January 2019 Performance Drug List - Standard Control for ...

1 January 2019. Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary . The CVS Caremark Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary 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.

2 Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER HEALTH CARE PROVIDER. Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered by CVS Caremark. Ask your doctor to consider administered by CVS Caremark. As a way to help manage health prescribing, when medically appropriate, a preferred medicine from care costs, authorize generic substitution whenever possible.

3 If you this list. Take this list along when you or a covered family member believe a brand-name product is necessary, consider prescribing a sees a doctor. brand name on this list. Please note: Please note: Your specific prescription benefit plan design may not cover Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in this document. Products recently approved by the Food This drug list represents a summary of prescription coverage. and Drug Administration (FDA) may not be covered upon It is not all-inclusive and does not guarantee coverage.

4 The release to the market. member's specific prescription benefit plan design may not cover certain products or categories, regardless of their You may be responsible for the full cost of non-formulary appearance in this document. Products recently approved by products that are removed from coverage. the FDA may not be covered upon release to the market. For specific information 1. regarding your prescription benefit The member's prescription benefit plan may have a different coverage and copay information, please visit copay1 for specific products on the list.

5 Or contact a CVS Caremark Customer Care representative. Unless specifically indicated, drug list products will include all dosage forms. CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or Log in to 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.

6 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 COLCRYS EMBEDA erythromycins ANTIFUNGALS. ULORIC HYSINGLA ER DIFICID fluconazole NSAIDs NUCYNTA itraconazole diclofenac sodium OPIOID ANALGESICS NUCYNTA ER FLUOROQUINOLONES. terbinafine tablet meloxicam codeine-acetaminophen OXYCONTIN ciprofloxacin naproxen fentanyl transdermal SUBSYS ciprofloxacin ext-rel ANTIVIRALS. fentanyl transmucosal levofloxacin CYTOMEGALOVIRUS.

7 NSAIDs, COMBINATIONS lozenge ANTI-INFECTIVES moxifloxacin AGENTS. diclofenac sodium- hydrocodone-acetaminophen ANTIBACTERIALS PENICILLINS valganciclovir misoprostol hydromorphone hydromorphone ext-rel CEPHALOSPORINS amoxicillin HERPES AGENTS. NSAIDs, TOPICAL methadone cefdinir amoxicillin-clavulanate acyclovir diclofenac sodium gel 1% morphine cefprozil dicloxacillin valacyclovir diclofenac sodium solution morphine ext-rel cefuroxime axetil penicillin VK. morphine suppository cephalexin INFLUENZA AGENTS. COX-2 INHIBITORS TETRACYCLINES.

8 Oxycodone SUPRAX oseltamivir celecoxib oxycodone-acetaminophen doxycycline hyclate RELENZA. tramadol ERYTHROMYCINS / minocycline GOUT MACROLIDES tetracycline tramadol ext-rel MISCELLANEOUS. allopurinol azithromycin ABSTRAL clindamycin colchicine tablet clarithromycin BELBUCA ivermectin probenecid clarithromycin ext-rel BUTRANS linezolid Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

9 Metronidazole ANTILIPEMICS torsemide SEROTONIN HYPNOTICS. nitrofurantoin BILE ACID RESINS triamterene- NOREPINEPHRINE NONBENZODIAZEPINES. sulfamethoxazole- cholestyramine hydrochlorothiazide REUPTAKE INHIBITORS eszopiclone trimethoprim colesevelam (SNRIs) zolpidem EMVERM HEART FAILURE. desvenlafaxine ext-rel zolpidem ext-rel XIFAXAN 550 MG CHOLESTEROL BIDIL duloxetine zolpidem sublingual ABSORPTION INHIBITORS CORLANOR venlafaxine BELSOMRA. ANTINEOPLASTIC. ezetimibe ENTRESTO venlafaxine ext-rel capsule AGENTS TRICYCLICS.

10 FIBRATES NITRATES MISCELLANEOUS. HORMONAL SILENOR. fenofibrate nitroglycerin lingual spray AGENTS. ANTINEOPLASTIC AGENTS nitroglycerin sublingual fenofibric acid bupropion MIGRAINE. ANTIANDROGENS. MISCELLANEOUS bupropion ext-rel ERGOTAMINE. bicalutamide HMG-CoA REDUCTASE mirtazapine DERIVATIVES. INHIBITORS / RANEXA. MISCELLANEOUS trazodone ergotamine-caffeine COMBINATIONS. VISTOGARD CENTRAL NERVOUS ANTIPARKINSONIAN. atorvastatin SELECTIVE SEROTONIN. SYSTEM AGENTS. ezetimibe-simvastatin AGONISTS. CARDIOVASCULAR.