Advanced Control Formulary Change Summary Report

 
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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.

     106-40278A 093020                                                                                                                  Pg. 1 of 41
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

     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.

     106-40278A 093020                                                                                                                   Pg. 2 of 41
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.

      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.

      106-40278A 093020                                                                                                                    Pg. 3 of 41
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)

     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.

     106-40278A 093020                                                                                                                    Pg. 4 of 41
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

     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.

     106-40278A 093020                                                                                                                  Pg. 5 of 41
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

     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.

     106-40278A 093020                                                                                                                 Pg. 6 of 41
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.

     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.

     106-40278A 093020                                                                                                                     Pg. 7 of 41
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

     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.

     106-40278A 093020                                                                                                                  Pg. 8 of 41
Advanced Control Formulary™
                                                                              Change Summary Report
                                                                              Effective 01-01-2021

                             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

     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.

     106-40278A 093020                                                                                                                 Pg. 9 of 41
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

     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.

     106-40278A 093020                                                                                                                   Pg. 10 of 41
Advanced Control Formulary™
                                                                                  Change Summary Report
                                                                                  Effective 01-01-2021

                                  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

      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.

      106-40278A 093020                                                                                                                    Pg. 11 of 41
Advanced Control Formulary™
                                                                                Change Summary Report
                                                                                Effective 01-01-2021

                             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

     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.

     106-40278A 093020                                                                                                                   Pg. 12 of 41
Advanced Control Formulary™
                                                                               Change Summary Report
                                                                               Effective 01-01-2021

                             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.

     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.

     106-40278A 093020                                                                                                                  Pg. 13 of 41
Advanced Control Formulary™
                                                                                    Change Summary Report
                                                                                    Effective 01-01-2021

     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).

     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.

     106-40278A 093020                                                                                                                         Pg. 14 of 41
Advanced Control Formulary™
                                                                                Change Summary Report
                                                                                Effective 01-01-2021

     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.

     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.

     106-40278A 093020                                                                                                                    Pg. 15 of 41
Advanced Control Formulary™
                                                                                    Change Summary Report
                                                                                    Effective 01-01-2021

                               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.

     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.

     106-40278A 093020                                                                                                                        Pg. 16 of 41
Advanced Control Formulary™
                                                                                Change Summary Report
                                                                                Effective 01-01-2021

                               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.

     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.

     106-40278A 093020                                                                                                                    Pg. 17 of 41
Advanced Control Formulary™
                                                                              Change Summary Report
                                                                              Effective 01-01-2021

                              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).

     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.

     106-40278A 093020                                                                                                                  Pg. 18 of 41
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 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,

     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.

     106-40278A 093020                                                                                                                     Pg. 19 of 41
Advanced Control Formulary™
                                                                              Change Summary Report
                                                                              Effective 01-01-2021

                              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)

     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.

     106-40278A 093020                                                                                                                  Pg. 20 of 41
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.

     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.

     106-40278A 093020                                                                                                                     Pg. 21 of 41
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

     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.

     106-40278A 093020                                                                                                                     Pg. 22 of 41
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

    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.

    106-40278A 093020                                                                                                                   Pg. 23 of 41
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,

      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.

      106-40278A 093020                                                                                                                  Pg. 24 of 41
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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