROTIDE GELSYN-3 mycophenolate mofetil S VOSEVI CIMDUO GENVOYA mycophenolate sodium VOTRIENT sapropterin cinacalcet GILENYA VUMERITY sildenafil COPAXONE glatiramer N SIMPONI ARIA X COPIKTRA GONAL-F nevirapine sirolimus COSENTYX nevirapine ext-rel XELJANZ H SKYLA CUTAQUIG NINLARO XELJANZ XR SKYRIZI cyclosporine HARVONI NIVESTYM XOLAIR sodium phenylbutyrate cyclosporine, modified HUMIRA NORDITROPIN XOSPATA SOMATULINE DEPOT CYSTAGON NORVIR XTANDI SPRYCEL I NOVOEIGHT D stavudine IBRANCE NUBEQA Y STELARA INTRAVENOUS deferasirox icatibant NUCALA YONSA STELARA deferiprone imatinib mesylate NUWIQ SUBCUTANEOUS deferoxamine INBRIJA Z STIVARGA DESCOVY INGREZZA O ZEJULA SUPARTZ FX dimethyl fumarate INTELENCE OCREVUS ZEPOSIA SUPPRELIN LA delayed-rel IRESSA ODEFSEY zidovudine SUTENT DOPTELET ISENTRESS ODOMZO ZIEXTENZO SYMTUZA

DOVATO OFEV ZIRABEV DUPIXENT OPSUMIT ZOLINZA DUROLANE

PREFERRED OPTIONS FOR EXCLUDED SPECIALTY MEDICATIONS 3 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ACTEMRA INTRAVENOUS REMICADE, SIMPONI ARIA GLASSIA PROLASTIN-C ADCIRCA sildenafil, tadalafil GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL ALIQOPA COPIKTRA GRANIX NIVESTYM ALPROLIX Consult doctor HEPSERA entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, APOKYN INBRIJA, KYNMOBI VEMLIDY APTIVUS Consult doctor HERCEPTIN, HERCEPTIN HYLECTA KANJINTI, TRAZIMERA ARALAST NP PROLASTIN-C HUMATROPE NORDITROPIN ASTAGRAF XL tacrolimus HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, AVASTIN ZIRABEV SUPARTZ FX AVONEX dimethyl fumarate delayed-rel, glatiramer, ILUMYA REMICADE AUBAGIO, BETASERON, COPAXONE, INFLECTRA REMICADE, SIMPONI ARIA, GILENYA, KESIMPTA, MAYZENT, STELARA INTRAVENOUS OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA INVIRASE atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA AVSOLA REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS JADENU deferasirox, deferiprone, deferoxamine BARACLUDE TABLET entecavir, lamivudine, KUVAN sapropterin tenofovir disoproxil fumarate, BARACLUDE SOLUTION, VEMLIDY KYPROLIS NINLARO, VELCADE BERINERT icatibant, RUCONEST LETAIRIS ambrisentan, bosentan, OPSUMIT BORTEZOMIB NINLARO, VELCADE LEXIVA atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA BUPHENYL sodium phenylbutyrate LILETTA KYLEENA, MIRENA, SKYLA CELLCEPT mycophenolate mofetil, mycophenolate sodium LUPRON DEPOT ELIGARD, FIRMAGON, ORIAHNN, ORILISSA CHORIONIC GONADOTROPIN OVIDREL LUPRON DEPOT-PED SUPPRELIN LA, TRIPTODUR CIMZIA LYOPHILIZED POWDER REMICADE, SIMPONI ARIA, STELARA INTRAVENOUS MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine-tenofovir disoproxil fumarate, MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, BIKTARVY, DOVATO, GENVOYA, SUPARTZ FX ODEFSEY, SYMTUZA, TRIUMEQ MYFORTIC mycophenolate mofetil, CUPRIMINE penicillamine capsule mycophenolate sodium DESFERAL deferasirox, deferiprone, deferoxamine NEULASTA, NEULASTA ONPRO ZIEXTENZO ELELYSO CERDELGA, CEREZYME NEUPOGEN NIVESTYM ENTYVIO (For Crohn’s Disease Only) REMICADE, STELARA INTRAVENOUS NOVAREL OVIDREL ENVARSUS XR tacrolimus NUTROPIN AQ NORDITROPIN EPIVIR HBV entecavir, lamivudine, OMNITROPE NORDITROPIN tenofovir disoproxil fumarate, ORENCIA INTRAVENOUS REMICADE, SIMPONI ARIA BARACLUDE SOLUTION, VEMLIDY ORTHOVISC DUROLANE, EUFLEXXA, GELSYN-3, EPOGEN ARANESP, RETACRIT SUPARTZ FX EXJADE deferasirox, deferiprone, deferoxamine OTREXUP RASUVO EXTAVIA dimethyl fumarate delayed-rel, glatiramer, PEGASYS Consult doctor AUBAGIO, BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, PLEGRIDY dimethyl fumarate delayed-rel, glatiramer, OCREVUS, REBIF, TYSABRI, VUMERITY, AUBAGIO, BETASERON, COPAXONE, ZEPOSIA GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, FERRIPROX deferasirox, deferiprone, deferoxamine ZEPOSIA FOLLISTIM AQ GONAL-F PREGNYL OVIDREL FULPHILA ZIEXTENZO PROCRIT ARANESP, RETACRIT GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, PROCYSBI CYSTAGON SUPARTZ FX PROGRAF tacrolimus GENOTROPIN NORDITROPIN

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* RAPAMUNE everolimus, sirolimus THIOLA, THIOLA EC Consult doctor RAVICTI sodium phenylbutyrate TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS REMODULIN treprostinil TRACLEER ambrisentan, bosentan, OPSUMIT RENFLEXIS REMICADE, SIMPONI ARIA, TRELSTAR MIXJECT ELIGARD, FIRMAGON STELARA INTRAVENOUS TRUXIMA RUXIENCE REPATHA PRALUENT UDENYCA ZIEXTENZO REVATIO sildenafil, tadalafil VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), RIABNI RUXIENCE HARVONI (genotypes 1, 4, 5, 6) RITUXAN RUXIENCE VIRACEPT atazanavir, lopinavir-ritonavir, EVOTAZ, PREZCOBIX, PREZISTA SABRIL vigabatrin VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, SAIZEN NORDITROPIN SUPARTZ FX SANDOSTATIN LAR SOMATULINE DEPOT XENAZINE tetrabenazine, AUSTEDO SIGNIFOR LAR SOMATULINE DEPOT ZARXIO NIVESTYM SOMAVERT SOMATULINE DEPOT ZEMAIRA PROLASTIN-C STRIBILD efavirenz-emtricitabine-tenofovir disoproxil fumarate, ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), efavirenz-lamivudine-tenofovir disoproxil fumarate, HARVONI (genotypes 1, 4, 5, 6) BIKTARVY, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ ZOLADEX ELIGARD, FIRMAGON, ORILISSA SYNVISC, SYNVISC-ONE DUROLANE, EUFLEXXA, GELSYN-3, ZORTRESS everolimus, sirolimus SUPARTZ FX ZYDELIG COPIKTRA SYPRINE trientine ZYTIGA abiraterone, XTANDI, YONSA TASIGNA imatinib mesylate, BOSULIF, SPRYCEL

TECFIDERA dimethyl fumarate delayed-rel, glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA

TABLE 1 - PREFERRED OPTIONS FOR INDICATION BASED SELF-ADMINISTERED AUTOIMMUNE EXCLUDED MEDICATIONS

CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S)

ANKYLOSING SPONDYLITIS CIMZIA PREFILLED SYRINGE COSENTYX SIMPONI ENBREL TALTZ HUMIRA

CROHN'S DISEASE CIMZIA PREFILLED SYRINGE HUMIRA STELARA SUBCUTANEOUS #

PSORIASIS CIMZIA PREFILLED SYRINGE HUMIRA COSENTYX OTEZLA ENBREL SKYRIZI STELARA SUBCUTANEOUS TALTZ TREMFYA

PSORIATIC ARTHRITIS CIMZIA PREFILLED SYRINGE COSENTYX ORENCIA CLICKJECT ENBREL ORENCIA SUBCUTANEOUS HUMIRA SIMPONI OTEZLA STELARA SUBCUTANEOUS TALTZ TREMFYA XELJANZ XELJANZ XR

RHEUMATOID ARTHRITIS ACTEMRA ACTPEN ENBREL ACTEMRA SUBCUTANEOUS HUMIRA CIMZIA PREFILLED SYRINGE KEVZARA KINERET ORENCIA CLICKJECT SIMPONI ORENCIA SUBCUTANEOUS RINVOQ XELJANZ XELJANZ XR

ULCERATIVE COLITIS SIMPONI HUMIRA STELARA SUBCUTANEOUS # XELJANZ # XELJANZ XR #

ALL OTHER CONDITIONS ACTEMRA ACTPEN ENBREL ACTEMRA SUBCUTANEOUS HUMIRA KINERET ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS

# After failure of HUMIRA

You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.

FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to Caremark.com to check coverage and copay information for a specific medicine.

§ Generics are available in this class and should be considered the first line of prescribing. * The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 3 An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication.

CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.

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