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

July 2020 ® 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 by CVS Caremark. Ask your doctor to consider administered by CVS Caremark. As a way to help manage health prescribing, when medically appropriate, a preferred medicine from care costs, authorize generic substitution whenever possible. If you this list. Take this list along when you or a covered family member believe a brand-name product is necessary, consider prescribing a sees a doctor. brand name 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 this document. Products recently approved by the U.S. Food 1 and Drug Administration (FDA) may not be covered upon coverage of certain products or vary copay amounts based on release to the market. the condition being treated. This drug list represents a summary of prescription coverage. • Your prescription benefit plan design may alter coverage of • certain products or vary copay1 amounts based on the condition It is not all-inclusive and does not guarantee coverage. The being treated. member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their • You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. • For specific information regarding your prescription benefit The member's prescription benefit plan may have a different 1 • coverage and copay information, please visit Caremark.com or copay1 for specific products on the list. 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 1 generic equivalent. This may result in your doctor prescribing, • Log in to Caremark.com to check coverage and copay when medically appropriate, a different brand-name product or information for a specific medicine. 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 SYMFI § NUCLEOSIDE REVERSE ANTIVIRALS HORMONAL SYMFI LO TRANSCRIPTASE § HEPATITIS B AGENTS ANTINEOPLASTIC AGENTS VISCOSUPPLEMENTS SYMTUZA INHIBITORS entecavir § ANTIANDROGENS GEL-ONE TEMIXYS abacavir tablet lamivudine abiraterone GELSYN-3 TRIUMEQ didanosine tenofovir disoproxil fumarate ERLEADA SUPARTZ FX TRUVADA lamivudine BARACLUDE SOLUTION NUBEQA VISCO-3 stavudine FUSION INHIBITORS VEMLIDY XTANDI zidovudine YONSA ANTI-INFECTIVES FUZEON EMTRIVA § HEPATITIS C AGENTS

ANTIRETROVIRAL AGENTS ribavirin § LUTEINIZING HORMONE- INTEGRASE INHIBITORS § NUCLEOTIDE REVERSE EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) RELEASING HORMONE § ANTIRETROVIRAL ISENTRESS TRANSCRIPTASE HARVONI (genotypes 1, 4, 5, 6) (LHRH) AGONISTS COMBINATIONS TIVICAY INHIBITORS VOSEVI 2 leuprolide acetate abacavir-lamivudine § NON-NUCLEOSIDE tenofovir disoproxil fumarate ELIGARD lamivudine-zidovudine REVERSE TRANSCRIPTASE ANTINEOPLASTIC ATRIPLA § PROTEASE INHIBITORS IMMUNOMODULATORS INHIBITORS AGENTS BIKTARVY atazanavir REVLIMID CIMDUO efavirenz § ALKYLATING AGENTS lopinavir-ritonavir solution THALOMID nevirapine DESCOVY KALETRA TABLET temozolomide nevirapine ext-rel EVOTAZ NORVIR § KINASE INHIBITORS EDURANT § ANTIMETABOLITES GENVOYA PREZISTA erlotinib INTELENCE ODEFSEY capecitabine imatinib mesylate PREZCOBIX

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.

AFINITOR § MOVEMENT DISORDERS HEREDITARY TYROSINEMIA PSORIASIS § RAPAMYCIN DERIVATIVES BOSULIF tetrabenazine TYPE 1 AGENTS HUMIRA sirolimus CABOMETYX AUSTEDO ORFADIN OTEZLA IBRANCE INGREZZA SKYRIZI RESPIRATORY IRESSA HUMAN GROWTH STELARA § MULTIPLE SCLEROSIS HORMONES ALPHA-1 ANTITRYPSIN KISQALI SUBCUTANEOUS AGENTS DEFICIENCY AGENTS KISQALI FEMARA HUMATROPE TALTZ PROLASTIN-C CO-PACK glatiramer TREMFYA RYDAPT § UREA CYCLE DISORDERS AUBAGIO § CYSTIC FIBROSIS SPRYCEL BETASERON sodium phenylbutyrate PSORIATIC ARTHRITIS tobramycin SUTENT COPAXONE COSENTYX MISCELLANEOUS inhalation solution TYKERB GILENYA ENBREL BETHKIS VOTRIENT CYSTAGON MAYZENT HUMIRA

REBIF OTEZLA § MISCELLANEOUS HEMATOLOGIC PULMONARY FIBROSIS TECFIDERA RHEUMATOID ARTHRITIS AGENTS bexarotene capsule TYSABRI HEMATOPOIETIC GROWTH ESBRIET LYNPARZA VUMERITY FACTORS ENBREL OFEV ODOMZO HUMIRA ARANESP RUBRACA ENDOCRINE AND ORENCIA CLICKJECT NEULASTA SEVERE ASTHMA AGENTS ZEJULA METABOLIC ORENCIA NIVESTYM DUPIXENT ZOLINZA SUBCUTANEOUS ACROMEGALY RETACRIT FASENRA RINVOQ CARDIOVASCULAR SOMATULINE DEPOT UDENYCA NUCALA XELJANZ SOMAVERT XOLAIR ANTILIPEMICS HEMOPHILIA A AGENTS XELJANZ XR

PCSK9 INHIBITORS § CALCIUM RECEPTOR ADYNOVATE ULCERATIVE COLITIS TOPICAL ANTAGONISTS JIVI PRALUENT HUMIRA DERMATOLOGY cinacalcet KOGENATE FS STELARA ATOPIC DERMATITIS PULMONARY ARTERIAL KOVALTRY SUBCUTANEOUS # HYPERTENSION CALCIUM REGULATORS NOVOEIGHT DUPIXENT XELJANZ # § ENDOTHELIN RECEPTOR PARATHYROID HORMONES NUWIQ XELJANZ XR # MOUTH / THROAT / ANTAGONISTS FORTEO DENTAL AGENTS HEMOPHILIA B AGENTS # After failure of HUMIRA ambrisentan TYMLOS REBINYN PROTECTANTS bosentan MISCELLANEOUS ALL OTHER CONDITIONS MUGARD OPSUMIT THROMBOCYTOPENIA ENBREL PROLIA AGENTS OPHTHALMIC § PHOSPHODIESTERASE HUMIRA INHIBITORS CONTRACEPTIVES MULPLETA RETINAL DISORDERS DISEASE-MODIFYING PROGESTIN INTRAUTERINE EYLEA sildenafil IMMUNOLOGIC ANTIRHEUMATIC DRUGS tadalafil DEVICES LUCENTIS AGENTS (DMARDs) KYLEENA RASUVO PROSTACYCLIN RECEPTOR MIRENA ALLERGENIC EXTRACTS AGONISTS SKYLA ORALAIR HEREDITARY ANGIOEDEMA UPTRAVI FIRAZYR FERTILITY REGULATORS AUTOIMMUNE AGENTS PROSTAGLANDIN See Table 1 for Indication Based RUCONEST GNRH / LHRH VASODILATORS ANTAGONISTS Coverage Details TAKHZYRO

ORENITRAM CETROTIDE ANKYLOSING SPONDYLITIS IMMUNOSUPPRESSANTS

§ ANTIMETABOLITES SOLUBLE GUANYLATE OVULATION STIMULANTS, COSENTYX CYCLASE STIMULATORS ENBREL mycophenolate mofetil GONADOTROPINS HUMIRA mycophenolate sodium ADEMPAS GONAL-F

OVIDREL CROHN'S DISEASE § CALCINEURIN INHIBITORS CENTRAL NERVOUS SYSTEM GAUCHER DISEASE HUMIRA cyclosporine STELARA cyclosporine, modified CERDELGA § ANTICONVULSANTS SUBCUTANEOUS # tacrolimus CEREZYME vigabatrin # After failure of HUMIRA QUICK REFERENCE DRUG LIST

A ambrisentan B bosentan CEREZYME ARANESP BOSULIF CETROTIDE abacavir tablet BARACLUDE SOLUTION atazanavir CIMDUO abacavir-lamivudine BETASERON ATRIPLA C cinacalcet abiraterone BETHKIS AUBAGIO CABOMETYX COPAXONE ADEMPAS bexarotene capsule AUSTEDO capecitabine COSENTYX ADYNOVATE BIKTARVY CERDELGA cyclosporine AFINITOR

cyclosporine, modified I nevirapine ext-rel S U CYSTAGON NIVESTYM IBRANCE sildenafil UDENYCA NORVIR imatinib mesylate sirolimus UPTRAVI D NOVOEIGHT INGREZZA SKYLA DESCOVY NUBEQA INTELENCE SKYRIZI V didanosine NUCALA IRESSA sodium phenylbutyrate VEMLIDY DUPIXENT NUWIQ ISENTRESS SOMATULINE DEPOT vigabatrin SOMAVERT E O VISCO-3 J SPRYCEL VOSEVI 2 EDURANT ODEFSEY JIVI stavudine VOTRIENT efavirenz ODOMZO STELARA VUMERITY OFEV ELIGARD K SUBCUTANEOUS EMTRIVA OPSUMIT X KALETRA TABLET SUPARTZ FX ENBREL ORALAIR KISQALI SUTENT XELJANZ entecavir ORENCIA CLICKJECT KISQALI FEMARA SYMFI XELJANZ XR EPCLUSA ORENCIA CO-PACK SYMFI LO XOLAIR ERLEADA SUBCUTANEOUS KOGENATE FS SYMTUZA XTANDI erlotinib ORENITRAM KOVALTRY ESBRIET ORFADIN T KYLEENA Y EVOTAZ OTEZLA tacrolimus YONSA EYLEA OVIDREL L tadalafil

TAKHZYRO Z F lamivudine P

lamivudine-zidovudine TALTZ ZEJULA PRALUENT FASENRA TECFIDERA leuprolide acetate zidovudine PREZCOBIX FIRAZYR TEMIXYS lopinavir-ritonavir solution ZOLINZA FORTEO PREZISTA LUCENTIS temozolomide FUZEON PROLASTIN-C LYNPARZA tenofovir disoproxil fumarate PROLIA tetrabenazine G M THALOMID R GEL-ONE MAYZENT TIVICAY GELSYN-3 RASUVO MIRENA tobramycin GENVOYA REBIF MUGARD inhalation solution GILENYA REBINYN MULPLETA TREMFYA glatiramer RETACRIT mycophenolate mofetil TRIUMEQ GONAL-F REVLIMID TRUVADA mycophenolate sodium ribavirin TYKERB H N RINVOQ TYMLOS HARVONI RUBRACA TYSABRI NEULASTA HUMATROPE RUCONEST nevirapine HUMIRA RYDAPT PREFERRED OPTIONS FOR EXCLUDED SPECIALTY MEDICATIONS 3 DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* ADCIRCA sildenafil, tadalafil ENVARSUS XR tacrolimus ALPROLIX Consult doctor EPIVIR HBV entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, VEMLIDY ASTAGRAF XL tacrolimus EPOGEN ARANESP, RETACRIT AVONEX glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY EUFLEXXA GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 BARACLUDE TABLET entecavir, lamivudine, tenofovir disoproxil fumarate, EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, BARACLUDE SOLUTION, VEMLIDY MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY BERINERT FIRAZYR, RUCONEST FOLLISTIM AQ GONAL-F BUPHENYL sodium phenylbutyrate FULPHILA NEULASTA, UDENYCA CELLCEPT mycophenolate mofetil, mycophenolate sodium GENOTROPIN HUMATROPE CHORIONIC OVIDREL GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL GONADOTROPIN GRANIX NIVESTYM COMPLERA ATRIPLA, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, SYMFI LO, SYMTUZA, TRIUMEQ HEPSERA entecavir, lamivudine, tenofovir disoproxil fumarate, BARACLUDE SOLUTION, VEMLIDY DUROLANE GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 HYALGAN GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 ELELYSO CERDELGA, CEREZYME LILETTA KYLEENA, MIRENA, SKYLA ELOCTATE ADYNOVATE, JIVI, KOGENATE FS, KOVALTRY, NOVOEIGHT, NUWIQ LUPRON DEPOT ELIGARD (For Prostate Cancer Only)

DRUG NAME(S) PREFERRED OPTION(S)* DRUG NAME(S) PREFERRED OPTION(S)* MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), REPATHA PRALUENT HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2 REVATIO sildenafil, tadalafil MONOVISC GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 SABRIL vigabatrin MYFORTIC mycophenolate mofetil, mycophenolate sodium SAIZEN HUMATROPE NEUPOGEN NIVESTYM SANDOSTATIN LAR SOMATULINE DEPOT, SOMAVERT NORDITROPIN HUMATROPE STRIBILD ATRIPLA, BIKTARVY, GENVOYA, ODEFSEY, SYMFI, NOVAREL OVIDREL SYMFI LO, SYMTUZA, TRIUMEQ NUTROPIN AQ HUMATROPE SYNVISC, SYNVISC-ONE GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 OMNITROPE HUMATROPE TASIGNA imatinib mesylate, BOSULIF, SPRYCEL ORTHOVISC GEL-ONE, GELSYN-3, SUPARTZ FX, VISCO-3 TOBI, TOBI PODHALER tobramycin inhalation solution, BETHKIS OTREXUP RASUVO VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) PEGASYS Consult doctor XENAZINE tetrabenazine, AUSTEDO PLEGRIDY glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, MAYZENT, REBIF, TECFIDERA, TYSABRI, VUMERITY ZARXIO NIVESTYM PREGNYL OVIDREL ZEMAIRA PROLASTIN-C PROCRIT ARANESP, RETACRIT ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) PROCYSBI CYSTAGON ZORTRESS sirolimus PROGRAF tacrolimus ZYTIGA abiraterone, XTANDI, YONSA RAPAMUNE sirolimus

RAVICTI sodium phenylbutyrate

TABLE 1 - PREFERRED OPTIONS FOR INDICATION BASED AUTOIMMUNE EXCLUDED MEDICATIONS

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

ANKYLOSING SPONDYLITIS CIMZIA COSENTYX SIMPONI ENBREL TALTZ HUMIRA

CROHN'S DISEASE CIMZIA HUMIRA ENTYVIO STELARA SUBCUTANEOUS #

PSORIASIS CIMZIA HUMIRA COSENTYX OTEZLA ENBREL SKYRIZI STELARA SUBCUTANEOUS TALTZ TREMFYA

PSORIATIC ARTHRITIS CIMZIA COSENTYX ORENCIA CLICKJECT ENBREL ORENCIA INTRAVENOUS HUMIRA ORENCIA SUBCUTANEOUS OTEZLA SIMPONI STELARA SUBCUTANEOUS TALTZ XELJANZ XELJANZ XR

RHEUMATOID ARTHRITIS ACTEMRA ENBREL CIMZIA HUMIRA KINERET ORENCIA CLICKJECT ORENCIA INTRAVENOUS ORENCIA SUBCUTANEOUS SIMPONI RINVOQ XELJANZ XELJANZ XR

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

ALL OTHER CONDITIONS ACTEMRA ENBREL KINERET HUMIRA ORENCIA CLICKJECT ORENCIA INTRAVENOUS 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 copay1 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 copay1 information for a specific medicine.

* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. § Generics are available in this class and should be considered the first line of prescribing. 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.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.