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

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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 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. 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
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