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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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 41Advanced 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).
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.
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