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Performance Drug List - Standard Control

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Performance Drug List - Standard Control October 2020 Performance Drug List - Standard Control The CVS Caremark® Performance Drug List - Standard Control 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 § GOUT tramadol ext-rel § ERYTHROMYCINS / minocycline allopurinol BELBUCA MACROLIDES tetracycline § NSAIDs colchicine tablet NUCYNTA azithromycin § ANTIFUNGALS diclofenac sodium probenecid NUCYNTA ER clarithromycin fluconazole ibuprofen SUBSYS clarithromycin ext-rel § OPIOID ANALGESICS itraconazole meloxicam XTAMPZA ER erythromycins 2 terbinafine tablet naproxen buprenorphine transdermal DIFICID VISCOSUPPLEMENTS codeine-acetaminophen § NSAIDs, COMBINATIONS ANTIRETROVIRAL AGENTS fentanyl transdermal DUROLANE § FLUOROQUINOLONES § ANTIRETROVIRAL diclofenac sodium- fentanyl transmucosal GEL-ONE ciprofloxacin COMBINATIONS misoprostol lozenge GELSYN-3 levofloxacin SUPARTZ FX abacavir-lamivudine § NSAIDs, TOPICAL hydrocodone ext-rel moxifloxacin hydrocodone-acetaminophen VISCO-3 ATRIPLA diclofenac sodium § PENICILLINS hydromorphone BIKTARVY gel 1% (except NDC^ ANTI-INFECTIVES hydromorphone ext-rel amoxicillin CIMDUO 69499031866) methadone ANTIBACTERIALS amoxicillin-clavulanate COMPLERA diclofenac sodium solution morphine dicloxacillin DESCOVY § CEPHALOSPORINS morphine ext-rel penicillin VK DOVATO § COX-2 INHIBITORS cefdinir morphine suppository EVOTAZ celecoxib cefprozil § TETRACYCLINES oxycodone GENVOYA cefuroxime axetil oxycodone-acetaminophen doxycycline hyclate 20 mg ODEFSEY cephalexin tramadol (except NDC^ 52817019610) doxycycline hyclate capsule PREZCOBIX SUPRAX 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. STRIBILD XTANDI § ANGIOTENSIN II § CALCIUM CHANNEL lorazepam SYMFI YONSA RECEPTOR ANTAGONIST / BLOCKER / ANTILIPEMIC oxazepam SYMFI LO CALCIUM CHANNEL COMBINATIONS § LUTEINIZING HORMONE- § ANTICONVULSANTS SYMTUZA BLOCKER / DIURETIC amlodipine-atorvastatin RELEASING HORMONE TEMIXYS COMBINATIONS carbamazepine (LHRH) AGONISTS TRIUMEQ amlodipine-valsartan- § DIGITALIS GLYCOSIDES carbamazepine ext-rel ELIGARD clobazam TRUVADA hydrochlorothiazide digoxin LUPRON DEPOT olmesartan-amlodipine- diazepam rectal gel INTEGRASE INHIBITORS § DIRECT RENIN divalproex sodium § KINASE INHIBITORS hydrochlorothiazide ISENTRESS INHIBITORS / DIURETIC divalproex sodium ext-rel TIVICAY imatinib mesylate § ANTIARRHYTHMICS COMBINATIONS ethosuximide AFINITOR sotalol aliskiren gabapentin § NUCLEOSIDE REVERSE BOSULIF MULTAQ TEKTURNA HCT lamotrigine TRANSCRIPTASE CABOMETYX lamotrigine ext-rel INHIBITORS COPIKTRA ANTILIPEMICS § DIURETICS levetiracetam abacavir tablet IBRANCE § BILE ACID RESINS amiloride levetiracetam ext-rel lamivudine IRESSA furosemide oxcarbazepine cholestyramine KISQALI hydrochlorothiazide phenobarbital § PROTEASE INHIBITORS colesevelam KISQALI FEMARA metolazone phenytoin atazanavir CO-PACK § CHOLESTEROL spironolactone- phenytoin sodium extended NORVIR RYDAPT ABSORPTION INHIBITORS hydrochlorothiazide primidone PREZISTA SPRYCEL ezetimibe torsemide tiagabine triamterene topiramate ANTIVIRALS § MISCELLANEOUS § FIBRATES triamterene- valproic acid § CYTOMEGALOVIRUS LYNPARZA fenofibrate 4 hydrochlorothiazide vigabatrin AGENTS ODOMZO fenofibric acid delayed-rel zonisamide HEART FAILURE valganciclovir RUBRACA FYCOMPA § HMG-CoA REDUCTASE VISTOGARD BIDIL OXTELLAR XR § HEPATITIS B AGENTS INHIBITORS / ZEJULA CORLANOR TROKENDI XR entecavir COMBINATIONS ENTRESTO VIMPAT lamivudine CARDIOVASCULAR atorvastatin § NITRATES VEMLIDY ezetimibe-simvastatin § ANTIDEMENTIA § ACE INHIBITORS fluvastatin nitroglycerin lingual spray donepezil § HEPATITIS C AGENTS fosinopril lovastatin nitroglycerin sublingual galantamine ribavirin lisinopril pravastatin galantamine ext-rel EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) quinapril PULMONARY ARTERIAL rosuvastatin memantine HARVONI (genotypes 1, 4, 5, 6) ramipril HYPERTENSION simvastatin rivastigmine 3 VOSEVI § ENDOTHELIN RECEPTOR § ACE INHIBITOR / rivastigmine transdermal § NIACINS ANTAGONISTS § HERPES AGENTS DIURETIC COMBINATIONS NAMZARIC niacin ext-rel ambrisentan acyclovir capsule, tablet fosinopril-hydrochlorothiazide bosentan ANTIDEPRESSANTS valacyclovir lisinopril-hydrochlorothiazide § OMEGA-3 FATTY ACIDS OPSUMIT § SELECTIVE SEROTONIN quinapril-hydrochlorothiazide omega-3 acid ethyl esters REUPTAKE INHIBITORS § INFLUENZA AGENTS § PHOSPHODIESTERASE § ANGIOTENSIN II VASCEPA (SSRIs) oseltamivir INHIBITORS RECEPTOR ANTAGONISTS / RELENZA PCSK9 INHIBITORS citalopram sildenafil DIURETIC COMBINATIONS escitalopram PRALUENT 6 § MISCELLANEOUS candesartan / candesartan- PROSTACYCLIN RECEPTOR fluoxetine clindamycin hydrochlorothiazide § BETA-BLOCKERS AGONISTS paroxetine HCl ivermectin irbesartan / irbesartan- paroxetine HCl ext-rel atenolol UPTRAVI sertraline linezolid hydrochlorothiazide carvedilol TRINTELLIX metronidazole losartan / losartan- carvedilol phosphate ext-rel § PROSTAGLANDIN VIIBRYD nitrofurantoin hydrochlorothiazide metoprolol succinate ext-rel VASODILATORS sulfamethoxazole- olmesartan / olmesartan- metoprolol tartrate ORENITRAM § SEROTONIN trimethoprim hydrochlorothiazide nadolol NOREPINEPHRINE vancomycin capsule telmisartan / telmisartan- SOLUBLE GUANYLATE pindolol REUPTAKE INHIBITORS EMVERM hydrochlorothiazide CYCLASE STIMULATORS propranolol (SNRIs) XIFAXAN 550 MG valsartan / valsartan- propranolol ext-rel ADEMPAS desvenlafaxine ext-rel hydrochlorothiazide BYSTOLIC ANTINEOPLASTIC § MISCELLANEOUS duloxetine AGENTS § ANGIOTENSIN II § CALCIUM CHANNEL ranolazine ext-rel venlafaxine RECEPTOR ANTAGONIST / BLOCKERS venlafaxine ext-rel capsule HORMONAL CALCIUM CHANNEL CENTRAL NERVOUS ANTINEOPLASTIC AGENTS amlodipine § MISCELLANEOUS BLOCKER COMBINATIONS 5 SYSTEM diltiazem ext-rel AGENTS § ANTIANDROGENS amlodipine-olmesartan nifedipine ext-rel ANTIANXIETY abiraterone amlodipine-telmisartan bupropion verapamil ext-rel 7 bicalutamide amlodipine-valsartan § BENZODIAZEPINES bupropion ext-rel ERLEADA alprazolam mirtazapine NUBEQA clonazepam trazodone diazepam 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.
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