Comprehensive Specialty Pharmacy Drug List - Caremark

1 October 2019 Comprehensive Specialty Pharmacy drug List Providing one of the broadest offerings of Specialty pharmaceuticals in the industry The Comprehensive Specialty Pharmacy drug List is a guide of medications available through CVS Specialty . Our goal is to help make your life better. With more than 40 years of experience, CVS Specialty provides quality care and service. We have a network of pharmacies that includes those with Joint Commission and URAC accreditation. The Joint Commission and URAC are nationally recognized symbols of quality that reflect an organization s commitment to meet high standards of quality and safety. This list represents brand-name products in CAPS and generic products in lowercase italics.

2 Please note: If you are a plan member or a health care provider, please visit , fax 1-800-323-2445 or call 1-800-237-2767 for specific information regarding medications available through CVS Specialty . e-Prescribe Specialty prescription (s) to CVS Specialty Pharmacy . ACROMEGALY octreotide acetate (SANDOSTATIN) SANDOSTATIN LAR SOMATULINE DEPOT* SOMAVERT* ALPHA-1 ANTITRYPSIN DEFICIENCY ARALAST NP* GLASSIA* ZEMAIRA* AMYLOIDOSIS ONPATTRO* VYNDAMAX* VYNDAQEL* ANEMIA ARANESP EPOGEN PROCRIT RETACRIT ASTHMA CINQAIR* DUPIXENT FASENRA* NUCALA* XOLAIR* ATOPIC DERMATITIS DUPIXENT CARDIAC DISORDERS dofetilide (TIKOSYN) COAGULATION DISORDERS CEPROTIN* CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES ARCALYST* ILARIS* CYSTIC FIBROSIS BETHKIS* KITABIS PAK* PULMOZYME TOBI PODHALER* tobramycin nebulizer (TOBI*)

3 ELECTROLYTE DISORDERS SAMSCA* GASTROINTESTINAL DISORDERS OTHER GATTEX* OCALIVA* SOLESTA* GOUT KRYSTEXXA* GROWTH HORMONE & RELATED DISORDERS Growth Hormone Disorders GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN AQ OMNITROPE SAIZEN SEROSTIM* ZOMACTON ZORBTIVE IGF-1 Deficiency INCRELEX* HEMATOPOIETICS MOZOBIL* HEMOPHILIA, VON WILLEBRAND DISEASE & RELATED BLEEDING DISORDERS ADVATE ADYNOVATE AFSTYLA ALPHANATE ALPHANINE SD ALPROLIX BEBULIN BENEFIX COAGADEX* CORIFACT* ELOCTATE FEIBA FIBRYGA HELIXATE FS HEMLIBRA HEMOFIL M HUMATE-P IDELVION IXINITY JIVI KOATE KOATE-DVI KOGENATE FS KOVALTRY MONONINE NOVOEIGHT* NOVOSEVEN RT NUWIQ OBIZUR* PROFILNINE PROFILNINE SD REBINYN RECOMBINATE RIASTAP RIXUBIS STIMATE TRETTEN* VONVENDI* WILATE XYNTHA HEPATITIS adefovir dipivoxil (HEPSERA) entecavir (BARACLUDE) EPCLUSA HARVONI INTRON-A* lamivudine (EPIVIR, EPIVIR HBV) LEDIPASVIR/SOFOSBUVIR MAVYRET PEGASYS PEGINTRON REBETOL SOLUTION ribasphere RIBASPHERE RIBAPAK ribavirin caps (ribasphere, REBETOL)

4 Ribavirin tabs (ribasphere, MODERIBA) SOFOSBUVIR/VELPATASVIR SOVALDI tenofovir disoproxil fumarate (VIREAD) VEMLIDY VIEKIRA PAK VOSEVI ZEPATIER HEREDITARY ANGIOEDEMA BERINERT* CINRYZE* HAEGARDA* icatibant acetate (FIRAZYR*) KALBITOR* RUCONEST* TAKHZYRO* HIV MEDICATIONS abacavir tab (ZIAGEN) abacavir/lamivudine (EPZICOM) abacavir/lamivudine/zidovudine tab (TRIZIVIR) APTIVUS atazanavir sulfate (REYATAZ) ATRIPLA BIKTARVY CIMDUO COMPLERA CRIXIVAN DELSTRIGO DESCOVY didanosine (VIDEX, VIDEX EC) DOVATO EDURANT efavirenz (SUSTIVA) EGRIFTA* Products distributed by CVS Specialty , as well as products covered by a member s prescription or medical benefit plan, may change from time to time.

5 In addition, a member s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document. *Indicates Limited Distribution products distributed by CVS Specialty or one of its affiliates, including Coram CVS Specialty Infusion Services. Call CVS Specialty at 1-800-237-2767 for specific medications available through CVS Specialty . This document contains confidential and proprietary information of CVS Specialty and may not be reproduced, distributed or printed without written permission from CVS Specialty . Listing is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty .

6 Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy . 2019 CVS Specialty . All rights reserved. 75-CTC14953D October 2019 v09162019 Comprehensive Specialty Pharmacy drug List Page 1 of 7 October 2019 EMTRIVA EVOTAZ fosamprenavir (LEXIVA) FUZEON GENVOYA INTELENCE INVIRASE ISENTRESS JULUCA lamivudine (EPIVIR) lamivudine/zidovudine (COMBIVIR) LEXIVA lopinavir/ritonavir soln (KALETRA) nevirapine (VIRAMUNE, VIRAMUNE XR) ODEFSEY PIFELTRO PREZCOBIX PREZISTA RESCRIPTOR RETROVIR INJECTABLE ritonavir (NORVIR) SELZENTRY stavudine (ZERIT) STRIBILD SYMFI SYMFI LO SYMTUZA tenofovir disoproxil fumarate (VIREAD) TIVICAY TRIUMEQ TROGARZO* TRUVADA TYBOST VIDEX SOLUTION VIRACEPT zidovudine (RETROVIR)

7 HORMONAL THERAPIES AVEED* ELIGARD FIRMAGON leuprolide acetate (LUPRON) LUPANETA PACK LUPRON DEPOT NATPARA* SUPPRELIN LA* TRELSTAR VANTAS ZOLADEX IMMUNE DEFICIENCIES & RELATED DISORDERS BIVIGAM* CUVITRU CYTOGAM GAMASTAN GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX* GAMUNEX C HEPAGAM B HIZENTRA* HYPERHEP B HYPERRHO S/D HYQVIA MICRHOGAM NABI-HB OCTAGAM PANZYGA PRIVIGEN RHOGAM RHOPHYLAC VARIZIG WINRHO SDF INFECTIOUS DISEASE OTHER ACTIMMUNE* ALFERON N INFERTILITY CETROTIDE CHORIONIC GONADOTROPIN FOLLISTIM AQ GANIRELIX ACETATE GONAL-F MENOPUR NOVAREL OVIDREL PREGNYL INFLAMMATORY BOWEL DISEASE CIMZIA ENTYVIO HUMIRA INFLECTRA REMICADE RENFLEXIS* SIMPONI STELARA TYSABRI* XELJANZ IRON OVERLOAD deferasirox (EXJADE*)

8 Deferoxamine (DESFERAL) JADENU* LYSOSOMAL STORAGE DISORDERS ALDURAZYME* CERDELGA* CEREZYME* CYSTAGON* ELAPRASE* ELELYSO* FABRAZYME* KANUMA* LUMIZYME* miglustat NAGLAZYME* VIMIZIM* VPRIV* MENTAL HEALTH CONDITIONS ZULRESSO* MOVEMENT DISORDERS APOKYN* AUSTEDO INBRIJA* NORTHERA* NUPLAZID* RADICAVA* SOLIRIS* tetrabenazine (XENAZINE*) MULTIPLE SCLEROSIS AUBAGIO* AVONEX BETASERON dalfampridine ER (AMPYRA*) EXTAVIA GILENYA glatiramer acetate (COPAXONE, glatopa) LEMTRADA* MAVENCLAD* MAYZENT* mitoxantrone hcl OCREVUS* PLEGRIDY* REBIF TECFIDERA* TYSABRI* NEUTROPENIA FULPHILA GRANIX LEUKINE NEULASTA NEUPOGEN NIVESTYM UDENYCA ZARXIO OCULAR DISORDERS EYLEA* ILUVIEN* LUCENTIS* MACUGEN* OZURDEX* RETISERT* VISUDYNE* ONCOLOGY INJECTABLE ADCETRIS* ARZERRA* AVASTIN azacitidine (VIDAZA) BAVENCIO* BELEODAQ* BELRAPZO* BENDAMUSTINE HYDROCHLORIDE BENDEKA* BLINCYTO* BORTEZOMIB CYRAMZA* DARZALEX* decitabine (DACOGEN)

9 ELZONRIS* EMPLICITI* ERBITUX EVOMELA* FOLOTYN FUSILEV GAZYVA* HALAVEN HERCEPTIN HERCEPTIN HYLECTA IMFINZI* INTRON A* ISTODAX* IXEMPRA JEVTANA KADCYLA KANJINTI* KEYTRUDA* KHAPZORY* KYPROLIS* LEVOLEUCOVORIN LUMOXITI* mitoxantrone MVASI* ONCASPAR OPDIVO* PERJETA* POLIVY* PORTRAZZA* POTELIGEO* PROLEUKIN RITUXAN RITUXAN HYCELA* ROMIDEPSIN SYLATRON* SYLVANT* TECENTRIQ* TEMODAR temsirolimus (TORISEL) TEPADINA THYROGEN* TREANDA valrubicin (VALSTAR) VECTIBIX Products distributed by CVS Specialty , as well as products covered by a member s prescription or medical benefit plan, may change from time to time. In addition, a member s specific benefit plan design may not cover certain products or categories, regardless of their appearance on this document.

10 *Indicates Limited Distribution products distributed by CVS Specialty or one of its affiliates, including Coram CVS Specialty Infusion Services. Call CVS Specialty at 1-800-237-2767 for specific medications available through CVS Specialty . This document contains confidential and proprietary information of CVS Specialty and may not be reproduced, distributed or printed without written permission from CVS Specialty . Listing is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Specialty . Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy .