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Advanced Control Formulary™ Change Summary Report Effective 07-01-2019

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Advanced Control Formulary™ Change Summary Report Effective 07-01-2019 Advanced Control Formulary™ Change Summary Report Effective 07-01-2019 This report highlights all changes (additions, deletions, and removals) to the CVS Caremark® Advanced Control Formulary. ADDITIONS: Therapeutic Category/ Product Subcategory Indication Options/Comments Brand Agents: Cimduo Anti-Infectives/ Antiretroviral Cimduo is indicated in combination with To provide an additional option for the treatment of HIV- (lamivudine and Agents/ Antiretroviral other antiretroviral agents for the treatment 1 infection. tenofovir disoproxil Combinations of human immunodeficiency virus type 1 fumarate) oral (HIV-1) infection in adult and pediatric tablet patients weighing at least 35 kg. Eylea (aflibercept) Topical/ Ophthalmic/ Retinal Eylea is indicated for the treatment of To provide an option for the treatment of neovascular intravitreal injection Disorders patients with: (wet) age-related macular degeneration, macular edema • Neovascular (Wet) Age-Related following retinal vein occlusion, diabetic macular edema, Macular Degeneration (AMD) and diabetic retinopathy in patients with diabetic macular • Macular Edema Following Retinal Vein edema. Occlusion (RVO) • Diabetic Macular Edema (DME) • Diabetic Retinopathy (DR) in Patients with DME. Lucentis Topical/ Ophthalmic/ Retinal Lucentis is indicated for the treatment of To provide an option for the treatment of neovascular (ranibizumab) Disorders patients with: (wet) age-related macular degeneration, macular edema intravitreal injection • Neovascular (Wet) Age-Related following retinal vein occlusion, diabetic macular edema, Macular Degeneration (AMD) diabetic retinopathy, and myopic choroidal • Macular Edema Following Retinal Vein neovascularization. Occlusion (RVO) • Diabetic Macular Edema (DME) This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019 CVS Caremark. All rights reserved. 106-40278A 043019 Pg. 1 of 27 Advanced Control Formulary™ Change Summary Report Effective 07-01-2019 Therapeutic Category/ Product Subcategory Indication Options/Comments • Diabetic Retinopathy (DR) • Myopic Choroidal Neovascularization (mCNV). Neulasta Hematologic/ Hematopoietic Neulasta is indicated to: To provide a long-acting colony-stimulating factor option (pegfilgrastim) Growth Factors • Decrease the incidence of infection, as for those who are receiving myelosuppressive anti- subcutaneous manifested by febrile neutropenia, in cancer therapy. solution for injection patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia • Increase survival in patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Subsyndrome of Acute Radiation Syndrome). Nivestym Hematologic/ Hematopoietic Nivestym is indicated to: To provide a short-acting colony-stimulating factor option (filgrastim-aafi) Growth Factors • Decrease the incidence of infection‚ as for those who are receiving myelosuppressive anti- intravenous/ manifested by febrile neutropenia‚ in cancer therapy. subcutaneous patients with nonmyeloid malignancies solution for injection receiving myelosuppressive anti-cancer drugs associated with a significant incidence of severe neutropenia with fever • Reduce the time to neutrophil recovery and the duration of fever, following induction or consolidation chemotherapy treatment of patients with acute myeloid leukemia (AML) This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019 CVS Caremark. All rights reserved. 106-40278A 043019 Pg. 2 of 27 Advanced Control Formulary™ Change Summary Report Effective 07-01-2019 Therapeutic Category/ Product Subcategory Indication Options/Comments • Reduce the duration of neutropenia and neutropenia-related clinical sequelae‚ e.g.‚ febrile neutropenia, in patients with nonmyeloid malignancies undergoing myeloablative chemotherapy followed by bone marrow transplantation (BMT) • Mobilize autologous hematopoietic progenitor cells into the peripheral blood for collection by leukapheresis • Reduce the incidence and duration of sequelae of severe neutropenia (e.g.‚ fever‚ infections‚ oropharyngeal ulcers) in symptomatic patients with congenital neutropenia‚ cyclic neutropenia‚ or idiopathic neutropenia. Symfi (efavirenz, Anti-Infectives/ Antiretroviral Symfi is indicated as a complete regimen for To provide an additional option for the treatment of HIV- lamivudine and Agents/ Antiretroviral the treatment of human immunodeficiency 1 infection. tenofovir disoproxil Combinations virus type 1 (HIV-1) infection in adult and fumarate) oral pediatric patients weighing at least 40 kg. tablet Symfi Lo Anti-Infectives/ Antiretroviral Symfi Lo is indicated as a complete regimen To provide an additional option for the treatment of HIV- (efavirenz, Agents/ Antiretroviral for the treatment of human 1 infection. lamivudine and Combinations immunodeficiency virus type 1 (HIV-1) tenofovir disoproxil infection in adult and pediatric patients fumarate) oral weighing at least 35 kg. tablet SymlinPen Endocrine and Metabolic/ SymlinPen is indicated for patients with type To provide an additional option for glycemic control in (pramlintide) Antidiabetics/ Amylin 1 or type 2 diabetes who use mealtime those with type 1 or type 2 diabetes mellitus. Analogs insulin and have failed to achieve desired This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019 CVS Caremark. All rights reserved. 106-40278A 043019 Pg. 3 of 27 Advanced Control Formulary™ Change Summary Report Effective 07-01-2019 Therapeutic Category/ Product Subcategory Indication Options/Comments subcutaneous glycemic control despite optimal insulin solution for injection therapy. Udenyca Hematologic/ Hematopoietic Udenyca is indicated to decrease the To provide a long-acting colony-stimulating factor option (pegfilgrastim-cbqv) Growth Factors incidence of infection, as manifested by for those who are receiving myelosuppressive anti- subcutaneous febrile neutropenia, in patients with non- cancer therapy. solution for injection myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia. V-Go Insulin Endocrine and Metabolic/ V-Go insulin infusion pump is used to allow To provide an option for continuous/basal and on- Infusion Pump Antidiabetics/ Supplies continuous subcutaneous basal insulin demand/bolus insulin delivery in insulin-dependent insulin infusion infusion and on-demand bolus dosing in diabetes. disposable pump those with insulin-dependent diabetes. Generic Agents: clindamycin Genitourinary/ Vaginal Anti- Clindamycin vaginal cream is indicated in To provide a generic option for the treatment of bacterial vaginal cream Infectives the treatment of bacterial vaginosis. vaginosis. metronidazole Genitourinary/ Vaginal Anti- Metronidazole vaginal gel is indicated in the To provide a generic option for the treatment of bacterial vaginal gel Infectives treatment of bacterial vaginosis. vaginosis. silodosin Genitourinary/ Benign Silodosin is indicated for the treatment of To provide an additional generic option for the treatment oral capsule Prostatic Hyperplasia the signs and symptoms of benign prostatic of benign prostatic hyperplasia (BPH). hyperplasia (BPH). sirolimus Immunologic Agents/ Sirolimus solution is indicated for the To provide an additional generic option for organ oral solution Immunosuppressants/ prophylaxis of organ rejection in patients rejection prophylaxis in renal transplant recipients. Rapamycin Derivatives aged ≥ 13 years receiving renal transplants. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2019 CVS Caremark. All rights reserved. 106-40278A 043019 Pg. 4 of 27 Advanced Control Formulary™ Change Summary Report Effective 07-01-2019 Therapeutic Category/ Product Subcategory Indication Options/Comments tadalafil Genitourinary/ Erectile Tadalafil is indicated for the treatment of: To provide an additional generic option for the treatment oral tablet Dysfunction/ • Erectile dysfunction (ED) of erectile dysfunction (ED) and benign prostatic Phosphodiesterase • The signs and symptoms of benign hyperplasia (BPH). Inhibitors prostatic hyperplasia (BPH) • ED and the signs and symptoms of BPH (ED/BPH). toremifene Antineoplastic Agents/ Toremifene is indicated for the treatment of To provide generic option for the treatment of metastatic oral tablet Hormonal Antineoplastic metastatic breast cancer in postmenopausal breast cancer. Agents/ Antiestrogens women with estrogen-receptor
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