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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 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 ALLERGENIC EXTRACTS MIRENA AGONISTS SKYLA ORALAIR HEREDITARY ANGIOEDEMA UPTRAVI FERTILITY REGULATORS AUTOIMMUNE AGENTS FIRAZYR RUCONEST PROSTAGLANDIN GNRH / LHRH See Table 1 for Indication Based VASODILATORS ANTAGONISTS Coverage Details TAKHZYRO ORENITRAM CETROTIDE ANKYLOSING SPONDYLITIS IMMUNOSUPPRESSANTS § ANTIMETABOLITES SOLUBLE GUANYLATE OVULATION STIMULANTS, COSENTYX CYCLASE STIMULATORS GONADOTROPINS ENBREL mycophenolate mofetil 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 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. 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
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  • 84 November 2008 Produced by NHS Tayside Drug and Therapeutics Committee Medicines Advisory Group (MAG)
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