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)

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

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.

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 positive or unknown tumors.

DELETIONS: Therapeutic Category/ Product Subcategory Indication Options/Comments Brand Agents: Cialis (tadalafil) Genitourinary/ Erectile Cialis is indicated for the treatment of: Availability of a generic option for the treatment of oral tablet Dysfunction/ • Erectile dysfunction (ED) 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 The preferred options on the Advanced Control BPH (ED/BPH). Formulary are sildenafil, tadalafil, vardenafil. Fareston Antineoplastic Agents/ Fareston is indicated for the treatment of Availability of a generic option for the treatment of (toremifene) Hormonal Antineoplastic metastatic breast cancer in postmenopausal metastatic breast cancer. oral tablet Agents/ Antiestrogens women with estrogen-receptor positive or unknown tumors. The preferred option on the Advanced Control Formulary is toremifene.

106-40278A 043019 Pg. 5 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Rapaflo (silodosin) Genitourinary/ Benign Rapaflo is indicated for the treatment of the Availability of generic options for the treatment of benign oral capsule Prostatic Hyperplasia signs and symptoms of benign prostatic prostatic hyperplasia (BPH). hyperplasia (BPH). The preferred options on the Advanced Control Formulary include alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, and terazosin. Savella, Savella Central Nervous System/ Savella is indicated for the management of Availability of another option for the treatment of Titration Pack Fibromyalgia fibromyalgia. fibromyalgia. (milnacipran) oral tablet The preferred option on the Advanced Control Formulary is Lyrica (pregabalin).

REMOVALS: Therapeutic Category/ Product Subcategory Indication Options/Comments Brand Agents: Ala-Quin Topical/ Dermatology/ Ala-Quin is indicated for: Contact or atopic Availability of other options for relief of various (clioquinol- Corticosteroids/ Combination dermatitis; impetiginized eczema; nummular inflammatory and pruritic conditions caused by bacterial hydrocortisone) Agents eczema; infantile eczema; endogenous infections. topical cream chronic infectious dermatitis; stasis dermatitis; pyoderma; nuchal eczema and Preferred options on the Advanced Control Formulary chronic eczematoid otitis externa; acne include desonide and hydrocortisone. urticata; localized or disseminated neurodermatitis; lichen simplex chronicus; anogenital pruritus (vulvae, scroti, ani); folliculitis; bacterial dermatoses; mycotic

106-40278A 043019 Pg. 6 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments dermatoses such as tinea (capitis, cruris, corporis, pedis); moniliasis; and intertrigo. Angeliq 0.25 mg- Endocrine and Metabolic/ Angeliq 0.25 mg drospirenone (DRSP)-0.5 Availability of other options for the treatment of 0.5 mg Estrogens/Progestins/ Oral mg estradiol (E2) is indicated in women with vasomotor symptoms associated with menopause. (drospirenone- an intact uterus for the treatment of: estradiol) • Moderate to severe vasomotor Preferred options on the Advanced Control Formulary oral tablet symptoms due to menopause. include estradiol-norethindrone, Premphase (estrogens, conjugated/medroxyprogesterone), and Prempro (estrogens, conjugated/medroxyprogesterone). Angeliq 0.5 mg-1 Endocrine and Metabolic/ Angeliq 0.5 mg DRSP-1 mg E2 is indicated Availability of other options for the treatment of mg (drospirenone- Estrogens/Progestins/ Oral in women with an intact uterus for the vasomotor and vulvar/vaginal atrophy symptoms estradiol) treatment of: associated with menopause. oral tablet • Moderate to severe vasomotor symptoms due to menopause Preferred options on the Advanced Control Formulary • Moderate to severe vulvar and vaginal include estradiol-norethindrone, Premphase (estrogens, atrophy symptoms due to menopause. conjugated/medroxyprogesterone), and Prempro (estrogens, conjugated/medroxyprogesterone). Astagraf XL Immunologic Agents/ Astagraf XL is indicated for the prophylaxis Availability of generic options for the prophylaxis of organ (tacrolimus) Immunosuppressants/ of organ rejection in kidney transplant rejection in transplant recipients. oral extended- Calcineurin Inhibitors patients in combination with other release capsule immunosuppressants in adult and pediatric Preferred options on the Advanced Control Formulary patients. include cyclosporine; cyclosporine, modified; and tacrolimus. Baraclude tablet Anti-Infectives/ Antivirals/ Baraclude is indicated for the treatment of Availability of other options for the treatment of chronic (entecavir) Hepatitis B Agents chronic hepatitis B virus (HBV) infection in hepatitis B virus (HBV) infection. oral tablet adults and children at least 2 years of age with evidence of active viral replication and either evidence of persistent elevations in

106-40278A 043019 Pg. 7 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments serum aminotransferases (ALT or AST) or Preferred options on the Advanced Control Formulary histologically active disease. include entecavir tablet, lamivudine, Baraclude solution (entecavir), and Viread (tenofovir disoproxil fumarate).

Canasa Gastrointestinal/ Canasa is indicated in adults for the Availability of other options for the treatment of ulcerative (mesalamine) Inflammatory Bowel treatment of mildly to moderately active proctitis. rectal suppository Disease/ Rectal Agents ulcerative proctitis. Preferred options on the Advanced Control Formulary include hydrocortisone enema, mesalamine rectal suspension, and Cortifoam (hydrocortisone acetate foam). Capex Topical/ Dermatology/ Capex is indicated for the treatment of Availability of generic options for the treatment of (fluocinolone Antiseborrheics seborrheic dermatitis of the scalp. seborrheic dermatitis of the scalp. acetonide) topical shampoo Preferred options on the Advanced Control Formulary include ketoconazole shampoo 2% and selenium sulfide shampoo 2.5%. Carafate Gastrointestinal/ Carafate tablets are indicated in: Availability of a generic option for the treatment and (sucralfate) Miscellaneous • Short-term treatment (up to 8 weeks) of maintenance therapy of duodenal ulcers. oral tablet active duodenal ulcer. While healing with sucralfate may occur during the The preferred option on the Advanced Control Formulary first week or two, treatment should be is sucralfate. continued for 4 to 8 weeks unless healing has been demonstrated by x- ray or endoscopic examination • Maintenance therapy for duodenal ulcer patients at reduced dosage after healing of acute ulcers.

106-40278A 043019 Pg. 8 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Carafate Gastrointestinal/ Carafate suspension is indicated in: Availability of a generic option for the treatment of active (sucralfate) Miscellaneous Short-term (up to 8 weeks) treatment of duodenal ulcers. oral suspension active duodenal ulcer. The preferred option on the Advanced Control Formulary is sucralfate. CellCept Immunologic Agents/ CellCept is indicated for the prophylaxis of Availability of generic options for the prophylaxis of organ (mycophenolate Immunosuppressants/ organ rejection in recipients of allogeneic rejection in transplant recipients. mofetil) Antimetabolites kidney, heart or liver transplants, and oral capsule, oral should be used in combination with other Preferred options on the Advanced Control Formulary tablet, oral immunosuppressants. include mycophenolate mofetil and mycophenolate suspension, sodium. intravenous solution for injection Chorionic Endocrine and Metabolic/ Chorionic Gonadotropin is indicated for: Availability of other options for the induction of ovulation Gonadotropin Fertility Regulators/ • Prepubertal cryptorchidism not due to and pregnancy in women. (chorionic Ovulation Stimulants, anatomical obstruction gonadotropin) Gonadotropins • Selected cases of hypogonadotropic The preferred option on the Advanced Control Formulary intramuscular hypogonadism (hypogonadism is Ovidrel (choriogonadotropin alfa). solution for secondary to a pituitary deficiency) in injection males • Induction of ovulation and pregnancy in the anovulatory, infertile woman in whom the cause of anovulation is secondary and not due to primary ovarian failure, and who has been appropriately pretreated with human menotropins.

106-40278A 043019 Pg. 9 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Clenpiq (sodium Gastrointestinal/ Laxatives Clenpiq is indicated for cleansing of the Availability of other options for colon cleansing prior to a picosulfate- colon as a preparation for colonoscopy in colonoscopy. magnesium oxide- adults. anhydrous citric Preferred options on the Advanced Control Formulary acid) include peg 3350-electrolyes and Suprep (sodium oral solution sulfate-potassium sulfate-magnesium sulfate). Denavir Topical/ Dermatology/ Denavir is indicated for the treatment of Availability of generic options for the treatment of (penciclovir) Miscellaneous Skin and recurrent herpes labialis (cold sores) in recurrent herpes labialis (cold sores). topical cream Mucous Membrane adults and pediatric patients 12 years of age and older. Preferred options on the Advanced Control Formulary include acyclovir and valacyclovir. Dermasorb HC Topical/ Dermatology/ Dermasorb HC is indicated for the relief of Availability of generic low-potency corticosteroids for the (hydrocortisone Corticosteroids/ Low the inflammatory and pruritic manifestations relief of inflammatory and pruritic conditions. lotion with Potency of corticosteroid-responsive dermatoses. shampoo and Preferred options on the Advanced Control Formulary body wash) include desonide and hydrocortisone. topical kit Dermasorb TA Topical/ Dermatology/ Dermasorb TA is indicated for the relief of Availability of generic medium-potency corticosteroids for (triamcinolone Corticosteroids/ Medium the inflammatory and pruritic manifestations the relief of inflammatory and pruritic conditions. acetonide with Potency of corticosteroid-responsive dermatoses. emollient cream) Preferred options on the Advanced Control Formulary topical kit include clocortolone, hydrocortisone butyrate, mometasone, and triamcinolone. Dermasorb XM Topical/ Dermatology/ Dermasorb XM is useful for the treatment of Availability of a generic option for the treatment of (urea cream with Emollients hyperkeratotic conditions such as dry, rough hyperkeratotic conditions. moisturizing skin, xerosis, ichthyosis, skin cracks and cream) fissures, dermatitis, eczema, psoriasis, The preferred option on the Advanced Control Formulary topical kit keratoses and calluses. is ammonium lactate 12%.

106-40278A 043019 Pg. 10 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Elestrin Endocrine and Metabolic/ Elestrin is indicated for the treatment of Availability of other options for the treatment of (estradiol) Estrogens/ Transdermal moderate to severe vasomotor symptoms vasomotor symptoms associated with menopause. transdermal gel due to menopause. Preferred options on the Advanced Control Formulary include estradiol, Divigel (estradiol), and Evamist (estradiol). Enlite Endocrine and Metabolic/ Enlite glucose system measures and Availability of another option for testing and monitoring continuous blood Antidiabetics/ Supplies transmits glucose information to a blood glucose levels. glucose continuous blood glucose monitor used by monitoring system those with diabetes. The preferred option on the Advanced Control Formulary is the Dexcom continuous glucose monitoring system. Envarsus XR Immunologic Agents/ Envarsus XR is indicated for: Availability of generic options for the prophylaxis of organ (tacrolimus) Immunosuppressants/ • The prophylaxis of organ rejection in de rejection in transplant recipients. oral tablet Calcineurin Inhibitors novo kidney transplant patients in combination with other Preferred options on the Advanced Control Formulary immunosuppressants include cyclosporine; cyclosporine, modified; and • The prophylaxis of organ rejection in tacrolimus. kidney transplant patients converted from tacrolimus immediate-release formulations in combination with other immunosuppressants. Epivir HBV Anti-Infectives/ Antivirals/ Epivir HBV is indicated for the treatment of Availability of other options for the treatment of chronic (lamivudine) Hepatitis Agents/ Hepatitis B chronic hepatitis B virus infection hepatitis B virus (HBV) infection. oral tablet, oral associated with evidence of hepatitis B viral solution replication and active liver inflammation. Preferred options on the Advanced Control Formulary include entecavir tablet, lamivudine, Baraclude solution (entecavir) and Viread (tenofovir disoproxil fumarate).

106-40278A 043019 Pg. 11 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Ertaczo Topical/ Dermatology/ Ertaczo is indicated for the topical treatment Availability of generic options for the treatment of tinea (sertaconazole Antifungals of interdigital tinea pedis in pedis. nitrate) immunocompetent patients 12 years of age topical cream and older caused by Trichophyton rubrum, Preferred options on the Advanced Control Formulary Trichophyton mentagrophytes, and include clotrimazole, econazole, ketoconazole, Epidermophyton floccosum. luliconazole, and oxiconazole. Estring (estradiol) Endocrine and Metabolic/ Estring is indicated for the treatment of Availability of other options for treating symptoms vaginal ring Estrogens/ Vaginal moderate to severe symptoms of vulvar and associated with menopause. vaginal atrophy due to menopause. Preferred options on the Advanced Control Formulary include vaginal estradiol and Premarin cream (estrogens, conjugated). FazaClo Central Nervous System/ FazaClo is indicated for: Availability of other antipsychotics for treatment-resistant (clozapine) Antipsychotics/ Atypicals • Treatment-resistant schizophrenia schizophrenia and reducing suicidal behavior in those orally • Reducing suicidal behavior in patients with schizophrenia or schizoaffective disorder. disintegrating with schizophrenia or schizoaffective tablet disorder. Preferred options on the Advanced Control Formulary include aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, and Vraylar (cariprazine). Femring Endocrine and Metabolic/ Femring is indicated for: Availability of other options for treating symptoms (estradiol acetate) Estrogens/ Vaginal • Treatment of moderate to severe associated with menopause. vaginal ring vasomotor symptoms due to menopause Preferred options on the Advanced Control Formulary • Treatment of moderate to severe vulvar include vaginal estradiol and Premarin cream (estrogens, and vaginal atrophy due to menopause. conjugated). Fluoroplex Topical/ Dermatology/ Fluoroplex is indicated for the topical Availability of other topical options for treatment of actinic (fluorouracil) Actinic Keratosis treatment of multiple actinic (solar) keratoses. topical cream keratoses.

106-40278A 043019 Pg. 12 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Preferred options on the Advanced Control Formulary include fluorouracil cream 5%, fluorouracil solution, imiquimod, and Tolak (fluorouracil cream 4%). Fosteum Nutritional/Supplements/ Fosteum is used for the clinical dietary Availability of generic options for treating osteopenia and (genistein-citrated Vitamins and Minerals management of the metabolic processes of osteoporosis. zinc bisglycinate- osteopenia and osteoporosis. cholecalciferol) Preferred options on the Advanced Control Formulary oral capsule include alendronate, ibandronate, and risedronate. Fosteum Plus Nutritional/Supplements/ Fosteum Plus is used for the clinical dietary Availability of generic options for treating osteopenia and (dicalcium malate- Vitamins and Minerals management of the metabolic processes of osteoporosis. pentacalcium osteopenia and osteoporosis. hydroxide Preferred options on the Advanced Control Formulary triphosphate- include alendronate, ibandronate, and risedronate. phosphate- genistein aglycone-citrated zinc bisglycinate- trans- menaquinone-7- cholecalciferol) oral capsule FreeStyle Libre Endocrine and Metabolic/ The FreeStyle Libre system is used to Availability of an additional option for testing and continuous Antidiabetics/ Supplies continually monitor blood glucose levels in monitoring blood glucose levels. glucose those who have diabetes. monitoring system The preferred option on the Advanced Control Formulary is the Dexcom continuous glucose monitoring system.

106-40278A 043019 Pg. 13 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Fulphila Hematologic/ Hematopoietic Fulphila is indicated to decrease the Availability of other long-acting colony-stimulating factor (pegfilgrastim- Growth Factors incidence of infection, as manifested by options for those who are receiving myelosuppressive jmdb) febrile neutropenia, in patients with non- anti-cancer therapy. subcutaneous myeloid malignancies receiving solution for myelosuppressive anti-cancer drugs Preferred options on the Advanced Control Formulary injection associated with a clinically significant include Neulasta (pegfilgrastim) and Udenyca incidence of febrile neutropenia. (pegfilgrastim-cbqv). Geodon Central Nervous System/ Geodon is indicated as an oral formulation Availability of other atypical antipsychotics for various (ziprasidone) Antipsychotics/ Atypicals for the: mental health conditions. oral capsule • Treatment of schizophrenia • Acute treatment as monotherapy of Preferred options on the Advanced Control Formulary manic or mixed episodes associated include aripiprazole, clozapine, olanzapine, quetiapine, with bipolar I disorder quetiapine ext-rel, risperidone, ziprasidone, and Vraylar • Maintenance treatment of bipolar I (cariprazine). disorder as an adjunct to lithium or valproate. Geodon Central Nervous System/ Geodon is indicated as an intramuscular Availability of other options for the acute treatment of (ziprasidone) Antipsychotics/ Atypicals injection for the: agitation in those with schizophrenia. intramuscular • Acute treatment of agitation in solution for schizophrenic patients. The preferred option on the Advanced Control Formulary injection is haloperidol. Granix (tbo- Hematologic/ Hematopoietic Granix is indicated in adult and pediatric Availability of another short-acting colony-stimulating filgrastim) Growth Factors patients 1 month and older for reduction in factor option for those who are receiving subcutaneous the duration of severe neutropenia in myelosuppressive anti-cancer therapy. solution for patients with non-myeloid malignancies injection receiving myelosuppressive anti-cancer The preferred option on the Advanced Control Formulary drugs associated with a clinically significant is Nivestym (filgrastim-aafi). incidence of febrile neutropenia.

106-40278A 043019 Pg. 14 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Guardian Endocrine and Metabolic/ Guardian Connect system measures and Availability of another option for testing and monitoring Connect Antidiabetics/ Supplies transmits glucose information to a blood glucose levels. continuous blood continuous blood glucose monitor used by glucose those with diabetes. The preferred option on the Advanced Control Formulary monitoring system is the Dexcom continuous glucose monitoring system. Hepsera (adefovir Anti-Infectives/ Antivirals/ Hepsera is indicated for the treatment of Availability of other options for the treatment of chronic dipivoxil) Hepatitis B Agents chronic hepatitis B in patients ≥12 years of hepatitis B virus (HBV) infection. oral tablet age. Preferred options on the Advanced Control Formulary include entecavir tablet, lamivudine, Baraclude solution (entecavir) and Viread (tenofovir disoproxil fumarate). Imvexxy Endocrine and Metabolic/ Imvexxy is indicated for the treatment of Availability of other options for treating symptoms (estradiol) Estrogens/ Vaginal moderate to severe dyspareunia, a associated with menopause. vaginal insert symptom of vulvar and vaginal atrophy, due to menopause. Preferred options on the Advanced Control Formulary include vaginal estradiol and Premarin cream (estrogens, conjugated). Minivelle Endocrine and Metabolic/ Minivelle is indicated for the treatment of Availability of other options for the treatment of (estradiol) Estrogens/ Transdermal moderate to severe vasomotor symptoms vasomotor symptoms associated with menopause. transdermal patch due to menopause and prevention of postmenopausal osteoporosis. Preferred options on the Advanced Control Formulary include estradiol patch, Divigel (estradiol), and Evamist (estradiol). Minolira Anti-Infectives/ Minolira is indicated to treat only Availability of generic options for the treatment of (minocycline) Antibacterials/ Tetracyclines inflammatory lesions of non-nodular inflammatory lesions associated with acne vulgaris. oral extended- moderate to severe acne vulgaris in release tablet patients 12 years of age and older. Preferred options on the Advanced Control Formulary include doxycycline hyclate, minocycline, and tetracycline.

106-40278A 043019 Pg. 15 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments MoviPrep (peg Gastrointestinal/ Laxatives MoviPrep is indicated for cleansing of the Availability of other options for colon cleansing prior to a 3350-sodium colon as a preparation for colonoscopy in colonoscopy. sulfate-sodium adults. chloride- Preferred options on the Advanced Control Formulary potassium include peg 3350-electrolyes and Suprep (sodium chloride-ascorbic sulfate-potassium sulfate-magnesium sulfate). acid-sodium ascorbate) powder for oral solution Myfortic Immunologic Agents/ Myfortic is indicated for prophylaxis of organ Availability of generic options for the prophylaxis of organ (mycophenolate Immunosuppressants/ rejection in adult patients receiving kidney rejection in renal transplant recipients. sodium) Antimetabolites transplants and in pediatric patients at least oral delayed- 5 years of age and older who are at least 6 Preferred options on the Advanced Control Formulary release tablet months post kidney transplant. include mycophenolate mofetil and mycophenolate sodium. Naftin (naftifine) Topical/ Dermatology/ Naftin cream is indicated for the treatment Availability of generic options for the treatment of tinea topical cream Antifungals of: interdigital tinea pedis, tinea cruris, and pedis, tinea cruris, and tinea corporis. tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton Preferred options on the Advanced Control Formulary mentagrophytes, and Epidermophyton include ciclopirox, clotrimazole, econazole, ketoconazole, floccosum. luliconazole, and oxiconazole. Naftin (naftifine) Topical/ Dermatology/ Naftin gel is indicated for the topical Availability of generic options for the treatment of tinea topical gel Antifungals treatment of tinea pedis, tinea cruris, and pedis, tinea cruris, and tinea corporis. tinea corporis caused by the organisms Trichophyton rubrum, Trichophyton Preferred options on the Advanced Control Formulary mentagrophytes, Trichophyton tonsurans, include ciclopirox, clotrimazole, econazole, ketoconazole, and Epidermophyton floccosum. luliconazole, and oxiconazole.

106-40278A 043019 Pg. 16 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Natazia (estradiol Endocrine and Metabolic/ Natazia is indicated for use by women to Availability of other oral contraceptive options. valerate and Contraceptives/ Four Phase prevent pregnancy. estradiol valerate- Preferred options on the Advanced Control Formulary dienogest) include ethinyl estradiol-drospirenone, ethinyl estradiol- oral tablet drospirenone-levomefolate, ethinyl estradiol- norethindrone acetate-iron, ethinyl estradiol- norgestimate, ethinyl estradiol-levonorgestrel, Safyral (ethinyl estradiol-drospirenone-levomefolate), Lo Loestrin FE (norethindrone acetate and ethinyl estradiol, ethinyl estradiol and ferrous fumarate). Novarel (chorionic Endocrine and Metabolic/ Novarel is indicated for: Availability of another option for the induction of ovulation gonadotropin) Fertility Regulators/ • Prepubertal cryptorchidism not due to and pregnancy in women. intramuscular Ovulation Stimulants, anatomic obstruction solution for Gonadotropins • Selected cases of hypogonadotropic The preferred option on the Advanced Control Formulary injection hypogonadism (hypogonadism is Ovidrel (choriogonadotropin alfa). secondary to a pituitary deficiency) in males • Induction of ovulation and pregnancy in the anovulatory, infertile woman in whom the cause of anovulation is secondary and not due to primary ovarian failure, and who has been appropriately pretreated with human menotropins. Noxafil Anti-Infectives/ Antifungals Noxafil is indicated for: Availability of generic options for the prophylaxis of (posaconazole) • Prophylaxis of invasive Aspergillus and Aspergillus and Candida infections in those who are oral delayed- Candida infections in patients who are immunocompromised. release tablet, at high risk of developing these intravenous infections due to being severely

106-40278A 043019 Pg. 17 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments solution for immunocompromised, such as HSCT Preferred options on the Advanced Control Formulary injection recipients with GVHD or those with include fluconazole and itraconazole. hematologic malignancies with prolonged neutropenia from chemotherapy. Noxafil Anti-Infectives/ Antifungals Noxafil is indicated for: Availability of generic options for the prophylaxis of (posaconazole) • Prophylaxis of invasive Aspergillus and Aspergillus and Candida infections in those who are oral suspension Candida infections in patients who are immunocompromised, and for the treatment of at high risk of developing these oropharyngeal candidiasis. infections due to being severely immunocompromised, such as HSCT Preferred options on the Advanced Control Formulary recipients with GVHD or those with include fluconazole and itraconazole. hematologic malignancies with prolonged neutropenia from chemotherapy • Treatment of oropharyngeal candidiasis (OPC), including OPC refractory (rOPC) to itraconazole and/or fluconazole. Nuvessa Genitourinary/ Anti- Nuvessa is indicated for the treatment of Availability of generic options for the treatment of (metronidazole) Infectives/ Vaginal bacterial vaginosis in non-pregnant women. bacterial vaginosis. vaginal gel Preferred options on the Advanced Control Formulary include clindamycin vaginal cream and metronidazole vaginal gel. Omnipod Insulin Endocrine and Metabolic/ Omnipod Insulin Management System is Availability of another option for continuous/basal and on- Management Antidiabetics/ Supplies used to allow continuous subcutaneous demand/bolus insulin delivery in insulin-dependent System basal insulin infusion and on-demand bolus diabetes.

106-40278A 043019 Pg. 18 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments insulin infusion dosing in those with insulin-dependent The preferred option on the Advanced Control Formulary disposable pump diabetes. is V-Go insulin infusion pump. OsmoPrep Gastrointestinal/ Laxatives OsmoPrep is indicated for cleansing of the Availability of other options for colon cleansing prior to a (sodium colon as a preparation for colonoscopy in colonoscopy. phosphate, adults. monobasic, Preferred options on the Advanced Control Formulary monohydrate- include peg 3350-electrolyes and Suprep (sodium sodium sulfate-potassium sulfate-magnesium sulfate). phosphate, dibasic anhydrous) oral tablet Otovel Topical/ Otic/ Anti- Otovel is indicated for the treatment of Availability of other options for the treatment of otic (ciprofloxacin- Infective/Anti-Inflammatory acute otitis media with tympanostomy tubes infections. fluocinolone) Combinations (AOMT) in pediatric patients (aged 6 otic solution months and older) due to Staphylococcus Preferred options on the Advanced Control Formulary aureus, Streptococcus pneumoniae, include ofloxacin otic and Ciprodex (ciprofloxacin- Haemophilus influenzae, Moraxella dexamethasone). catarrhalis, and Pseudomonas aeruginosa. Pancreaze Gastrointestinal/ Pancreatic Pancreaze is indicated for the treatment of Availability of other pancreatic enzymes for the treatment (pancrelipase) Enzymes exocrine pancreatic insufficiency due to of pancreatic insufficiency. oral delayed- cystic fibrosis or other conditions. release capsule Preferred options on the Advanced Control Formulary include Creon (pancrelipase delayed-rel), Viokace (pancrelipase), and Zenpep (pancrelipase delayed-rel). Paxil (paroxetine) Central Nervous System/ Paxil is indicated for: Availability of other options for the treatment of major oral tablet, oral Antidepressants/ Selective • Major depressive disorder depressive disorder, obsessive compulsive disorder, suspension Serotonin Reuptake • Obsessive compulsive disorder panic disorder, social anxiety disorder, generalized Inhibitors (SSRIs) • Panic disorder anxiety disorder, and posttraumatic stress disorder.

106-40278A 043019 Pg. 19 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments • Social Anxiety Disorder • Generalized Anxiety Disorder Preferred options on the Advanced Control Formulary • Posttraumatic Stress Disorder include citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCl ext-rel, sertraline, Trintellix (vortioxetine), and Viibryd (vilazodone). Paxil CR Central Nervous System/ Paxil CR is indicated for: Availability of other options for the treatment of major (paroxetine) Antidepressants/ Selective • Major depressive disorder depressive disorder, panic disorder, social anxiety oral extended- Serotonin Reuptake • Panic disorder disorder, and premenstrual dysphoric disorder. release tablet Inhibitors (SSRIs) • Social Anxiety Disorder • Premenstrual dysphoric disorder Preferred options on the Advanced Control Formulary include citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCl ext-rel, sertraline, Trintellix (vortioxetine), and Viibryd (vilazodone). Pertzye Gastrointestinal/ Pancreatic Pertzye is indicated for the treatment of Availability of other pancreatic enzymes for the treatment (pancrelipase) Enzymes exocrine pancreatic insufficiency due to of pancreatic insufficiency. oral delayed- cystic fibrosis or other conditions. release capsule Preferred options on the Advanced Control Formulary include Creon (pancrelipase delayed-rel), Viokace (pancrelipase), and Zenpep (pancrelipase delayed-rel). Picato (ingenol Topical/ Dermatology/ Picato is indicated for the topical treatment Availability of other topical options for treatment of actinic mebutate) Actinic Keratosis of actinic keratosis. keratoses. topical gel Preferred options on the Advanced Control Formulary include fluorouracil cream 5%, fluorouracil solution, imiquimod, and Tolak (fluorouracil cream 4%). Plenvu (peg Gastrointestinal/ Laxatives Plenvu is indicated for cleansing of the Availability of other options for colon cleansing prior to a 3350-sodium colon in preparation for colonoscopy in colonoscopy. sulfate-sodium adults. chloride-

106-40278A 043019 Pg. 20 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments potassium Preferred options on the Advanced Control Formulary chloride-ascorbic include peg 3350-electrolyes and Suprep (sodium acid-sodium sulfate-potassium sulfate-magnesium sulfate). ascorbate) powder for oral solution Prefest (estradiol- Endocrine and Metabolic/ Prefest is indicated in women who have a Availability of other options for the treatment of norgestimate) Estrogens/Progestins/ Oral uterus for the: vasomotor and vulvar/vaginal atrophy symptoms oral tablet • Treatment of moderate to severe associated with menopause, and for prevention of vasomotor symptoms associated with postmenopausal osteoporosis. the menopause • Treatment of moderate to severe Preferred options on the Advanced Control Formulary symptoms of vulvar and vaginal atrophy include estradiol-norethindrone, Premphase (estrogens, associated with the menopause conjugated-medroxyprogesterone), and Prempro • Prevention of postmenopausal (estrogens, conjugated-medroxyprogesterone). osteoporosis. Pregnyl (chorionic Endocrine and Metabolic/ Pregnyl is indicated for: Availability of another options for the induction of gonadotropin) Fertility Regulators/ • Prepubertal cryptorchidism not due to ovulation and pregnancy in women. intramuscular Ovulation Stimulants, anatomical obstruction solution for Gonadotropins • Selected cases of hypogonadotropic The preferred option on the Advanced Control Formulary injection hypogonadism (hypogonadism is Ovidrel (choriogonadotropin alfa). secondary to a pituitary deficiency) in males • Induction of ovulation and pregnancy in the anovulatory, infertile woman in whom the cause of anovulation is secondary and not due to primary ovarian failure, and who has been

106-40278A 043019 Pg. 21 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments appropriately pretreated with human menotropins. Prepopik (sodium Gastrointestinal/ Laxatives Prepopik is indicated for cleansing of the Availability of other options for colon cleansing prior to a picosulfate- colon as a preparation for colonoscopy in colonoscopy. magnesium oxide- adults and pediatric patients ages 9 years anhydrous citric and older. Preferred options on the Advanced Control Formulary acid) include peg 3350-electrolyes and Suprep (sodium powder for oral sulfate-potassium sulfate-magnesium sulfate). solution Pristiq Central Nervous System/ Pristiq is indicated for the treatment of Availability of generic options for the treatment of major (desvenlafaxine Antidepressants/ Selective adults with major depressive disorder depressive disorder. succinate) Norepinephrine Reuptake (MDD). oral extended- Inhibitors (SNRIs) Preferred options on the Advanced Control Formulary release tablet include desvenlafaxine ext-rel, duloxetine, venlafaxine, and venlafaxine ext-rel capsule. ProCort Topical/ Dermatology/ ProCort is indicated for the relief of the Availability of a generic low potency corticosteroid for the (hydrocortisone- Corticosteroids/ Low inflammatory and pruritic manifestations of relief of inflammatory and pruritic conditions. pramoxine) Potency corticosteroid-responsive dermatoses. rectal cream The preferred option on the Advanced Control Formulary hydrocortisone. Rapamune Immunologic Agents/ Rapamune is indicated for: Availability of a generic option for the prophylaxis of (sirolimus) Immunosuppressants/ • The prophylaxis of organ rejection in organ rejection in renal transplant recipients and the oral tablet, oral Rapamycin Derivatives patients aged ≥13 years receiving renal treatment of lymphangioleiomyomatosis (LAM). solution transplants • The treatment of patients with The preferred option on the Advanced Control Formulary lymphangioleiomyomatosis (LAM). is sirolimus. Rheumate (folate- Nutritional/Supplements/ Rheumate is used for the clinical dietary Availability of a generic option for folate supplementation methylcobalamin- Vitamins and Minerals management of the metabolic effects of during methotrexate therapy.

106-40278A 043019 Pg. 22 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments curcuminoid methotrexate therapy for rheumatoid turmerone arthritis (RA). The preferred option on the Advanced Control Formulary complex) is folic acid. oral capsule Sancuso Gastrointestinal/ Antiemetics Sancuso is indicated for the prevention of Availability of generic options for the prevention of (granisetron) nausea and vomiting in patients receiving chemotherapy-induced nausea and vomiting. transdermal patch moderately and/or highly emetogenic chemotherapy for up to 5 consecutive days. Preferred options on the Advanced Control Formulary include granisetron and ondansetron. Seysara Anti-Infectives/ Seysara is indicated for the treatment of Availability of other options for the treatment of (sarecycline) Antibacterials/ Tetracyclines inflammatory lesions of non-nodular inflammatory lesions associated with acne vulgaris. oral tablet moderate to severe acne vulgaris in patients 9 years of age and older. Preferred options on the Advanced Control Formulary include doxycycline hyclate, minocycline, and tetracycline. Solodyn Anti-Infectives/ Solodyn is indicated to treat only Availability of other options for the treatment of (minocycline) Antibacterials/ Tetracyclines inflammatory lesions of non-nodular inflammatory lesions associated with acne vulgaris. oral extended- moderate to severe acne vulgaris in release tablet patients 12 years of age and older. Preferred options on the Advanced Control Formulary include doxycycline hyclate, minocycline, and tetracycline. Solosec Genitourinary/ Anti- Solosec is indicated for the treatment of Availability of generic options for the treatment of (secnidazole) Infectives/ Vaginal bacterial vaginosis in adult women. bacterial vaginosis. oral granules Preferred options on the Advanced Control Formulary include clindamycin vaginal cream and metronidazole vaginal gel.

106-40278A 043019 Pg. 23 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Syndros Gastrointestinal/ Antiemetics Syndros is indicated in adults for the Availability of a generic option for the treatment of (dronabinol) treatment of: anorexia in those with AIDS, as well as the treatment of oral solution • Anorexia associated with weight loss in chemotherapy-induced nausea and vomiting. patients with AIDS • Nausea and vomiting associated with The preferred option on the Advanced Control Formulary cancer chemotherapy in patients who is dronabinol. have failed to respond adequately to conventional antiemetic treatments. Taytulla (ethinyl Endocrine and Metabolic/ Taytulla is indicated for use by women to Availability of other monophasic oral contraceptive estradiol- Contraceptives/ Monophasic prevent pregnancy. options. norethindrone acetate-iron) Preferred options on the Advanced Control Formulary oral capsule include ethinyl estradiol-drospirenone, ethinyl estradiol- drospirenone-levomefolate, ethinyl estradiol- norethindrone acetate-iron, and Safyral (ethinyl estradiol- drospirenone-levomefolate). Trianex Topical/ Dermatology/ Trianex is indicated for the relief of the Availability of generic medium-potency corticosteroids for (triamcinolone Corticosteroids/ Medium inflammatory and pruritic manifestations of the relief of inflammatory and pruritic conditions. acetonide) Potency corticosteroid responsive dermatoses. topical ointment Preferred options on the Advanced Control Formulary include clocortolone, hydrocortisone butyrate, mometasone, and triamcinolone. Vasculera Nutritional/Supplements/ Vasculera is used to address the Availability of other options for dietary supplementation in (diosmiplex) Vitamins and Minerals biochemical pathway to avoid the maintaining the integrity of vein walls and decreasing oral tablet progression to chronic venous disease inflammation to prevent progression to chronic venous (CVD), including relief of leg edema (fluid disease (CVD). retention), varicose veins, leg ulcers, stasis dermatitis (skin disease leading to ulcers), Consult doctor for preferred options on the Advanced and hemorrhoids. Control Formulary.

106-40278A 043019 Pg. 24 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Vemlidy (tenofovir Anti-Infectives/ Antivirals/ Vemlidy is indicated for the treatment of Availability of other options for the treatment of chronic alafenamide) Hepatitis B Agents chronic hepatitis B virus infection in adults hepatitis B virus (HBV) infection. oral tablet with compensated liver disease. Preferred options on the Advanced Control Formulary include entecavir tablet, lamivudine, Baraclude solution (entecavir), and Viread (tenofovir disoproxil fumarate). Vusion Topical/ Dermatology/ Vusion is indicated for adjunctive treatment Availability of a generic option for the adjunctive (miconazole-zinc Antifungal of diaper dermatitis when complicated by treatment of diaper dermatitis. oxide) documented candidiasis (microscopic topical ointment evidence of pseudohyphae and/or budding The preferred option on the Advanced Control Formulary yeast) in immunocompetent pediatric is nystatin. patients 4 weeks and older. Ximino Anti-Infectives/ Ximino is indicated to treat only Availability of generic options for the treatment of (minocycline) Antibacterials/ Tetracyclines inflammatory lesions of non-nodular inflammatory lesions associated with acne vulgaris. oral extended- moderate to severe acne vulgaris in release capsule patients 12 years of age and older. Preferred options on the Advanced Control Formulary include doxycycline hyclate, minocycline, and tetracycline. Xolegel Topical/ Dermatology/ Xolegel is indicated for topical treatment of Availability of generic options for the treatment of (ketoconazole) Antiseborrheics seborrheic dermatitis in immunocompetent seborrheic dermatitis. topical gel adults and children 12 years of age and older. Preferred options on the Advanced Control Formulary include ciclopirox and ketoconazole. Xolegel CorePak Topical/ Dermatology/ Xolegel CorePak is indicated for topical Availability of generic options for the treatment of (ketoconazole- Antiseborrheics treatment of seborrheic dermatitis. seborrheic dermatitis. hydrocortisone) topical kit Preferred options on the Advanced Control Formulary include ciclopirox and ketoconazole.

106-40278A 043019 Pg. 25 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments Xolegel Duo Topical/ Dermatology/ Xolegel Duo is indicated for topical Availability of generic options for the treatment of (ketoconazole- Antiseborrheics treatment of seborrheic dermatitis. seborrheic dermatitis. pyrithione zinc) topical kit Preferred options on the Advanced Control Formulary include ciclopirox, ketoconazole cream, ketoconazole shampoo 2% and selenium sulfide shampoo 2.5%. Zarxio (filgrastim- Hematologic/ Hematopoietic Zarxio is indicated to: Availability of another short-acting colony-stimulating sndz) Growth Factors • Decrease the incidence of infection‚ as factor option for those who are receiving solution for manifested by febrile neutropenia‚ in myelosuppressive anti-cancer therapy. injection patients with nonmyeloid malignancies receiving myelosuppressive anticancer The preferred option on the Advanced Control Formulary drugs associated with a significant is Nivestym (filgrastim-aafi). 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) • 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

106-40278A 043019 Pg. 26 of 27

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

Therapeutic Category/ Product Subcategory Indication Options/Comments • Reduce the incidence and duration of sequelae of neutropenia (e.g.‚ fever‚ infections‚ oropharyngeal ulcers) in symptomatic patients with congenital neutropenia‚ cyclic neutropenia‚ or idiopathic neutropenia. Zortress Immunologic Agents/ Zortress is indicated for the prophylaxis of Availability of a generic option for the prophylaxis of (everolimus) Immunosuppressants/ organ rejection in adult patients: organ rejection in kidney and liver transplant recipients. oral tablet Rapamycin Derivatives • Kidney transplant • Liver transplant. The preferred option on the Advanced Control Formulary is sirolimus.

106-40278A 043019 Pg. 27 of 27