January 2021 Updated 11/01/2020 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 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 • The member's prescription benefit plan design may alter coverage this document. Products recently approved by the U.S. Food and of certain products or vary copay1 amounts based on the condition Drug Administration (FDA) may not be covered upon release being treated. to the market. • This drug list represents a summary of prescription coverage. It is • Your prescription benefit plan design may alter coverage of certain not all-inclusive and does not guarantee coverage. The member’s products or vary copay1 amounts based on the condition being specific prescription benefit plan design may not cover certain treated. products or categories, regardless of their appearance in this • You may be responsible for the full cost of non-formulary products document. Products recently approved by the FDA may not be that are removed from coverage. covered upon release to the market. • For specific information regarding your prescription benefit • The member's prescription benefit plan may have a different coverage and copay1 information, please visit Caremark.com copay1 for specific products on the list. or contact a CVS Caremark Customer Care representative. • Unless specifically indicated, drug list products will include all • CVS Caremark may contact your doctor after receiving your dosage forms. prescription to request consideration of a drug list product or • Log in to Caremark.com to check coverage and copay1 generic equivalent. This may result in your doctor prescribing, information for a specific medicine. when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. • In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. ANALGESICS § OPIOID ANALGESICS VISCOSUPPLEMENTS § FLUOROQUINOLONES ANTIRETROVIRAL AGENTS buprenorphine transdermal DUROLANE ciprofloxacin § ANTIRETROVIRAL § NSAIDs codeine-acetaminophen EUFLEXXA levofloxacin COMBINATIONS diclofenac sodium fentanyl transdermal GELSYN-3 moxifloxacin abacavir-lamivudine ibuprofen fentanyl transmucosal SUPARTZ FX ATRIPLA meloxicam § PENICILLINS lozenge BIKTARVY naproxen (except naproxen CR or ANTI-INFECTIVES amoxicillin hydrocodone ext-rel CIMDUO naproxen suspension) hydrocodone-acetaminophen amoxicillin-clavulanate ANTIBACTERIALS COMPLERA dicloxacillin § NSAIDs, COMBINATIONS hydromorphone DESCOVY § CEPHALOSPORINS penicillin VK hydromorphone ext-rel DOVATO diclofenac sodium- cefdinir methadone EVOTAZ misoprostol § TETRACYCLINES cefprozil morphine GENVOYA cefuroxime axetil doxycycline hyclate 20 mg § NSAIDs, TOPICAL morphine ext-rel ODEFSEY morphine suppository cephalexin doxycycline hyclate capsule diclofenac sodium gel 1% PREZCOBIX SUPRAX minocycline oxycodone diclofenac sodium solution STRIBILD oxycodone-acetaminophen tetracycline § ERYTHROMYCINS / SYMFI tramadol (except NDC^ 52817019610) § COX-2 INHIBITORS MACROLIDES § ANTIFUNGALS SYMFI LO celecoxib tramadol ext-rel SYMTUZA azithromycin fluconazole BELBUCA TEMIXYS clarithromycin itraconazole § GOUT NUCYNTA TRIUMEQ terbinafine tablet clarithromycin ext-rel allopurinol NUCYNTA ER TRUVADA erythromycins colchicine tablet SUBSYS DIFICID XTAMPZA ER probenecid 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. INTEGRASE INHIBITORS § KINASE INHIBITORS § ANGIOTENSIN II § CALCIUM CHANNEL § MISCELLANEOUS ISENTRESS imatinib mesylate RECEPTOR ANTAGONIST / BLOCKERS ranolazine ext-rel TIVICAY AFINITOR CALCIUM CHANNEL amlodipine ALECENSA BLOCKER / DIURETIC diltiazem ext-rel (except generics CENTRAL NERVOUS § NUCLEOSIDE REVERSE ALUNBRIG COMBINATIONS for CARDIZEM LA) SYSTEM TRANSCRIPTASE BOSULIF amlodipine-valsartan- nifedipine ext-rel INHIBITORS ANTIANXIETY CABOMETYX hydrochlorothiazide verapamil ext-rel § BENZODIAZEPINES abacavir tablet COPIKTRA olmesartan-amlodipine- § CALCIUM CHANNEL lamivudine IBRANCE hydrochlorothiazide alprazolam BLOCKER / ANTILIPEMIC IRESSA clonazepam § PROTEASE INHIBITORS § ANTIARRHYTHMICS COMBINATIONS KISQALI diazepam atazanavir KISQALI FEMARA sotalol amlodipine-atorvastatin lorazepam NORVIR CO-PACK MULTAQ oxazepam § DIGITALIS GLYCOSIDES PREZISTA RYDAPT ANTILIPEMICS § ANTICONVULSANTS SPRYCEL digoxin ANTIVIRALS ACL INHIBITORS / carbamazepine XOSPATA § DIRECT RENIN § CYTOMEGALOVIRUS COMBINATIONS carbamazepine ext-rel AGENTS INHIBITORS / DIURETIC MULTIPLE MYELOMA NEXLETOL clobazam COMBINATIONS valganciclovir PROTEASOME INHIBITORS NEXLIZET diazepam rectal gel aliskiren divalproex sodium NINLARO § HEPATITIS B AGENTS § BILE ACID RESINS TEKTURNA HCT divalproex sodium ext-rel VELCADE entecavir cholestyramine ethosuximide § DIURETICS lamivudine § MISCELLANEOUS colesevelam gabapentin amiloride VEMLIDY ERIVEDGE lamotrigine § CHOLESTEROL furosemide LYNPARZA lamotrigine ext-rel § HEPATITIS C AGENTS ABSORPTION INHIBITORS hydrochlorothiazide ODOMZO levetiracetam ribavirin metolazone PERJETA ezetimibe levetiracetam ext-rel EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) spironolactone- PHESGO oxcarbazepine HARVONI (genotypes 1, 4, 5, 6) § FIBRATES hydrochlorothiazide RUBRACA phenobarbital VOSEVI 2 fenofibrate (except fenofibrate torsemide phenytoin VISTOGARD tablet 120 mg) triamterene phenytoin sodium extended § HERPES AGENTS ZEJULA fenofibric acid delayed-rel triamterene- primidone acyclovir capsule, tablet CARDIOVASCULAR hydrochlorothiazide tiagabine § HMG-CoA REDUCTASE valacyclovir topiramate § ACE INHIBITORS INHIBITORS / HEART FAILURE valproic acid § INFLUENZA AGENTS COMBINATIONS BIDIL fosinopril vigabatrin oseltamivir CORLANOR lisinopril atorvastatin zonisamide RELENZA ENTRESTO quinapril ezetimibe-simvastatin FYCOMPA ramipril fluvastatin NAYZILAM § MISCELLANEOUS § NITRATES lovastatin OXTELLAR XR clindamycin § ACE INHIBITOR / isosorbide dinitrate (except pravastatin TROKENDI XR ivermectin DIURETIC COMBINATIONS isosorbide dinitrate 40 mg) rosuvastatin VALTOCO linezolid isosorbide mononitrate fosinopril-hydrochlorothiazide simvastatin VIMPAT metronidazole nitroglycerin lingual spray lisinopril-hydrochlorothiazide XCOPRI § NIACINS nitrofurantoin quinapril-hydrochlorothiazide nitroglycerin sublingual pyrimethamine niacin ext-rel § ANTIDEMENTIA sulfamethoxazole- § ANGIOTENSIN II PULMONARY ARTERIAL donepezil trimethoprim RECEPTOR ANTAGONISTS / § OMEGA-3 FATTY ACIDS HYPERTENSION galantamine vancomycin capsule DIURETIC COMBINATIONS omega-3 acid ethyl esters § ENDOTHELIN RECEPTOR galantamine ext-rel EMVERM VASCEPA ANTAGONISTS candesartan / candesartan- memantine XIFAXAN 550 MG hydrochlorothiazide ambrisentan PCSK9 INHIBITORS rivastigmine irbesartan / irbesartan- bosentan rivastigmine transdermal ANTINEOPLASTIC hydrochlorothiazide PRALUENT OPSUMIT NAMZARIC AGENTS losartan / losartan- § BETA-BLOCKERS § PHOSPHODIESTERASE HORMONAL hydrochlorothiazide ANTIDEPRESSANTS atenolol INHIBITORS ANTINEOPLASTIC AGENTS olmesartan / olmesartan- § SELECTIVE SEROTONIN carvedilol hydrochlorothiazide sildenafil REUPTAKE INHIBITORS § ANTIANDROGENS carvedilol phosphate ext-rel telmisartan / telmisartan- (SSRIs) abiraterone metoprolol succinate ext-rel PROSTACYCLIN RECEPTOR hydrochlorothiazide bicalutamide metoprolol tartrate AGONISTS citalopram valsartan / valsartan- ERLEADA nadolol escitalopram hydrochlorothiazide UPTRAVI fluoxetine (except fluoxetine tablet 60 mg, NUBEQA pindolol XTANDI § ANGIOTENSIN II propranolol § PROSTAGLANDIN fluoxetine tablet [generics for SARAFEM]) paroxetine HCl YONSA RECEPTOR ANTAGONIST / propranolol ext-rel VASODILATORS CALCIUM CHANNEL BYSTOLIC ORENITRAM paroxetine HCl ext-rel § LUTEINIZING HORMONE- BLOCKER COMBINATIONS sertraline RELEASING HORMONE SOLUBLE GUANYLATE TRINTELLIX amlodipine-olmesartan (LHRH) AGONISTS CYCLASE STIMULATORS amlodipine-telmisartan ELIGARD ADEMPAS amlodipine-valsartan LUPRON DEPOT Your specific