Formulary Drug Removals
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- Bruno Perkins
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1 July 2016 Below is a list of medicines by drug class that have been removed from your plan s formulary. If you continue using one of the drugs listed below and identified as a Removal, you may be required to pay the full cost. If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary options listed below. Category * Allergic Reaction (Anaphylaxis) Treatment * Allergies * Nasal Steroids / Combinations Allergies * Ophthalmic Anti-infectives, Antivirals * Cytomegalovirus Agents Anti-infectives, Antivirals * Hepatitis C Agents Anti-infectives, Antivirals * Herpes Agents Antiobesity Agents * Newer Agents Asthma * Beta Agonists, Short-Acting Asthma * Steroid Inhalants Asthma * or Chronic Obstructive Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations Attention Deficit Hyperactivity Disorder Agents * Cardiovascular Antilipemics * Fibrates Cardiovascular Antilipemics * HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations ADRENACLICK BECONASE AQ OMNARIS QNASL RHINOCORT AQUA VERAMYST ZETONNA DYMISTA LASTACAFT VALCYTE VIEKIRA PAK VALTREX QSYMIA XOPENEX HFA AEROSPAN ALVESCO SYMBICORT ADDERALL XR INTUNIV TRICOR ADVICOR ALTOPREV LESCOL XL LIPITOR LIPTRUZET LIVALO AUVI-Q, EPIPEN, EPIPEN JR flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX flunisolide spray, fluticasone spray, triamcinolone spray or NASONEX WITH azelastine spray or olopatadine spray azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO valganciclovir HARVONI acyclovir, valacyclovir BELVIQ, CONTRAVE, SAXENDA PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR ADVAIR, DULERA amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, QUILLIVANT XR, STRATTERA, VYVANSE fenofibrate, fenofibric acid atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, VYTORIN
2 Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergics Depression * Antidepressants, Selective Norepinephrine Reuptake Inhibitors (SNRIs) Depression * Antidepressants, Miscellaneous Agents Depression *, Schizophrenia * Antipsychotics, Atypicals Dermatology Actinic Keratosis * Dermatology Rosacea * Dermatology Skin Inflammation and Hives * Corticosteroids Biguanides Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations Injectable Incretin Mimetics INCRUSE ELLIPTA TUDORZA CYMBALTA OLEPTRO ABILIFY fluorouracil cream 0.5% CARAC NORITATE clobetasol spray CLOBEX SPRAY OLUX-E APEXICON E FORTAMET GLUMETZA RIOMET NESINA ONGLYZA KAZANO KOMBIGLYZE XR OSENI BYDUREON BYETTA SPIRIVA duloxetine, venlafaxine, venlafaxine ext-rel, KHEDEZLA, PRISTIQ trazodone aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA metronidazole, sulfacetamide-sulfur, FINACEA, SOOLANTRA clobetasol foam desoximetasone, fluocinonide metformin, metformin ext-rel JANUVIA, TRADJENTA JANUMET, JANUMET XR, JENTADUETO TRULICITY, VICTOZA Insulins APIDRA HUMALOG NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN 70/30 1 NOVOLIN 70/30 1 HUMULIN N 1 NOVOLIN N 1 HUMULIN R 1 NOVOLIN R 1 NOTE: Humulin R U-500 concentrate vial will not be subject to removal and will continue to be covered. Insulin Sensitizers ACTOS pioglitazone
3 Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitor / Biguanide Combinations Supplies 2, 3 Erectile Dysfunction * Phosphodiesterase Inhibitors Gastrointestinal Agents * Irritable Bowel Disease - Constipation Predominant Gastrointestinal Agents * Opioid-induced Constipation Gastrointestinal Agents * Proton Pump Inhibitors (PPIs) Glaucoma * Prostaglandin Analogs Growth Hormones * Hematologic * Platelet Aggregation Inhibitors Antagonists Antagonist / Diuretic Combinations Antagonist / Calcium Channel Blocker Combinations Antagonist / Calcium Channel Blocker / Diuretic Combinations INVOKANA INVOKAMET ACCU-CHEK STRIPS AND KITS BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS 4 All other test strips that are not ONETOUCH brand LEVITRA VIAGRA AMITIZA RELISTOR PREVACID PROTONIX LUMIGAN GENOTROPIN NUTROPIN AQ OMNITROPE SAIZEN PLAVIX ATACAND DIOVAN EDARBI TEVETEN ATACAND HCT DIOVAN HCT EDARBYCLOR TEVETEN HCT EXFORGE EXFORGE HCT FARXIGA, JARDIANCE XIGDUO XR ONETOUCH ULTRA STRIPS AND KITS 2, ONETOUCH VERIO STRIPS AND KITS 2 CIALIS LINZESS MOVANTIK esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT latanoprost, travoprost, TRAVATAN Z, ZIOPTAN HUMATROPE, NORDITROPIN clopidogrel, BRILINTA, EFFIENT candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT amlodipine-telmisartan, amlodipine-valsartan, AZOR amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR
4 Calcium Channel Blockers Inflammatory Bowel Disease (IBD), Ulcerative Colitis * Aminosalicylates Kidney Disease * Phosphate Binders Multiple Sclerosis Agents * NORVASC CARDIZEM CARDIZEM CD CARDIZEM LA (and its generics) Matzim LA ASACOL HD DELZICOL FOSRENOL AVONEX EXTAVIA PLEGRIDY amlodipine diltiazem ext-rel (except generic of CARDIZEM LA) balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS calcium acetate, PHOSLYRA, RENVELA, VELPHORO glatiramer, AUBAGIO, BETASERON, COPAXONE 40 MG, GILENYA, REBIF, TECFIDERA Musculoskeletal Agents * AMRIX cyclobenzaprine Opioid Dependence Agents * ZUBSOLV buprenorphine-naloxone sublingual tablet, SUBOXONE FILM Osteoarthritis * Viscosupplements Overactive Bladder / Incontinence * Urinary Antispasmodics Pain and Inflammation * Corticosteroids Pain and Inflammation * Nonsteroidal Anti-inflammatory Drugs (NSAIDs) / Combinations Prostate Condition * Benign Prostatic Hyperplasia Agents / Combinations Sleep * Hypnotics, Non-benzodiazepines Testosterone Replacement * Androgens EUFLEXXA MONOVISC ORTHOVISC DETROL LA OXYTROL TOVIAZ RAYOS ARTHROTEC DUEXIS VIMOVO PENNSAID NAPRELAN JALYN INTERMEZZO LUNESTA ROZEREM testosterone gel 1% 5 ANDROGEL FORTESTA NATESTO TESTIM VOGELXO GEL-ONE, HYALGAN, SUPARTZ FX oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE dexamethasone, methylprednisolone, prednisone celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole or DEXILANT diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL celecoxib, diclofenac sodium, meloxicam, naproxen dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO eszopiclone, zolpidem, zolpidem ext-rel, SILENOR ANDRODERM, AXIRON
5 New-to-Market Agents 4 Specialty Hepatitis C * New-to-market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS Caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). As new specialty products launch, all existing products in the class will be re-evaluated to determine appropriate formulary placement and potentially excluded, added back to formulary or not listed. As new Hepatitis C products launch, all existing products in the class will be re-evaluated to determine appropriate formulary placement and potentially excluded, added back to formulary or not listed. The listed formulary options are subject to change. ABILIFY ACCU-CHEK STRIPS AND KITS 3 ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALTOPREV ALVESCO AMITIZA AMRIX ANDROGEL APEXICON E APIDRA ARTHROTEC ASACOL HD ATACAND ATACAND HCT AVONEX BECONASE AQ BREEZE 2 STRIPS AND KITS 3 BYDUREON BYETTA CARAC CARDIZEM CARDIZEM CD CARDIZEM LA (and its generics) clobetasol spray CLOBEX SPRAY CONTOUR NEXT STRIPS AND KITS 3 CONTOUR STRIPS AND KITS 3 CYMBALTA DELZICOL DETROL LA DIOVAN DIOVAN HCT DUEXIS DYMISTA EDARBI EDARBYCLOR EUFLEXXA EXFORGE EXFORGE HCT EXTAVIA List of fluorouracil cream 0.5% FORTAMET FORTESTA FOSRENOL FREESTYLE STRIPS AND KITS 3, 4 GENOTROPIN GLUMETZA HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 1 HUMULIN N 1 HUMULIN R 1 INCRUSE ELLIPTA INTERMEZZO INTUNIV INVOKAMET INVOKANA JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LEVITRA LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA Matzim LA MONOVISC NAPRELAN NATESTO NESINA NORITATE NORVASC NUTROPIN AQ OLEPTRO OLUX-E OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI OXYTROL PENNSAID PLAVIX PLEGRIDY PREVACID PROTONIX QNASL QSYMIA RAYOS RELISTOR RHINOCORT AQUA RIOMET ROZEREM SAIZEN SYMBICORT TESTIM testosterone gel 1% 5 TEVETEN TEVETEN HCT TOVIAZ TRICOR TUDORZA VALCYTE VALTREX VERAMYST VIAGRA VIEKIRA PAK VIMOVO VOGELXO XOPENEX HFA ZETONNA ZUBSOLV
6 This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available drug options. Log in to to check coverage and copay information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CVS Caremark assumes no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. 1 Rebranded or private label formulations are not covered (i.e., RELION). 2 A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information on how to obtain a blood glucose meter, call: ONETOUCH brand test strips are the only preferred options. 4 An exception process is in place for specific clinical circumstances that may require continued coverage for FREESYTLE diabetic test strips. If your doctor believes you have a specific clinical need for this product, he or she should fax an exception request to: Your plan may choose to provide an exception process for additional medications on this list and new-to-market agents. 5 Listing reflects the authorized generics for TESTIM and VOGELXO. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. This document contains confidential and proprietary information of CVS Caremark and cannot be reproduced, distributed or printed without written permission from CVS Caremark. CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor CVS Caremark. All rights reserved A
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