01-2021-Acf-Formulary-Changes

Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

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: Abilify Maintena Central Nervous Abilify Maintena is indicated for: To provide a long-acting injectable antipsychotic option. (aripiprazole ext-rel) System/ Antipsychotics/ • Treatment of schizophrenia in adults intramuscular Atypicals • Maintenance monotherapy treatment of extended-release bipolar I disorder in adults suspension for injection Alecensa (alectinib) Antineoplastic Agents/ Alecensa is indicated for the treatment of To provide an option for the treatment of ALK-positive oral capsule Kinase Inhibitors patients with anaplastic lymphoma kinase non-small cell lung cancer. (ALK)-positive metastatic non-small cell lung cancer as detected by an FDA- approved test. Alunbrig (brigatinib) Antineoplastic Agents/ Alunbrig is indicated for the treatment of To provide an option for the treatment of ALK-positive oral tablet, oral Kinase Inhibitors adult patients with anaplastic lymphoma non-small cell lung cancer. initiation pack kinase (ALK)-positive metastatic non-small cell lung cancer as detected by an FDA- approved test. Annovera Endocrine and Annovera is indicated for use by females of To provide an additional vaginal contraceptive option. (segesterone acetate- Metabolic/ reproductive potential to prevent pregnancy. ethinyl estradiol) Contraceptives/ Vaginal vaginal ring

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. ©2020 CVS Caremark. All rights reserved.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Bijuva (estradiol- Endocrine and Bijuva is indicated in a woman with a uterus To provide an additional option for the treatment of progesterone) Metabolic/ Menopausal for the treatment of moderate to severe moderate to severe vasomotor symptoms associated oral capsule Symptom Agents/ Oral vasomotor symptoms due to menopause. with menopause. Breztri Aerosphere Respiratory/ Breztri Aerosphere is indicated for the To provide an additional triple therapy option for the (budesonide- Anticholinergic / Beta maintenance treatment of patients with maintenance treatment of chronic obstructive pulmonary glycopyrrolate- Agonist / Steroid chronic obstructive pulmonary disease. disease. formoterol) Inhalant Combinations inhalation aerosol Clenpiq (sodium Gastrointestinal/ Clenpiq is indicated for cleansing of the To provide an additional option for colon cleansing prior picosulfate-magnesium Laxatives colon as a preparation for colonoscopy in to a colonoscopy. oxide-citric acid) adults and pediatric patients ages 9 years oral solution and older. Doptelet Hematologic/ Doptelet is indicated for the treatment of: To provide an additional option for the treatment of (avatrombopag) Thrombocytopenia • Thrombocytopenia in adult patients with thrombocytopenia. oral tablet Agents chronic liver disease who are scheduled to undergo a procedure • Thrombocytopenia in adult patients with chronic immune thrombocytopenia who have had an insufficient response to a previous treatment Duobrii (halobetasol Topical/ Dermatology/ Duobrii is indicated for the topical treatment To provide an additional topical option for the treatment propionate-tazarotene) Antipsoriatics of plaque psoriasis in adults. of plaque psoriasis. topical lotion Durolane (sodium Analgesics/ Durolane is indicated for the treatment of To provide an additional viscosupplement option for hyaluronate) Viscosupplements pain in osteoarthritis of the knee in patients osteoarthritis. intra-articular gel for who have failed to respond adequately to injection

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments conservative non-pharmacological therapy or simple analgesics (e.g. acetaminophen). Enstilar (calcipotriene- Topical/ Dermatology/ Enstilar is indicated for the topical treatment To provide an additional topical option for the treatment betamethasone Antipsoriatics of plaque psoriasis in patients 12 years and of plaque psoriasis. dipropionate) older. topical foam Erivedge (vismodegib) Antineoplastic Agents/ Erivedge is indicated for the treatment of To provide an option for the treatment of metastatic oral capsule Miscellaneous adults with metastatic basal cell carcinoma, basal cell carcinoma. or with locally advanced basal cell carcinoma that has recurred following surgery or who are not candidates for surgery and who are not candidates for radiation. Euflexxa (sodium Analgesics/ Euflexxa is indicated for the treatment of To provide an additional viscosupplement option for hyaluronate) Viscosupplements pain in osteoarthritis of the knee in patients osteoarthritis. intra-articular solution who have failed to respond adequately to for injection conservative non-pharmacologic therapy and simple analgesics (e.g., acetaminophen). Flarex Topical/ Ophthalmic/ Flarex is indicated for use in the treatment To provide an additional ophthalmic anti-inflammatory (fluorometholone Anti-Inflammatories/ of steroid responsive inflammatory option. acetate) Steroidal conditions of the palpebral and bulbar ophthalmic suspension conjunctiva, cornea, and anterior segment of the eye. Imvexxy (estradiol) Endocrine and Imvexxy is indicated for the treatment of To provide an additional vaginal option for the treatment vaginal insert Metabolic/ Menopausal moderate to severe dyspareunia, a of dyspareunia.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Symptom Agents/ symptom of vulvar and vaginal atrophy, due Vaginal to menopause. Inbrija (levodopa) Central Nervous Inbrija is indicated for the intermittent To provide an option for the treatment of “off” episodes inhalation powder System/ treatment of “off” episodes in patients with (return of Parkinson’s symptoms) in those with Antiparkinsonian Agents Parkinson's disease treated with carbidopa- Parkinson’s disease. levodopa. Kesimpta Central Nervous Kesimpta is indicated for the treatment of To provide an additional option for the treatment of (ofatumumab) System/ Multiple relapsing forms of multiple sclerosis, to relapsing forms of multiple sclerosis. subcutaneous solution Sclerosis Agents include clinically isolated syndrome, for injection relapsing-remitting disease, and active secondary progressive disease, in adults. Kevzara (sarilumab) Immunologic Agents/ Kevzara is indicated for treatment of adult To provide an additional option for the treatment of subcutaneous solution Autoimmune Agents/ patients with moderately to severely active moderately to severely active rheumatoid arthritis. for injection Rheumatoid Arthritis rheumatoid arthritis who have had an inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs). Latuda (lurasidone) Central Nervous Latuda is indicated for the treatment of: To provide an additional oral antipsychotic option. oral tablet System/ Antipsychotics/ • Schizophrenia in adults and Atypicals adolescents (13 to 17 years) • Depressive episode associated with Bipolar I Disorder (bipolar depression) in adults and pediatric patients (10 to 17 years) as monotherapy • Depressive episode associated with Bipolar I Disorder (bipolar depression)

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments in adults as adjunctive therapy with lithium or valproate Nayzilam (midazolam) Central Nervous Nayzilam is indicated for the acute To provide an additional option for the treatment of nasal spray System/ Anticonvulsants treatment of intermittent, stereotypic acute, intermittent seizures. episodes of frequent seizure activity (i.e., seizure clusters, acute repetitive seizures) that are distinct from a patient's usual seizure pattern in patients with epilepsy 12 years of age and older. Nexletol (bempedoic Cardiovascular/ Nexletol is indicated as an adjunct to diet To provide an adjunctive option for the treatment of acid) Antilipemics/ ACL and maximally tolerated statin therapy for atherosclerotic cardiovascular disease and familial oral tablet Inhibitors / Combinations the treatment of adults with heterozygous hypercholesterolemia. familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of low-density lipoprotein cholesterol (LDL-C). Nexlizet (bempedoic Cardiovascular/ Nexlizet is indicated as an adjunct to diet To provide an adjunctive option for the treatment of acid-ezetimibe) Antilipemics/ ACL and maximally tolerated statin therapy for atherosclerotic cardiovascular disease and familial oral tablet Inhibitors / Combinations the treatment of adults with heterozygous hypercholesterolemia. familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of low-density lipoprotein cholesterol (LDL-C). Ninlaro (ixazomib) Antineoplastic Agents/ Ninlaro is indicated in combination with To provide an additional option for the treatment of oral capsule Multiple Myeloma/ lenalidomide and dexamethasone for the multiple myeloma. Proteasome Inhibitors treatment of patients with multiple myeloma

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments who have received at least one prior therapy. Norditropin Endocrine and Norditropin is indicated for: To provide an option for the treatment of growth (somatropin) Metabolic/ Human • Pediatric: Treatment of pediatric hormone deficiency. subcutaneous solution Growth Hormones patients with growth failure due to for injection inadequate secretion of endogenous growth hormone (GH), short stature associated with Noonan syndrome, short stature associated with Turner syndrome, short stature born small for gestational age with no catch-up growth by age 2 to 4 years, Idiopathic Short Stature, and growth failure due to Prader-Willi Syndrome • Adult: Replacement of endogenous GH in adults with growth hormone deficiency Ocrevus (ocrelizumab) Central Nervous Ocrevus is indicated for the treatment of: To provide an option for the treatment of primary intravenous solution for System/ Multiple • Relapsing forms of multiple sclerosis, to progressive multiple sclerosis and an additional option injection Sclerosis Agents include clinically isolated syndrome, for the treatment of relapsing forms of multiple sclerosis. relapsing-remitting disease, and active secondary progressive disease, in adults • Primary progressive multiple sclerosis, in adults

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Omnipod Insulin Endocrine and Omnipod is used to allow continuous To provide an additional continuous/basal and on- Infusion Pump Metabolic/ Antidiabetics/ subcutaneous basal insulin infusion and on- demand/bolus insulin delivery option in insulin- insulin infusion Supplies demand bolus dosing in those with insulin- dependent diabetes. disposable pump dependent diabetes. Omnipod DASH Endocrine and Omnipod DASH is used to allow continuous To provide an additional continuous/basal and on- Insulin Infusion Pump Metabolic/ Antidiabetics/ subcutaneous basal insulin infusion and on- demand/bolus insulin delivery option in insulin- insulin management Supplies demand bolus dosing in those with insulin- dependent diabetes. system dependent diabetes. OneTouch Lancets Endocrine and OneTouch lancets are supplies that aid in To provide a preferred lancet option for testing blood lancets Metabolic/ Antidiabetics/ the testing of blood glucose levels in those glucose levels. Supplies who have diabetes. OneTouch Lancing Endocrine and OneTouch lancing devices are supplies that To provide a preferred lancing device option for testing Devices Metabolic/ Antidiabetics/ aid in the testing of blood glucose levels in blood glucose levels. lancing devices Supplies those who have diabetes. OneTouch Ultra, Endocrine and OneTouch Ultra and OneTouch Verio strips To provide an option for testing and monitoring blood OneTouch Verio Metabolic/ Antidiabetics/ and kits are used to test and monitor blood glucose levels. Strips and Kits Supplies glucose levels in those who have diabetes. blood glucose test strips, monitoring kits Oracea (doxycycline Topical/ Dermatology/ Oracea is indicated for the treatment of only To provide an oral option for the treatment of rosacea. monohydrate delayed- Rosacea inflammatory lesions (papules and pustules) rel) of rosacea in adult patients. oral delayed-release capsule Perjeta (pertuzumab) Antineoplastic Agents/ Perjeta is indicated for: To provide an additional option for the treatment of intravenous solution for Miscellaneous • Use in combination with trastuzumab human epidermal growth factor receptor 2 (HER2)- injection and docetaxel for treatment of patients positive breast cancer.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments with HER2-positive metastatic breast cancer who have not received prior anti- HER2 therapy or chemotherapy for metastatic disease • Use in combination with trastuzumab and chemotherapy as: o Neoadjuvant treatment of patients with HER2-positive, locally advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer o Adjuvant treatment of patients with HER2-positive early breast cancer at high risk of recurrence Perseris (risperidone Central Nervous Perseris is indicated for the treatment of To provide a long-acting injectable antipsychotic option. ext-rel) System/ Antipsychotics/ schizophrenia in adults. subcutaneous Atypicals extended-release suspension for injection Phesgo (pertuzumab- Antineoplastic Agents/ Phesgo is indicated for: To provide an additional option for the treatment of trastuzumab- Miscellaneous • Use in combination with chemotherapy human epidermal growth factor receptor 2 (HER2)- hyaluronidase-zzxf) as: positive breast cancer. subcutaneous solution o Neoadjuvant treatment of patients for injection with HER2-positive, locally

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Therapeutic Category/ Product Subcategory Indication Options/Comments advanced, inflammatory, or early stage breast cancer (either greater than 2 cm in diameter or node positive) as part of a complete treatment regimen for early breast cancer o Adjuvant treatment of patients with HER2-positive early breast cancer at high risk of recurrence • Use in combination with docetaxel for treatment of patients with HER2- positive metastatic breast cancer who have not received prior anti-HER2 therapy or chemotherapy for metastatic disease Sancuso (granisetron) Gastrointestinal/ Sancuso is indicated for the prevention of To provide an additional option for the prevention of transdermal patch Antiemetics nausea and vomiting in adults receiving chemotherapy-induced nausea and vomiting. moderately and/or highly emetogenic chemotherapy for up to 5 consecutive days. Saphris (asenapine) Central Nervous Saphris is indicated for: To provide an additional oral antipsychotic option. sublingual tablet System/ Antipsychotics/ • Schizophrenia in adults Atypicals • Bipolar I disorder o Acute monotherapy treatment of manic or mixed episodes, in adults and pediatric patients 10 to 17 years of age

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments o Adjunctive treatment to lithium or valproate in adults o Maintenance monotherapy treatment in adults Simbrinza Topical/ Ophthalmic/ Simbrinza is indicated for the reduction of To provide an additional option for the reduction of (brinzolamide- Carbonic Anhydrase elevated intraocular pressure in patients elevated intraocular pressure. brimonidine) Inhibitor / with open-angle glaucoma or ocular ophthalmic suspension Sympathomimetic hypertension. Combinations Taclonex Topical/ Dermatology/ Taclonex ointment is indicated for the To provide an additional topical option for the treatment (calcipotriene- Antipsoriatics topical treatment of plaque psoriasis in of plaque psoriasis. betamethasone patients 12 years of age and older. dipropionate) topical ointment Taclonex Topical/ Dermatology/ Taclonex suspension is indicated for the To provide an additional topical option for the treatment (calcipotriene- Antipsoriatics topical treatment of plaque psoriasis of the of plaque psoriasis. betamethasone scalp and body in patients 12 years and dipropionate) older. topical suspension Toujeo (insulin Endocrine and Toujeo is indicated to improve glycemic To provide an additional long-acting insulin option for the glargine) Metabolic/ Antidiabetics/ control in adults and pediatric patients 6 management of diabetes mellitus. subcutaneous solution Insulins years and older with diabetes mellitus. for injection Valtoco (diazepam) Central Nervous Valtoco is indicated for the acute treatment To provide an additional option for the treatment of nasal spray System/ Anticonvulsants of intermittent, stereotypic episodes of acute, intermittent seizures. frequent seizure activity (i.e., seizure clusters, acute repetitive seizures) that are

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Therapeutic Category/ Product Subcategory Indication Options/Comments distinct from a patient's usual seizure pattern in patients with epilepsy 6 years of age and older. Velcade (bortezomib) Antineoplastic Agents/ Velcade is indicated for: To provide an additional option for the treatment of intravenous / Multiple Myeloma/ • Treatment of adult patients with multiple multiple myeloma and mantle cell lymphoma. subcutaneous solution Proteasome Inhibitors myeloma for injection • Treatment of adult patients with mantle cell lymphoma Xcopri (cenobamate) Central Nervous Xcopri is indicated for the treatment of To provide an additional option for the treatment of oral tablet, oral titration System/ Anticonvulsants partial-onset seizures in adult patients. partial-onset seizures in adults. pack, oral maintenance pack Xospata (gilteritinib Antineoplastic Agents/ Xospata is indicated for the treatment of To provide an option for the treatment of relapsed or fumarate) Kinase Inhibitors adult patients who have relapsed or refractory acute myeloid leukemia with a specific type of oral tablet refractory acute myeloid leukemia with a genetic mutation. FMS-like tyrosine kinase 3 (FLT3) mutation as detected by an FDA-approved test. Zeposia (ozanimod) Central Nervous Zeposia is indicated for the treatment of To provide an additional option for the treatment of oral capsule, oral System/ Multiple relapsing forms of multiple sclerosis, to relapsing forms of multiple sclerosis. starter pack Sclerosis Agents include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. Ziextenzo Hematologic/ Ziextenzo is indicated to decrease the To provide a long-acting colony-stimulating factor option (pegfilgrastim-bmez) Hematopoietic Growth incidence of infection, as manifested by for those who are receiving myelosuppressive anti- subcutaneous solution Factors febrile neutropenia, in patients with non- cancer therapy. for injection myeloid malignancies receiving myelosuppressive anti-cancer drugs

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Therapeutic Category/ Product Subcategory Indication Options/Comments associated with a clinically significant incidence of febrile neutropenia. Generic Agents: aprepitant Gastrointestinal/ Aprepitant is indicated: To provide an additional generic option for the oral capsule Antiemetics • In combination with other antiemetic prevention of chemotherapy-induced nausea and agents, in patients 12 years of age and vomiting and postoperative nausea and vomiting. older for prevention of: o Acute and delayed nausea and vomiting associated with initial and repeat courses of highly emetogenic cancer chemotherapy including high-dose cisplatin o Nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy • For prevention of postoperative nausea and vomiting in adults ciprofloxacin- Topical/ Otic/ Anti- Ciprofloxacin-dexamethasone is indicated To provide an additional generic otic anti-infective and dexamethasone Infective / Anti- for the treatment of infections caused by anti-inflammatory option for the treatment of ear otic suspension Inflammatory susceptible isolates of the designated infections. Combinations microorganisms in the specific conditions listed below: • Acute Otitis Media (AOM) in pediatric patients (age 6 months and older) with tympanostomy tubes due to Staphylococcus aureus, Streptococcus

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Therapeutic Category/ Product Subcategory Indication Options/Comments pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Pseudomonas aeruginosa • Acute Otitis Externa (AOE) in pediatric (age 6 months and older), adult and elderly patients due to Staphylococcus aureus and Pseudomonas aeruginosa dimethyl fumarate Central Nervous Dimethyl fumarate is indicated for the To provide an additional generic option for the treatment delayed-rel System/ Multiple treatment of relapsing forms of multiple of relapsing forms of multiple sclerosis. oral delayed-release Sclerosis Agents sclerosis, to include clinically isolated capsule syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults. isosorbide Cardiovascular/ Nitrates/ Isosorbide mononitrate is indicated for the To provide an additional oral nitrate option. mononitrate Oral prevention and treatment of angina pectoris oral tablet due to coronary artery disease. pyrimethamine Anti-Infectives/ Pyrimethamine is indicated for the treatment To provide a generic option for the treatment of oral tablet Miscellaneous of toxoplasmosis when used conjointly with toxoplasmosis. a sulfonamide, since synergism exists with this combination.

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DELETIONS: Therapeutic Category/ Product Subcategory Indication Options/Comments Brand Agents: Accu-Chek Lancets Endocrine and Accu-Chek lancets are supplies that aid in Availability of an additional lancet option for testing lancets Metabolic/ Antidiabetics/ the testing of blood glucose levels in those blood glucose levels. Supplies who have diabetes. The preferred option on the Advanced Control Formulary is OneTouch lancets. Accu-Chek Lancing Endocrine and Accu-Chek lancing devices are supplies Availability of an additional lancing device option for Devices Metabolic/ Antidiabetics/ that aid in the testing of blood glucose testing blood glucose levels. lancing devices Supplies levels in those who have diabetes. The preferred option on the Advanced Control Formulary is OneTouch Lancing Devices. Aristada (aripiprazole Central Nervous Aristada is indicated for the treatment of Availability of additional long-acting injectable lauroxil ext-rel) System/ Antipsychotics/ schizophrenia in adults. antipsychotic options. intramuscular Atypicals extended-release Preferred options on the Advanced Control Formulary suspension for injection include Abilify Maintena (aripiprazole ext-rel injection) and Perseris (risperidone ext-rel injection). Aristada Initio Central Nervous Aristada Initio, in combination with oral Availability of additional long-acting injectable (aripiprazole lauroxil System/ Antipsychotics/ aripiprazole, is indicated for the initiation of antipsychotic options. ext-rel) Atypicals Aristada when used for the treatment of intramuscular schizophrenia in adults. Preferred options on the Advanced Control Formulary extended-release include Abilify Maintena (aripiprazole ext-rel injection) suspension for injection and Perseris (risperidone ext-rel injection).

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REMOVALS: Therapeutic Category/ Product Subcategory Indication Options/Comments Brand Agents: Accu-Chek Aviva Endocrine and Accu-Chek strips and kits are used to test Availability of additional options for testing and Plus, Accu-Chek Metabolic/ Antidiabetics/ and monitor blood glucose levels in those monitoring blood glucose levels. Compact Plus, Accu- Supplies who have diabetes. Chek Guide, Accu- Preferred options on the Advanced Control Formulary Chek SmartView include OneTouch Ultra strips and kits and OneTouch Strips and Kits Verio strips and kits. blood glucose test strips, monitoring kits Adzenys ER Central Nervous Adzenys ER is indicated for the treatment of Availability of additional options for the treatment of (amphetamine ext-rel) System/ Attention Deficit Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder. oral extended-release Hyperactivity Disorder (ADHD) in patients 6 years and older. suspension Preferred options on the Advanced Control Formulary include amphetamine-dextroamphetamine mixed salts ext-rel (excluding certain NDCs), dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel (excluding certain NDCs), Mydayis (amphetamine-dextroamphetamine mixed salts ext-rel), and Vyvanse (lisdexamfetamine). Akynzeo (netupitant- Gastrointestinal/ Akynzeo capsule is indicated in combination Availability of additional options for the prevention of palonosetron) Antiemetics with dexamethasone in adults for the chemotherapy-induced nausea and vomiting. oral capsule prevention of acute and delayed nausea and vomiting associated with initial and Preferred options on the Advanced Control Formulary repeat courses of cancer chemotherapy, include aprepitant WITH granisetron, ondansetron, or including, but not limited to, highly Sancuso (granisetron). emetogenic chemotherapy.

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Therapeutic Category/ Product Subcategory Indication Options/Comments Akynzeo Gastrointestinal/ Akynzeo injection is indicated in Availability of additional options for the prevention of (fosnetupitant- Antiemetics combination with dexamethasone in adults chemotherapy-induced nausea and vomiting. palonosetron) for the prevention of acute and delayed intravenous solution for nausea and vomiting associated with initial Preferred options on the Advanced Control Formulary injection and repeat courses of highly emetogenic include aprepitant WITH granisetron, ondansetron, or cancer chemotherapy. Sancuso (granisetron). Amitiza (lubiprostone) Gastrointestinal/ Irritable Amitiza is indicated for the treatment of: Availability of additional options for the treatment of oral capsule Bowel Syndrome • Chronic idiopathic constipation (CIC) in chronic idiopathic constipation, opioid-induced adults constipation, and irritable bowel syndrome with • Opioid-induced constipation (OIC) in constipation. adult patients with chronic, non-cancer pain, including patients with chronic Preferred options on the Advanced Control Formulary pain related to prior cancer or its include Linzess (linaclotide), Movantik (naloxegol), and treatment who do not require frequent Symproic (naldemedine). (e.g., weekly) opioid dosage escalation • Irritable bowel syndrome with constipation (IBS-C) in women ≥ 18 years old Anzemet (dolasetron Gastrointestinal/ Anzemet is indicated for the prevention of Availability of additional options for the prevention of mesylate) Antiemetics nausea and vomiting associated with chemotherapy-induced nausea and vomiting. oral tablet moderately emetogenic cancer chemotherapy, including initial and repeat Preferred options on the Advanced Control Formulary courses in adults and children 2 years and include granisetron, ondansetron, and Sancuso older. (granisetron). Apokyn (apomorphine) Central Nervous Apokyn is indicated for the acute, Availability of an additional option for the treatment of subcutaneous solution System/ intermittent treatment of hypomobility, "off" “off” episodes (return of Parkinson’s symptoms) in those for injection Antiparkinsonian Agents episodes ("end-of-dose wearing off" and with advanced Parkinson’s disease.

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Therapeutic Category/ Product Subcategory Indication Options/Comments unpredictable "on/off" episodes) associated with advanced Parkinson's disease. The preferred option the Advanced Control Formulary is Inbrija (levodopa inhalation powder). Aralast NP (alpha-1 Respiratory/ Alpha-1 Aralast NP is indicated for chronic Availability of an additional option for the treatment of proteinase inhibitor) Antitrypsin Deficiency augmentation therapy in adults with emphysema due to an inherited disorder known as intravenous solution for Agents clinically evident emphysema due to severe alpha1-antitrypsin deficiency. injection congenital deficiency of alpha1-antitrypsin inhibitor. The preferred option on the Advanced Control Formulary is Prolastin-C (alpha-1 proteinase inhibitor). Azesco (multivitamin Nutritional/Supplements/ Azesco is used: Availability of additional prenatal vitamin options. with iron) Vitamins and Minerals/ • For the clinical dietary management of oral tablet Prenatal Vitamins suboptimal nutritional status in patients Preferred options on the Advanced Control formulary where advanced folate supplementation include prenatal vitamins and Citranatal (prenatal is required and nutritional vitamins with folic acid). supplementation in physiologically stressful conditions for maintenance of good health is needed • Throughout pregnancy, during the postnatal period for both lactating and non-lactating mothers, and throughout the childbearing years • For improving the nutritional status of women prior to conception Azopt (brinzolamide) Topical/ Ophthalmic/ Azopt is indicated for the treatment of Availability of a generic ophthalmic carbonic anhydrase ophthalmic suspension Carbonic Anhydrase elevated intraocular pressure in patients inhibitor option. Inhibitors with ocular hypertension or open-angle glaucoma.

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Therapeutic Category/ Product Subcategory Indication Options/Comments The preferred option on the Advanced Control Formulary is dorzolamide. Besivance Topical/ Ophthalmic/ Besivance is indicated for the treatment of Availability of generic ophthalmic anti-infective options. (besifloxacin) Anti-Infectives bacterial conjunctivitis caused by ophthalmic suspension susceptible isolates of the following Preferred options on the Advanced Control Formulary bacteria: Aerococcus viridans, CDC include ciprofloxacin, erythromycin, gentamicin, coryneform group G, Corynebacterium levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, and pseudodiphtheriticum, Corynebacterium tobramycin. striatum, Haemophilus influenzae, Moraxella catarrhalis, Moraxella lacunata, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus lugdunensis, Staphylococcus warneri, Streptococcus mitis group, Streptococcus oralis, Streptococcus pneumoniae, Streptococcus salivarius. Betoptic S (betaxolol) Topical/ Ophthalmic/ Betoptic S is indicated for the treatment of Availability of additional ophthalmic beta-blocker ophthalmic suspension Beta-Blockers/ Selective elevated intraocular pressure (IOP) in options. patients with chronic open-angle glaucoma or ocular hypertension. Preferred options on the Advanced Control Formulary include timolol maleate solution and Betimol (timolol hemihydrate). Bevespi Aerosphere Respiratory/ Bevespi Aerosphere is indicated for the Availability of additional dual therapy options for the (glycopyrrolate- Anticholinergic / Beta maintenance treatment of patients with maintenance treatment of chronic obstructive pulmonary formoterol) Agonist Combinations/ chronic obstructive pulmonary disease disease. inhalation aerosol Long Acting (COPD).

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Therapeutic Category/ Product Subcategory Indication Options/Comments Preferred options on the Advanced Control Formulary include Anoro Ellipta (umeclidinium-vilanterol) and Stiolto Respimat (tiotropium-olodaterol). Bortezomib Antineoplastic Agents/ Bortezomib is indicated for: Availability of additional options for the treatment of (bortezomib) Multiple Myeloma/ • Treatment of patients with multiple multiple myeloma and mantle cell lymphoma. intravenous solution for Proteasome Inhibitors myeloma injection • Treatment of patients with mantle cell Preferred options on the Advanced Control Formulary lymphoma who have received at least 1 include Ninlaro (ixazomib) and Velcade (bortezomib). prior therapy Briviact (brivaracetam) Central Nervous Briviact oral tablet and oral solution are Availability of additional anticonvulsant options. oral tablet, oral solution System/ Anticonvulsants indicated for the treatment of partial-onset seizures in patients 4 years of age and Preferred options on the Advanced Control Formulary older. include carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, Oxtellar XR (oxcarbazepine ext-rel), Trokendi XR (topiramate ext-rel), Vimpat (lacosamide), and Xcopri (cenobamate). Briviact (brivaracetam) Central Nervous Briviact injection is indicated for the Availability of additional anticonvulsant options. intravenous solution for System/ Anticonvulsants treatment of partial-onset seizures only in injection adult patients (16 years of age and older). Preferred options on the Advanced Control Formulary include carbamazepine, carbamazepine ext-rel, divalproex sodium, divalproex sodium ext-rel, gabapentin, lamotrigine, lamotrigine ext-rel,

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Therapeutic Category/ Product Subcategory Indication Options/Comments levetiracetam, levetiracetam ext-rel, oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended, primidone, tiagabine, topiramate, valproic acid, zonisamide, Oxtellar XR (oxcarbazepine ext-rel), Trokendi XR (topiramate ext-rel), Vimpat (lacosamide), and Xcopri (cenobamate). Ciloxan (ciprofloxacin) Topical/ Ophthalmic/ Ciloxan ointment is indicated for the Availability of generic ophthalmic anti-infective options. ophthalmic ointment Anti-Infectives treatment of bacterial conjunctivitis caused by susceptible strains of the Preferred options on the Advanced Control Formulary microorganisms listed below: include ciprofloxacin, erythromycin, gentamicin, • Gram-Positive: Staphylococcus aureus, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, and Staphylococcus epidermidis, tobramycin. Streptococcus pneumoniae, Streptococcus (Viridans Group) • Gram-Negative: Haemophilus influenzae Ciloxan (ciprofloxacin) Topical/ Ophthalmic/ Ciloxan solution is indicated for the Availability of generic ophthalmic anti-infective options. ophthalmic solution Anti-Infectives treatment of infections caused by susceptible strains of the designated Preferred options on the Advanced Control Formulary microorganisms in the conditions listed include ciprofloxacin, erythromycin, gentamicin, below: levofloxacin, moxifloxacin, ofloxacin, sulfacetamide, and • Corneal Ulcers: Pseudomonas tobramycin. aeruginosa, Serratia marcescens, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Streptococcus (Viridans Group)

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments • Conjunctivitis: Haemophilus influenzae, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae Cipro HC Otic Topical/ Otic/ Anti- Cipro HC Otic is indicated for the treatment Availability of generic otic anti-infective and/or anti- (ciprofloxacin- Infective / Anti- of acute otitis externa in adult and pediatric inflammatory options. hydrocortisone) Inflammatory patients, one year and older, due to otic suspension Combinations susceptible strains of Pseudomonas Preferred options on the Advanced Control Formulary aeruginosa, Staphylococcus aureus, and include ciprofloxacin-dexamethasone and ofloxacin otic. Proteus mirabilis. Ciprodex Topical/ Otic/ Anti- Ciprodex is indicated for the treatment of Availability of generic otic anti-infective and/or anti- (ciprofloxacin- Infective / Anti- infections caused by susceptible isolates of inflammatory options. dexamethasone) Inflammatory the designated microorganisms in the otic suspension Combinations specific conditions listed below: Preferred options on the Advanced Control Formulary • Acute Otitis Media (AOM) in pediatric include ciprofloxacin-dexamethasone and ofloxacin otic. patients (age 6 months and older) with tympanostomy tubes due to Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Pseudomonas aeruginosa • Acute Otitis Externa (AOE) in pediatric (age 6 months and older), adult and elderly patients due to Staphylococcus aureus and Pseudomonas aeruginosa Daraprim Anti-Infectives/ Daraprim is indicated for the treatment of Availability of a generic option for the treatment of (pyrimethamine) Miscellaneous toxoplasmosis when used conjointly with a toxoplasmosis.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments oral tablet sulfonamide, since synergism exists with this combination. The preferred option on the Advanced Control Formulary is pyrimethamine. Daytrana Central Nervous Daytrana is indicated for the treatment of Availability of additional options for the treatment of (methylphenidate) System/ Attention Deficit Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder. transdermal patch Hyperactivity Disorder (ADHD). Preferred options on the Advanced Control Formulary include amphetamine-dextroamphetamine mixed salts ext-rel (excluding certain NDCs), dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel (excluding certain NDCs), Mydayis (amphetamine-dextroamphetamine mixed salts ext-rel), and Vyvanse (lisdexamfetamine). Depo-subQ Provera Endocrine and Depo-subQ Provera is indicated in females Availability of a generic injectable option for 104 Metabolic/ of reproductive age for: contraception and the management of endometriosis- (medroxyprogesterone Contraceptives/ • Prevention of pregnancy associated pain. acetate) Injectable • Management of endometriosis- subcutaneous associated pain The preferred option on the Advanced Control suspension for injection Formulary is medroxyprogesterone acetate 150 mg/mL. Differin Lotion Topical/ Dermatology/ Differin Lotion is indicated for the topical Availability of additional options for the topical treatment (adapalene) Acne/ Topical treatment of acne vulgaris in patients 12 of acne. topical lotion years and older. Preferred options on the Advanced Control Formulary include adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments (adapalene-benzoyl peroxide), and Onexton (clindamycin-benzoyl peroxide). Duavee (conjugated Endocrine and Duavee is indicated for treatment of the Availability of additional options for the treatment of estrogens- Metabolic/ Menopausal following conditions in women with a uterus: vasomotor symptoms associated with menopause and bazedoxifene) Symptom Agents/ Oral • Treatment of moderate to severe prevention of postmenopausal osteoporosis. oral tablet vasomotor symptoms associated with menopause Preferred options on the Advanced Control Formulary • Prevention of postmenopausal include estradiol-norethindrone, raloxifene, and Bijuva osteoporosis (estradiol-progesterone). Emend (aprepitant) Gastrointestinal/ Emend capsule is indicated in combination Availability of a generic option for the prevention of oral capsule Antiemetics with other antiemetic agents, in patients 12 chemotherapy-induced nausea and vomiting. years of age and older for prevention of: • Acute and delayed nausea and vomiting The preferred option on the Advanced Control associated with initial and repeat Formulary is aprepitant. courses of highly emetogenic cancer chemotherapy including high-dose cisplatin • Nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy Emend (aprepitant) Gastrointestinal/ Emend suspension is indicated in Availability of a generic option for the prevention of powder for oral Antiemetics combination with other antiemetic agents, in chemotherapy-induced nausea and vomiting. suspension patients 6 months of age and older for prevention of: The preferred option on the Advanced Control • Acute and delayed nausea and vomiting Formulary is aprepitant. associated with initial and repeat courses of highly emetogenic cancer

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments chemotherapy including high-dose cisplatin • Nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy Emend (fosaprepitant) Gastrointestinal/ Emend injection is indicated in adults and Availability of a generic option for the prevention of intravenous solution for Antiemetics pediatric patients 6 months of age and chemotherapy-induced nausea and vomiting. injection older, in combination with other antiemetic agents, for the prevention of: The preferred option on the Advanced Control • Acute and delayed nausea and vomiting Formulary is aprepitant. associated with initial and repeat courses of highly emetogenic cancer chemotherapy including high-dose cisplatin • Delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy Fycompa Central Nervous Fycompa is indicated for: Availability of additional anticonvulsant options. (perampanel) System/ Anticonvulsants • Treatment of partial-onset seizures with oral tablet, oral or without secondarily generalized Preferred options on the Advanced Control Formulary suspension seizures in patients with epilepsy 4 include carbamazepine, carbamazepine ext-rel, years of age and older divalproex sodium, divalproex sodium ext-rel, • Adjunctive therapy in the treatment of gabapentin, lamotrigine, lamotrigine ext-rel, primary generalized tonic-clonic levetiracetam, levetiracetam ext-rel, oxcarbazepine, seizures in patients with epilepsy 12 phenobarbital, phenytoin, phenytoin sodium extended, years of age and older primidone, tiagabine, topiramate, valproic acid,

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments zonisamide, Oxtellar XR (oxcarbazepine ext-rel), Trokendi XR (topiramate ext-rel), Vimpat (lacosamide), and Xcopri (cenobamate). Gel-One (sodium Analgesics/ Gel-One is indicated for the treatment of Availability of additional viscosupplement options for hyaluronate) Viscosupplements pain in osteoarthritis of the knee in patients osteoarthritis. intra-articular gel for who have failed to respond adequately to injection non-pharmacologic therapy, non-steroidal Preferred options on the Advanced Control Formulary anti-inflammatory drugs (NSAIDs) or simple include Durolane (sodium hyaluronate), Euflexxa analgesics (e.g., acetaminophen). (sodium hyaluronate), Gelsyn-3 (sodium hyaluronate), and Supartz FX (sodium hyaluronate). Glassia (alpha-1 Respiratory/ Alpha-1 Glassia is indicated for chronic Availability of an additional option for the treatment of proteinase inhibitor) Antitrypsin Deficiency augmentation and maintenance therapy in emphysema due to an inherited disorder known as intravenous solution for Agents adults with clinically evident emphysema alpha1-antitrypsin deficiency. injection due to severe hereditary deficiency of alpha1-antitrypsin inhibitor. The preferred option on the Advanced Control Formulary is Prolastin-C (alpha-1 proteinase inhibitor). GoLYTELY (peg 3350- Gastrointestinal/ GoLYTELY is indicated for cleansing of the Availability of additional options for colon cleansing prior electrolytes) Laxatives colon in preparation for colonoscopy and to a colonoscopy. powder for oral solution barium enema X-ray examination in adults. Preferred options on the Advanced Control Formulary include peg 3350-electrolytes and Clenpiq (sodium picosulfate-magnesium oxide-citric acid). Humatrope Endocrine and Humatrope is indicated for: Availability of an additional option for the treatment of (somatropin) Metabolic/ Human • Pediatric: growth failure due to growth hormone deficiency. subcutaneous solution Growth Hormones inadequate secretion of endogenous for injection growth hormone (GH); short stature The preferred option on the Advanced Control associated with Turner syndrome; Formulary is Norditropin (somatropin).

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Idiopathic Short Stature, height standard deviation score <-2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range; short stature or growth failure in short stature homeobox- containing gene deficiency; short stature born small for gestational age with no catch-up growth by 2 years to 4 years of age • Adult: replacement of endogenous GH in adults with GH deficiency Incruse Ellipta Respiratory/ Incruse Ellipta is indicated for the Availability of additional long-acting anticholinergic (umeclidinium bromide) Anticholinergics maintenance treatment of patients with options for the maintenance treatment of chronic oral inhalation powder chronic obstructive pulmonary disease obstructive pulmonary disease. (COPD). Preferred options on the Advanced Control Formulary include Spiriva (tiotropium) and Yupelri (revefenacin inhalation solution). Intrarosa (prasterone) Endocrine and Intrarosa is indicated for the treatment of Availability of additional vaginal options for the treatment vaginal insert Metabolic/ Menopausal moderate to severe dyspareunia, a of dyspareunia. Symptom Agents/ symptom of vulvar and vaginal atrophy, due Vaginal to menopause. Preferred options on the Advanced Control Formulary include estradiol and Imvexxy (estradiol). Invega Sustenna Central Nervous Invega Sustenna is indicated for: Availability of additional long-acting injectable (paliperidone palmitate System/ Antipsychotics/ • Treatment of schizophrenia in adults antipsychotic options. ext-rel) Atypicals

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments intramuscular • Treatment of schizoaffective disorder in Preferred options on the Advanced Control Formulary extended-release adults as monotherapy and as an include Abilify Maintena (aripiprazole ext-rel injection) suspension for injection adjunct to mood stabilizers or and Perseris (risperidone ext-rel injection). antidepressants Kyprolis (carfilzomib) Antineoplastic Agents/ Kyprolis is indicated: Availability of additional options for the treatment of intravenous solution for Multiple Myeloma/ • In combination with dexamethasone or relapsed or refractory multiple myeloma. injection Proteasome Inhibitors with lenalidomide plus dexamethasone for the treatment of patients with Preferred options on the Advanced Control Formulary relapsed or refractory multiple myeloma include Ninlaro (ixazomib) and Velcade (bortezomib). who have received one to three lines of therapy • As a single agent for the treatment of patients with relapsed or refractory multiple myeloma who have received one or more lines of therapy Lacrisert Topical/ Ophthalmic/ Lacrisert is indicated in: Availability of an additional option for the treatment of (hydroxypropyl Artificial Tears • Moderate to severe dry eye syndromes, dry eye. cellulose) including keratoconjunctivitis ophthalmic insert sicca (especially in patients who remain The preferred option on the Advanced Control symptomatic after an adequate trial of Formulary is Xiidra (lifitegrast). artificial tear solutions) • Exposure keratitis • Decreased corneal sensitivity • Recurrent corneal erosions Maxidex Topical/ Ophthalmic/ Maxidex is indicated for steroid responsive Availability of additional ophthalmic anti-inflammatory (dexamethasone) Anti-Inflammatories/ inflammatory conditions of the palpebral options. ophthalmic suspension Steroidal and bulbar conjunctiva, cornea, and anterior

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments segment of the globe such as allergic Preferred options on the Advanced Control Formulary conjunctivitis, acne rosacea, superficial include dexamethasone, loteprednol, prednisolone punctate keratitis, herpes zoster keratitis, acetate 1%, Flarex (fluorometholone acetate), and FML iritis, cyclitis, selected infective S.O.P. (fluorometholone). conjunctivitides when the inherent hazard of steroid use is accepted to obtain an advisable diminution in edema and inflammation; corneal injury from chemical, radiation, or thermal burns, or penetration of foreign bodies. Mirvaso (brimonidine) Topical/ Dermatology/ Mirvaso is indicated for the topical treatment Availability of additional topical options for the treatment topical gel Rosacea of persistent (nontransient) facial erythema of rosacea. of rosacea in adults 18 years of age or older. Preferred option on the Advanced Control Formulary include azelaic acid gel, metronidazole, and Finacea Foam (azelaic acid). Neulasta, Neulasta Hematologic/ Neulasta and Neulasta Onpro are indicated Availability of an additional long-acting colony- Onpro (pegfilgrastim) Hematopoietic Growth to: stimulating factor option for those who are receiving subcutaneous solution Factors • Decrease the incidence of infection, as myelosuppressive anti-cancer therapy. for injection manifested by febrile neutropenia, in patients with non-myeloid malignancies The preferred option on the Advanced Control receiving myelosuppressive anti-cancer Formulary is Ziextenzo (pegfilgrastim-bmez). drugs associated with a clinically significant incidence of febrile neutropenia • Increase survival in patients acutely exposed to myelosuppressive doses of

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments radiation (Hematopoietic Subsyndrome of Acute Radiation Syndrome) NuvaRing (ethinyl Endocrine and NuvaRing is indicated for use by women to Availability of additional vaginal contraceptive options. estradiol-etonogestrel) Metabolic/ prevent pregnancy. vaginal ring Contraceptives/ Vaginal Preferred options on the Advanced Control Formulary include ethinyl estradiol-etonogestrel and Annovera (segesterone acetate-ethinyl estradiol). Osphena (ospemifene) Endocrine and Osphena is indicated for: Availability of a generic oral estrogen option. oral tablet Metabolic/ Menopausal • Treatment of moderate to severe Symptom Agents/ Oral dyspareunia, a symptom of vulvar and The preferred option on the Advanced Control vaginal atrophy, due to menopause Formulary is estradiol. • Treatment of moderate to severe vaginal dryness, a symptom of vulvar and vaginal atrophy, due to menopause Premarin (estrogens, Endocrine and Premarin is indicated for: Availability of a generic oral estrogen option. conjugated) Metabolic/ Menopausal • Treatment of moderate to severe oral tablet Symptom Agents/ Oral vasomotor symptoms due to The preferred option on the Advanced Control menopause Formulary is estradiol. • Treatment of moderate to severe vulvar and vaginal atrophy due to menopause • Treatment of hypoestrogenism due to hypogonadism, castration or primary ovarian failure • Treatment of breast cancer (for palliation inly) in appropriately-selected women and men with metastatic disease

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments • Treatment of advanced androgen- dependent carcinoma of the prostate (for palliation only)Prevention of postmenopausal osteoporosis Premarin Cream Endocrine and Premarin Cream is indicated for: Availability of additional vaginal estrogen options for the (estrogens, conjugated) Metabolic/ Menopausal • Treatment of atrophic vaginitis and treatment of dyspareunia. vaginal cream Symptom Agents/ kraurosis vulvae Vaginal • Treatment of moderate to severe Preferred options on the Advanced Control Formulary dyspareunia, a symptom of vulvar and include estradiol and Imvexxy (estradiol). vaginal atrophy, due to menopause Premphase Endocrine and Premphase is indicated in a woman with a Availability of additional oral estrogen/progestin options. (estrogens, conjugated- Metabolic/ Menopausal uterus for: medroxyprogesterone Symptom Agents/ Oral • Treatment of moderate to severe Preferred options on the Advanced Control Formulary acetate) vasomotor symptoms due to include estradiol-norethindrone and Bijuva (estradiol- oral tablet menopause progesterone). • Treatment of moderate to severe vulvar and vaginal atrophy due to menopause • Prevention of postmenopausal osteoporosis Prempro (estrogens, Endocrine and Prempro is indicated in a woman with a Availability of additional oral estrogen/progestin options. conjugated- Metabolic/ Menopausal uterus for: medroxyprogesterone Symptom Agents/ Oral • Treatment of moderate to severe Preferred options on the Advanced Control Formulary acetate) vasomotor symptoms due to include estradiol-norethindrone and Bijuva (estradiol- oral tablet menopause progesterone). • Treatment of moderate to severe vulvar and vaginal atrophy due to menopause

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments • Prevention of postmenopausal osteoporosis Prolensa (bromfenac) Topical/ Ophthalmic/ Prolensa is indicated for the treatment of Availability of generic ophthalmic anti-inflammatory ophthalmic solution Anti-Inflammatories/ postoperative inflammation and reduction of options. Nonsteroidal ocular pain in patients who have undergone cataract surgery. Preferred options on the Advanced Control Formulary include bromfenac, diclofenac, and ketorolac. Provad (bacillus Gastrointestinal/ Provad is a probiotic formulation for the Availability of additional probiotic supplementation subtilis) Probiotics clinical dietary management of suboptimal options. oral capsule nutritional status in patients where advanced supplementation is required and Consult doctor for preferred options on the Advanced nutritional supplementation in Control Formulary. physiologically stressful conditions for maintenance of good health is needed. Relistor Gastrointestinal/ Opioid- Relistor tablet is indicated for the treatment Availability of additional options for the treatment of (methylnaltrexone) Induced Constipation of opioid-induced constipation (OIC) in opioid-induced constipation. oral tablet adults with chronic non-cancer pain, including patients with chronic pain related Preferred options on the Advanced Control Formulary to prior cancer or its treatment who do not include Movantik (naloxegol) and Symproic require frequent (e.g., weekly) opioid (naldemedine). dosage escalation. Relistor Gastrointestinal/ Opioid- Relistor injection is indicated for Availability of additional options for the treatment of (methylnaltrexone) Induced Constipation • Treatment of opioid-induced opioid-induced constipation. subcutaneous solution constipation (OIC) in adults with chronic for injection non-cancer pain, including patients with Preferred options on the Advanced Control Formulary chronic pain related to prior cancer or include Movantik (naloxegol) and Symproic its treatment who do not require (naldemedine).

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments frequent (e.g., weekly) opioid dosage escalation • Treatment of OIC in adults with advanced illness or pain caused by active cancer who require opioid dosage escalation for palliative care Rexulti (brexpiprazole) Central Nervous Rexulti is indicated for: Availability of additional oral antipsychotic options. oral tablet System/ Antipsychotics/ • Use as an adjunctive therapy to Atypicals antidepressants for the treatment of Preferred options on the Advanced Control Formulary major depressive disorder (MDD) include aripiprazole, clozapine, olanzapine, quetiapine, • Treatment of schizophrenia quetiapine ext-rel, risperidone, ziprasidone, Latuda (lurasidone), Saphris (asenapine), and Vraylar (cariprazine). Rhofade Topical/ Dermatology/ Rhofade is indicated for the topical Availability of additional topical options for the treatment (oxymetazoline) Rosacea treatment of persistent facial erythema of rosacea. topical cream associated with rosacea in adults. Preferred options on the Advanced Control Formulary include azelaic acid gel, metronidazole, and Finacea Foam (azelaic acid). Risperdal CONSTA Central Nervous Risperdal CONSTA is indicated: Availability of additional long-acting injectable (risperidone System/ Antipsychotics/ • For the treatment of schizophrenia antipsychotic options. microspheres) Atypicals • As monotherapy or as adjunctive intramuscular therapy to lithium or valproate for the Preferred options on the Advanced Control Formulary extended-release maintenance treatment of Bipolar I include Abilify Maintena (aripiprazole ext-rel injection) suspension for injection Disorder and Perseris (risperidone ext-rel injection). Signifor LAR Endocrine and Signifor LAR is indicated for the treatment Availability of an additional option for the treatment of (pasireotide) Metabolic/ Acromegaly of: acromegaly.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments intramuscular • Patients with acromegaly who have had suspension for injection an inadequate response to surgery The preferred option on the Advanced Control and/or for whom surgery is not an Formulary is Somatuline Depot (lanreotide acetate). option • Patients with Cushing’s disease for whom pituitary surgery is not an option or has not been curative Somavert Endocrine and Somavert is indicated for the treatment of Availability of an additional option for the treatment of (pegvisomant) Metabolic/ Acromegaly acromegaly in patients who have had an acromegaly. subcutaneous solution inadequate response to surgery or radiation for injection therapy, or for whom these therapies are The preferred option on the Advanced Control not appropriate. Formulary is Somatuline Depot (lanreotide acetate). Soolantra (ivermectin) Topical/ Dermatology/ Soolantra is indicated for the treatment of Availability of additional topical options for the treatment topical cream Rosacea inflammatory lesions of rosacea. of rosacea.

Preferred options on the Advanced Control Formulary include azelaic acid gel, metronidazole, and Finacea Foam (azelaic acid). Suprep (sodium Gastrointestinal/ Suprep is indicated for cleansing of the Availability of additional options for colon cleansing prior sulfate-potassium Laxatives colon in preparation for colonoscopy in adult to a colonoscopy. sulfate-magnesium and pediatric patients 12 years of age and sulfate) older. Preferred options on the Advanced Control Formulary oral solution include peg 3350-electrolytes and Clenpiq (sodium picosulfate-magnesium oxide-citric acid). Tazorac (tazarotene) Topical/ Dermatology/ Tazorac cream 0.05% and 0.1% are Availability of additional options for the topical treatment topical cream Acne/ Topical indicated for: of acne. • Topical treatment of plaque psoriasis

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Preferred options on the Advanced Control Formulary Tazorac cream 0.1% is indicated for: include adapalene, benzoyl peroxide, clindamycin gel • Topical treatment of acne vulgaris (except NDC 68682046275), clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo (adapalene-benzoyl peroxide), and Onexton (clindamycin-benzoyl peroxide).

Availability of generic options for the topical treatment of plaque psoriasis.

Preferred options on the Advanced Control Formulary include calcipotriene ointment and calcipotriene solution. Tazorac (tazarotene) Topical/ Dermatology/ Tazorac gel 0.05% and 0.1% are indicated Availability of additional options for the topical treatment topical gel Acne/ Topical for: of acne. • Topical treatment of plaque psoriasis of up to 20% body surface area Preferred options on the Advanced Control Formulary involvement include adapalene, benzoyl peroxide, clindamycin gel (except NDC 68682046275), clindamycin solution, Tazorac gel 0.1% is indicated for: clindamycin-benzoyl peroxide, erythromycin solution, • Topical treatment of mild to moderate erythromycin-benzoyl peroxide, tretinoin, Epiduo facial acne vulgaris (adapalene-benzoyl peroxide), and Onexton (clindamycin-benzoyl peroxide).

Availability of generic options for the topical treatment of plaque psoriasis.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Preferred options on the Advanced Control Formulary include calcipotriene ointment and calcipotriene solution. Tecfidera (dimethyl Central Nervous Tecfidera is indicated for the treatment of Availability of additional options for the treatment of fumarate delayed-rel) System/ Multiple relapsing forms of multiple sclerosis, to relapsing forms of multiple sclerosis. oral delayed-release Sclerosis Agents include clinically isolated syndrome, capsule relapsing-remitting disease, and active Preferred options on the Advanced Control Formulary secondary progressive disease, in adults. include dimethyl fumarate delayed-rel, glatiramer, Aubagio (teriflunomide), Betaseron (interferon beta-1b), Copaxone (glatiramer), Gilenya (fingolimod), Kesimpta (ofatumumab), Mayzent (siponimod), Ocrevus (ocrelizumab), Rebif (interferon beta-1a), Tysabri (natalizumab), Vumerity (diroximel fumarate delayed- rel), and Zeposia (ozanimod). TobraDex (tobramycin- Topical/ Ophthalmic/ TobraDex is indicated for steroid-responsive Availability of a generic ophthalmic anti-infective and dexamethasone) Anti-Infective / Anti- inflammatory ocular conditions for which a anti-inflammatory option. ophthalmic ointment, Inflammatory corticosteroid is indicated and where ophthalmic suspension Combinations superficial bacterial ocular infection or a risk The preferred option on the Advanced Control of bacterial ocular infection exists. Formulary is tobramycin-dexamethasone. TobraDex ST Topical/ Ophthalmic/ TobraDex ST is indicated for steroid- Availability of a generic ophthalmic anti-infective and (tobramycin- Anti-Infective / Anti- responsive inflammatory ocular conditions anti-inflammatory option. dexamethasone) Inflammatory for which a corticosteroid is indicated and ophthalmic suspension Combinations where superficial bacterial ocular infection The preferred option on the Advanced Control or a risk of bacterial ocular infection exists. Formulary is tobramycin-dexamethasone. Tracleer (bosentan) Cardiovascular/ Tracleer is indicated for the treatment of Availability of additional options for the treatment of oral tablet, oral soluble Pulmonary Arterial pulmonary arterial hypertension (PAH) pulmonary arterial hypertension. tablet Hypertension/ (World Health Organization Group 1):

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Endothelin Receptor • In adults to improve exercise ability and Preferred options on the Advanced Control Formulary Antagonists to decrease clinical worsening include ambrisentan, bosentan, and Opsumit • In pediatric patients aged 3 years and (macitentan). older with idiopathic or congenital PAH to improve pulmonary vascular resistance, which is expected to result in an improvement in exercise ability Trulance (plecanatide) Gastrointestinal/ Irritable Trulance is indicated in adults for the Availability of an additional option for the treatment of oral tablet Bowel Syndrome treatment of: chronic idiopathic constipation and irritable bowel • Chronic idiopathic constipation (CIC) syndrome with constipation. • Irritable bowel syndrome with constipation (IBS-C) The preferred option on the Advanced Control Formulary is Linzess (linaclotide). Udenyca Hematologic/ Udenyca is indicated to decrease the Availability of an additional long-acting colony- (pegfilgrastim-cbqv) Hematopoietic Growth incidence of infection, as manifested by stimulating factor option for those who are receiving subcutaneous solution Factors febrile neutropenia, in patients with non- myelosuppressive anti-cancer therapy. for injection myeloid malignancies receiving myelosuppressive anti-cancer drugs The preferred option on the Advanced Control associated with a clinically significant Formulary is Ziextenzo (pegfilgrastim-bmez). incidence of febrile neutropenia. Varubi (rolapitant) Gastrointestinal/ Varubi is indicated in combination with other Availability of a generic option for the prevention of oral tablet Antiemetics antiemetic agents in adults for the chemotherapy-induced nausea and vomiting. prevention of delayed nausea and vomiting associated with initial and repeat courses of The preferred option on the Advanced Control emetogenic cancer chemotherapy, Formulary is aprepitant. including, but not limited to, highly emetogenic chemotherapy.

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Versacloz (clozapine) Central Nervous Versacloz is indicated for: Availability of a generic oral antipsychotic option for oral suspension System/ Antipsychotics/ • Treatment-resistant schizophrenia treatment-resistant schizophrenia. Atypicals • Reducing suicidal behavior in patients with schizophrenia or schizoaffective The preferred option on the Advanced Control disorder Formulary is clozapine. Viibryd (vilazodone) Central Nervous Viibryd is indicated for the treatment of Availability of additional selective serotonin reuptake oral tablet, oral starter System/ major depressive disorder (MDD) in adults. inhibitor options. kit Antidepressants/ Selective Serotonin Preferred options on the Advanced Control Formulary Reuptake Inhibitors include citalopram, escitalopram, fluoxetine (except (SSRIs) fluoxetine tablet 60 mg and generics for Sarafem), paroxetine HCl, paroxetine HCl ext-rel, sertraline, and Trintellix (vortioxetine). Visco-3 (sodium Analgesics/ Visco-3 is indicated for the treatment of pain Availability of additional viscosupplement options for hyaluronate) Viscosupplements in osteoarthritis of the knee in patients who osteoarthritis. intra-articular solution have failed to respond adequately to for injection conservative non-pharmacologic therapy Preferred options on the Advanced Control Formulary and simple analgesics (e.g., include Durolane (sodium hyaluronate), Euflexxa acetaminophen). (sodium hyaluronate), Gelsyn-3 (sodium hyaluronate), and Supartz FX (sodium hyaluronate). Zalvit (multivitamin Nutritional/Supplements/ Zalvit is used: Availability of additional prenatal vitamin options. with iron) Vitamins and Minerals/ • Throughout pregnancy, during the oral tablet Prenatal Vitamins postnatal period for both lactating and Preferred options on the Advanced Control formulary non-lactating mothers, and throughout include prenatal vitamins and Citranatal (prenatal the childbearing years vitamins with folic acid). • For improving the nutritional status of women prior to conception

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments Zelac (lactobacillus Gastrointestinal/ Zelac is a probiotic formulation for the Availability of additional probiotic supplementation acidophilus and Probiotics clinical dietary management of suboptimal options. bifidobacterium nutritional status in patients where animalis lactis) advanced supplementation is required and Consult doctor for preferred options on the Advanced oral capsule nutritional supplementation in Control Formulary. physiologically stressful conditions for maintenance of good health is needed. Zirgan (ganciclovir) Topical/ Ophthalmic/ Zirgan is indicated for the treatment of acute Availability of a generic ophthalmic antiviral option. ophthalmic gel Antivirals herpetic keratitis (dendritic ulcers). The preferred option on the Advanced Control Formulary is trifluridine. Generic Agents: calcipotriene- Topical/ Dermatology/ Calcipotriene-betamethasone ointment is Availability of additional topical options for the treatment betamethasone Antipsoriatics indicated for the topical treatment of plaque of plaque psoriasis. topical ointment psoriasis in patients 12 years of age and older. Preferred options on the Advanced Control Formulary include calcipotriene ointment or solution WITH desoximetasone, fluocinonide (except fluocinonide cream 0.1%), or Bryhali (halobetasol propionate); Duobrii (halobetasol propionate-tazarotene), Enstilar (calcipotriene-betamethasone dipropionate), or Taclonex (calcipotriene-betamethasone dipropionate). calcipotriene- Topical/ Dermatology/ Calcipotriene-betamethasone suspension is Availability of additional topical options for the treatment betamethasone Antipsoriatics indicated for the topical treatment of plaque of plaque psoriasis. topical suspension psoriasis of the scalp in patients 12 years and older and plaque psoriasis of the scalp Preferred options on the Advanced Control Formulary include calcipotriene ointment or solution WITH

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments and body in patients age 18 years and desoximetasone, fluocinonide (except fluocinonide older. cream 0.1%), or Bryhali (halobetasol propionate); Duobrii (halobetasol propionate-tazarotene), Enstilar (calcipotriene-betamethasone dipropionate), or Taclonex (calcipotriene-betamethasone dipropionate). doxycycline Topical/ Dermatology/ Doxycycline monohydrate delayed-rel is Availability of an additional oral option for the treatment monohydrate Rosacea indicated for the treatment of only of rosacea. delayed-rel capsule inflammatory lesions (papules and pustules) oral delayed-release of rosacea in adult patients. The preferred option on the Advanced Control capsule Formulary is Oracea (doxycycline monohydrate delayed-rel). isosorbide dinitrate Cardiovascular/ Nitrates/ Isosorbide dinitrate is indicated for the Availability of additional generic oral nitrate options. 40 mg Oral prevention of angina pectoris due to oral tablet coronary artery disease. Preferred options on the Advanced Control Formulary include isosorbide dinitrate (except isosorbide dinitrate 40 mg) and isosorbide mononitrate. metaxalone 400 mg Central Nervous Metaxalone is indicated as an adjunct to Availability of additional generic options for the oral tablet System/ Musculoskeletal rest, physical therapy, and other measures treatment of pain associated with acute musculoskeletal Therapy Agents for the relief of discomforts associated with disorders. acute, painful musculoskeletal conditions. Preferred options on the Advanced Control Formulary include carisoprodol, chlorzoxazone 500 mg (except NDC 73007001303), cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, and methocarbamol (except NDCs 69036091010, 69036093090, 70868090190).

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

Therapeutic Category/ Product Subcategory Indication Options/Comments methocarbamol (NDC Central Nervous Methocarbamol is indicated as an adjunct to Availability of additional generic options for the 69036091010 only) System/ Musculoskeletal rest, physical therapy, and other measures treatment of pain associated with acute musculoskeletal oral tablet Therapy Agents for the relief of discomfort associated with disorders. acute, painful musculoskeletal conditions. Preferred options on the Advanced Control Formulary include carisoprodol, chlorzoxazone 500 mg (except NDC 73007001303), cyclobenzaprine (except cyclobenzaprine tablet 7.5 mg), metaxalone 800 mg, and methocarbamol (except NDCs 69036091010, 69036093090, 70868090190). oxymorphone ext-rel Analgesics/ Opioid Oxymorphone ext-rel is indicated for the Availability of additional long-acting options for pain oral extended-release Analgesics management of pain severe enough to management. tablet require daily, around-the-clock, long-term opioid treatment and for which alternative Preferred options on the Advanced Control Formulary treatment options are inadequate. include fentanyl transdermal, hydrocodone ext-rel, methadone, morphine ext-rel, Nucynta ER (tapentadol ext-rel), and Xtampza ER (oxycodone ext-rel).

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Advanced Control Formulary™ Change Summary Report Effective 01-01-2021

OTHER: Therapeutic Category/ Product Subcategory Indication Options/Comments Tremfya (guselkumab) Immunologic Agents/ Tremfya is indicated for the treatment of Now excluded for psoriatic arthritis. subcutaneous solution Autoimmune Agents/ adult patients with: for injection Psoriatic Arthritis • Moderate-to-severe plaque psoriasis Preferred options on the Advanced Control Formulary who are candidates for systemic include Cosentyx (secukinumab), Enbrel (etanercept), therapy or phototherapy Humira (adalimumab), and Otezla (apremilast). • Active psoriatic arthritis Note: Tremfya remains preferred for psoriasis.

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