October 2021 Preferred Drug List The Preferred Drug List, administered by CVS Caremark® on behalf of Siemens, 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 not covered without a prior authorization for medical covered upon release to the market. necessity. • The member's prescription benefit plan may have a different • For specific information regarding your prescription benefit copay for specific products on the list. coverage and copay1 information, please visit Caremark.com • Unless specifically indicated, drug list products will include all or contact a CVS Caremark Customer Care representative dosage forms. at 1-866-478-5802. • 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 fentanyl transdermal SUPRAX itraconazole fentanyl transmucosal terbinafine tablet ANTINEOPLASTIC § ERYTHROMYCINS / § COX-2 INHIBITORS lozenge AGENTS MACROLIDES ANTIVIRALS celecoxib hydrocodone ext-rel HORMONAL hydrocodone-acetaminophen azithromycin § CYTOMEGALOVIRUS § GOUT ANTINEOPLASTIC AGENTS hydromorphone clarithromycin AGENTS § ANTIANDROGENS allopurinol hydromorphone ext-rel clarithromycin ext-rel valganciclovir colchicine tablet methadone erythromycins bicalutamide probenecid morphine DIFICID § HERPES AGENTS CARDIOVASCULAR MITIGARE morphine ext-rel acyclovir capsule, tablet § FLUOROQUINOLONES morphine suppository valacyclovir § ACE INHIBITORS § NSAIDs oxycodone ciprofloxacin diclofenac sodium § INFLUENZA AGENTS fosinopril oxycodone-acetaminophen levofloxacin ibuprofen lisinopril tramadol (except NDC^ 52817019610) moxifloxacin oseltamivir meloxicam tablet quinapril tramadol ext-rel tablet RELENZA naproxen (except naproxen CR or § PENICILLINS ramipril BELBUCA naproxen suspension) amoxicillin § MISCELLANEOUS NUCYNTA § ACE INHIBITOR / amoxicillin-clavulanate clindamycin § NSAIDs, COMBINATIONS NUCYNTA ER DIURETIC COMBINATIONS dicloxacillin ivermectin SUBSYS fosinopril-hydrochlorothiazide diclofenac sodium- penicillin VK linezolid XTAMPZA ER lisinopril-hydrochlorothiazide misoprostol metronidazole § TETRACYCLINES quinapril-hydrochlorothiazide ANTI-INFECTIVES nitrofurantoin (except NDC^ § NSAIDs, TOPICAL doxycycline hyclate 20 mg 70408023932) § ANGIOTENSIN II diclofenac sodium gel 1% ANTIBACTERIALS doxycycline hyclate capsule pyrimethamine RECEPTOR ANTAGONISTS / diclofenac sodium solution § CEPHALOSPORINS minocycline sulfamethoxazole- DIURETIC COMBINATIONS tetracycline cefdinir trimethoprim § OPIOID ANALGESICS candesartan / candesartan- cefprozil vancomycin capsule buprenorphine transdermal § ANTIFUNGALS hydrochlorothiazide cefuroxime axetil EMVERM codeine-acetaminophen fluconazole irbesartan / irbesartan- cephalexin XIFAXAN 550 MG 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. hydrochlorothiazide lorazepam § MISCELLANEOUS MIGRAINE § BETA-BLOCKERS losartan / losartan- oxazepam AGENTS ACUTE MIGRAINE AGENTS atenolol hydrochlorothiazide bupropion § Triptans carvedilol § ANTICONVULSANTS olmesartan / olmesartan- bupropion ext-rel (except carvedilol phosphate ext-rel carbamazepine eletriptan hydrochlorothiazide bupropion ext-rel tablet 450 mg) metoprolol succinate ext-rel carbamazepine ext-rel naratriptan telmisartan / telmisartan- mirtazapine metoprolol tartrate clobazam rizatriptan hydrochlorothiazide trazodone sumatriptan valsartan / valsartan- nadolol diazepam rectal gel zolmitriptan hydrochlorothiazide pindolol divalproex sodium § ANTIPARKINSONIAN propranolol divalproex sodium ext-rel AGENTS ONZETRA XSAIL § ANGIOTENSIN II ZEMBRACE SYMTOUCH propranolol ext-rel ethosuximide amantadine RECEPTOR ANTAGONIST / ZOMIG NASAL SPRAY BYSTOLIC gabapentin carbidopa-levodopa CALCIUM CHANNEL lamotrigine carbidopa-levodopa ext-rel § CALCIUM CHANNEL Miscellaneous BLOCKER COMBINATIONS lamotrigine ext-rel carbidopa-levodopa- BLOCKERS NURTEC ODT amlodipine-olmesartan levetiracetam entacapone amlodipine REYVOW amlodipine-telmisartan levetiracetam ext-rel entacapone UBRELVY diltiazem ext-rel (except generics amlodipine-valsartan oxcarbazepine pramipexole for CARDIZEM LA) phenobarbital pramipexole ext-rel PREVENTIVE MIGRAINE § ANGIOTENSIN II nifedipine ext-rel phenytoin rasagiline AGENTS RECEPTOR ANTAGONIST / verapamil ext-rel phenytoin sodium extended ropinirole CALCIUM CHANNEL Monoclonal Antibodies primidone ropinirole ext-rel BLOCKER / DIURETIC § CALCIUM CHANNEL AIMOVIG rufinamide selegiline COMBINATIONS BLOCKER / ANTILIPEMIC AJOVY tiagabine NEUPRO COMBINATIONS EMGALITY amlodipine-valsartan- topiramate hydrochlorothiazide amlodipine-atorvastatin valproic acid ANTIPSYCHOTICS § MUSCULOSKELETAL olmesartan-amlodipine- § DIGITALIS GLYCOSIDES zonisamide § ATYPICALS THERAPY AGENTS hydrochlorothiazide FYCOMPA aripiprazole digoxin cyclobenzaprine (except NAYZILAM § ANTIARRHYTHMICS clozapine cyclobenzaprine tablet 7.5 mg) § DIRECT RENIN OXTELLAR XR olanzapine disopyramide INHIBITORS / DIURETIC TROKENDI XR quetiapine § NARCOLEPSY sotalol VALTOCO COMBINATIONS quetiapine ext-rel armodafinil MULTAQ VIMPAT aliskiren risperidone modafinil XCOPRI ziprasidone SUNOSI ANTILIPEMICS TEKTURNA HCT ACL INHIBITORS / § ANTIDEMENTIA ABILIFY MAINTENA § DIURETICS LATUDA POSTHERPETIC COMBINATIONS donepezil amiloride PERSERIS NEURALGIA (PHN) NEXLETOL galantamine furosemide VRAYLAR GRALISE NEXLIZET galantamine ext-rel hydrochlorothiazide memantine § ATTENTION DEFICIT PSYCHOTHERAPEUTIC - § BILE ACID RESINS metolazone rivastigmine spironolactone- HYPERACTIVITY DISORDER MISCELLANEOUS cholestyramine rivastigmine transdermal hydrochlorothiazide amphetamine- § OPIOID ANTAGONISTS colesevelam NAMZARIC dextroamphetamine mixed torsemide naloxone injection § CHOLESTEROL triamterene ANTIDEPRESSANTS salts NARCAN NASAL SPRAY ABSORPTION INHIBITORS triamterene- amphetamine- § SELECTIVE SEROTONIN dextroamphetamine mixed § PARTIAL OPIOID AGONIST ezetimibe hydrochlorothiazide REUPTAKE INHIBITORS salts ext-rel † / OPIOID ANTAGONIST (SSRIs) § FIBRATES HEART FAILURE atomoxetine COMBINATIONS citalopram fenofibrate (except fenofibrate capsule BIDIL dexmethylphenidate ext-rel buprenorphine-naloxone escitalopram 50 mg, 130 mg; fenofibrate tablet 40 mg, CORLANOR guanfacine ext-rel sublingual fluoxetine (except fluoxetine tablet 60 120 mg) ENTRESTO methylphenidate ZUBSOLV mg, fluoxetine tablet [generics for † fenofibric acid delayed-rel methylphenidate ext-rel § NITRATES SARAFEM]) MYDAYIS PSEUDOBULBAR AFFECT § HMG-CoA REDUCTASE isosorbide dinitrate (except paroxetine HCl VYVANSE AGENTS INHIBITORS / isosorbide dinitrate 40 mg) paroxetine HCl ext-rel (except NUEDEXTA COMBINATIONS isosorbide mononitrate NDC^ 60505367503) § FIBROMYALGIA ENDOCRINE AND atorvastatin nitroglycerin lingual spray sertraline pregabalin METABOLIC ezetimibe-simvastatin nitroglycerin sublingual TRINTELLIX HYPNOTICS fluvastatin § MISCELLANEOUS § SEROTONIN § NONBENZODIAZEPINES § ANDROGENS lovastatin ranolazine ext-rel NOREPINEPHRINE testosterone gel (except authorized pravastatin eszopiclone REUPTAKE INHIBITORS generics for TESTIM and VOGELXO) rosuvastatin ramelteon CENTRAL NERVOUS (SNRIs) testosterone solution simvastatin zolpidem ANDRODERM SYSTEM desvenlafaxine ext-rel zolpidem ext-rel NATESTO § NIACINS duloxetine ANTIANXIETY BELSOMRA venlafaxine niacin ext-rel ANTIDIABETICS § BENZODIAZEPINES venlafaxine ext-rel capsule § TRICYCLICS AMYLIN ANALOGS § OMEGA-3 FATTY ACIDS alprazolam doxepin omega-3 acid ethyl esters clonazepam