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Performance Drug List - Standard Control for Clients ® with Advanced Control Specialty Formulary

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July 2021 Performance Drug List - Standard Control for Clients ® with Advanced Control Specialty Formulary The CVS Caremark® Performance Drug List - Standard Control for Clients with 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 • This drug list represents a summary of prescription coverage. It is this document. Products recently approved by the U.S. Food and not all-inclusive and does not guarantee coverage. The member’s Drug Administration (FDA) may not be covered upon release specific prescription benefit plan design may not cover certain to the market. 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 copay1 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 § OPIOID ANALGESICS ANTI-INFECTIVES § PENICILLINS § INFLUENZA AGENTS buprenorphine transdermal amoxicillin oseltamivir § NSAIDs ANTIBACTERIALS codeine-acetaminophen amoxicillin-clavulanate RELENZA diclofenac sodium fentanyl transdermal § CEPHALOSPORINS dicloxacillin § MISCELLANEOUS ibuprofen fentanyl transmucosal cefdinir penicillin VK meloxicam lozenge cefprozil clindamycin § TETRACYCLINES naproxen (except naproxen CR or hydrocodone ext-rel cefuroxime axetil ivermectin naproxen suspension) hydrocodone-acetaminophen cephalexin doxycycline hyclate 20 mg linezolid hydromorphone SUPRAX doxycycline hyclate capsule metronidazole § NSAIDs, COMBINATIONS hydromorphone ext-rel minocycline nitrofurantoin (except diclofenac sodium- § ERYTHROMYCINS / methadone tetracycline NDC^ 70408023932) misoprostol MACROLIDES pyrimethamine morphine azithromycin § ANTIFUNGALS § NSAIDs, TOPICAL morphine ext-rel sulfamethoxazole- morphine suppository clarithromycin fluconazole trimethoprim diclofenac sodium gel 1% oxycodone clarithromycin ext-rel itraconazole vancomycin capsule diclofenac sodium solution oxycodone-acetaminophen erythromycins terbinafine tablet EMVERM § COX-2 INHIBITORS tramadol (except NDC^ 52817019610) DIFICID XIFAXAN 550 MG ANTIVIRALS tramadol ext-rel tablet celecoxib § FLUOROQUINOLONES § CYTOMEGALOVIRUS BELBUCA ciprofloxacin AGENTS § GOUT NUCYNTA levofloxacin valganciclovir allopurinol NUCYNTA ER moxifloxacin SUBSYS colchicine tablet § HERPES AGENTS probenecid XTAMPZA ER acyclovir capsule, tablet MITIGARE valacyclovir 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. ANTINEOPLASTIC § BILE ACID RESINS metolazone memantine § ATTENTION DEFICIT AGENTS cholestyramine spironolactone- rivastigmine HYPERACTIVITY DISORDER colesevelam hydrochlorothiazide rivastigmine transdermal amphetamine- HORMONAL torsemide NAMZARIC dextroamphetamine ANTINEOPLASTIC AGENTS § CHOLESTEROL triamterene mixed salts ANTIDEPRESSANTS § ANTIANDROGENS ABSORPTION INHIBITORS triamterene- amphetamine- bicalutamide ezetimibe hydrochlorothiazide § SELECTIVE SEROTONIN dextroamphetamine REUPTAKE INHIBITORS mixed salts ext-rel † § MISCELLANEOUS § FIBRATES HEART FAILURE (SSRIs) atomoxetine BIDIL VISTOGARD fenofibrate (except citalopram dexmethylphenidate ext-rel CORLANOR fenofibrate capsule 50 mg, 130 mg; escitalopram guanfacine ext-rel CARDIOVASCULAR ENTRESTO fenofibrate tablet 40 mg, 120 mg) fluoxetine (except fluoxetine tablet 60 mg, methylphenidate fenofibric acid delayed-rel fluoxetine tablet [generics for SARAFEM]) methylphenidate ext-rel † § ACE INHIBITORS § NITRATES paroxetine HCl MYDAYIS fosinopril § HMG-CoA REDUCTASE isosorbide dinitrate (except paroxetine HCl ext-rel VYVANSE lisinopril INHIBITORS / isosorbide dinitrate 40 mg) sertraline quinapril COMBINATIONS isosorbide mononitrate TRINTELLIX § FIBROMYALGIA ramipril atorvastatin nitroglycerin lingual spray pregabalin ezetimibe-simvastatin nitroglycerin sublingual § SEROTONIN § ACE INHIBITOR / fluvastatin NOREPINEPHRINE HYPNOTICS DIURETIC COMBINATIONS § MISCELLANEOUS lovastatin REUPTAKE INHIBITORS § NONBENZODIAZEPINES fosinopril-hydrochlorothiazide ranolazine ext-rel (SNRIs) pravastatin eszopiclone lisinopril-hydrochlorothiazide rosuvastatin desvenlafaxine ext-rel quinapril-hydrochlorothiazide CENTRAL NERVOUS ramelteon simvastatin duloxetine zolpidem SYSTEM venlafaxine § ANGIOTENSIN II § NIACINS zolpidem ext-rel RECEPTOR ANTAGONISTS / ANTIANXIETY venlafaxine ext-rel capsule BELSOMRA niacin ext-rel DIURETIC COMBINATIONS § BENZODIAZEPINES § MISCELLANEOUS § TRICYCLICS candesartan / candesartan- § OMEGA-3 FATTY ACIDS alprazolam AGENTS doxepin hydrochlorothiazide clonazepam omega-3 acid ethyl esters bupropion irbesartan / irbesartan- diazepam VASCEPA bupropion ext-rel (except MIGRAINE hydrochlorothiazide lorazepam bupropion ext-rel tablet 450 mg) ACUTE MIGRAINE AGENTS losartan / losartan- § BETA-BLOCKERS oxazepam mirtazapine § Triptans hydrochlorothiazide atenolol § ANTICONVULSANTS trazodone olmesartan / olmesartan- carvedilol eletriptan hydrochlorothiazide carvedilol phosphate ext-rel carbamazepine § ANTIPARKINSONIAN naratriptan telmisartan / telmisartan- metoprolol succinate ext-rel carbamazepine ext-rel AGENTS rizatriptan hydrochlorothiazide clobazam sumatriptan metoprolol tartrate amantadine valsartan / valsartan- diazepam rectal gel zolmitriptan nadolol carbidopa-levodopa hydrochlorothiazide divalproex sodium ONZETRA XSAIL pindolol carbidopa-levodopa ext-rel propranolol divalproex sodium ext-rel carbidopa-levodopa- ZEMBRACE SYMTOUCH § ANGIOTENSIN II ethosuximide ZOMIG NASAL SPRAY propranolol ext-rel RECEPTOR ANTAGONIST / entacapone BYSTOLIC gabapentin entacapone Miscellaneous CALCIUM CHANNEL lamotrigine pramipexole BLOCKER COMBINATIONS § CALCIUM CHANNEL lamotrigine ext-rel NURTEC ODT pramipexole ext-rel amlodipine-olmesartan BLOCKERS levetiracetam REYVOW rasagiline amlodipine-telmisartan amlodipine levetiracetam ext-rel UBRELVY ropinirole amlodipine-valsartan diltiazem ext-rel (except oxcarbazepine ropinirole ext-rel PREVENTIVE MIGRAINE generics for CARDIZEM LA) phenobarbital § ANGIOTENSIN II selegiline AGENTS nifedipine ext-rel phenytoin RECEPTOR ANTAGONIST / NEUPRO verapamil ext-rel phenytoin sodium extended Monoclonal Antibodies CALCIUM CHANNEL primidone ANTIPSYCHOTICS AIMOVIG BLOCKER / DIURETIC § CALCIUM CHANNEL rufinamide AJOVY COMBINATIONS BLOCKER / ANTILIPEMIC § ATYPICALS tiagabine EMGALITY COMBINATIONS aripiprazole amlodipine-valsartan- topiramate clozapine § MUSCULOSKELETAL hydrochlorothiazide amlodipine-atorvastatin valproic acid olanzapine THERAPY AGENTS olmesartan-amlodipine- zonisamide § DIGITALIS GLYCOSIDES quetiapine hydrochlorothiazide FYCOMPA cyclobenzaprine (except quetiapine ext-rel digoxin NAYZILAM cyclobenzaprine tablet 7.5 mg) § ANTIARRHYTHMICS risperidone OXTELLAR XR disopyramide § DIRECT RENIN ziprasidone § NARCOLEPSY TROKENDI XR sotalol INHIBITORS / DIURETIC ABILIFY MAINTENA armodafinil VALTOCO MULTAQ COMBINATIONS LATUDA modafinil VIMPAT aliskiren PERSERIS SUNOSI XCOPRI ANTILIPEMICS TEKTURNA HCT VRAYLAR ACL INHIBITORS / POSTHERPETIC § ANTIDEMENTIA COMBINATIONS § DIURETICS NEURALGIA (PHN) donepezil amiloride GRALISE NEXLETOL galantamine furosemide
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