Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
For specific information, visit
www.caremark.com
or contact a CVS Caremark Customer Care representative.
January 2013
Performance Drug List
The
CVS Caremark Performance Drug List
is a guide within select therapeutic categories for clients, plan members and health care
providers.
Generics should be considered the first line of prescribing
. If there is no generic available, there may be more than one
brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically
appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive
list. This list represents brand products in CAPS and generic products in lowercase
italics
.
PLAN MEMBER
Your benefit plan provides you with a prescription benefit program
administered by CVS Caremark. Ask your doctor to consider
prescribing, when medically appropriate, a preferred medicine from
this list. Take this list along when you or a covered family member
sees a doctor.
Please note:
•
Your specific prescription benefit plan design may not cover
certain products or categories, regardless of their appearance in
this document.
•
You may be responsible for the full cost of non-formulary
products that are removed from coverage.
•
For specific information regarding your prescription benefit
coverage and copay
1
information, please visit
www.caremark.com
or contact a CVS Caremark Customer
Care representative.
•
CVS Caremark may contact your doctor after receiving your
prescription to request consideration of a drug list product or
generic equivalent. This may result in your doctor prescribing,
when medically appropriate, a different brand-name product or
generic equivalent in place of your original prescription.
•
Any brand drug for which a generic product becomes available
may be designated as a non-preferred product.
HEALTH CARE PROVIDER
Your patient is covered under a prescription benefit plan
administered by CVS Caremark. As a way to help manage health
care costs, authorize generic substitution whenever possible. If you
believe a brand-name product is necessary, consider prescribing a
brand name on this list.
Please note:
•
Generics should be considered the first line of prescribing.
•
This drug list represents a summary of prescription coverage.
It is not inclusive and does not guarantee coverage.
•
The member's prescription benefit plan may have a different
copay for specific products on the list.
•
Unless specifically indicated, drug list products will include all
dosage forms.
•
Log in to
www.caremark.com
to check coverage and copay
information for a specific medicine.
ANALGESICS
§ NSAIDs
diclofenac
meloxicam
naproxen
NSAIDs, COMBINATIONS
VIMOVO
NSAIDs, TOPICAL
PENNSAID
VOLTAREN GEL
COX-2 INHIBITORS
CELEBREX
§ OPIOID ANALGESICS
codeine-acetaminophen
hydrocodone-
acetaminophen
tramadol
tramadol ext-rel
§ OPIOID ANALGESICS, CII
fentanyl transdermal
hydromorphone
morphine
morphine ext-rel
morphine suppository
oxycodone
oxycodone-acetaminophen
AVINZA
EXALGO
KADIAN
NUCYNTA
NUCYNTA ER
OPANA ER
OXYCONTIN
VISCOSUPPLEMENTS
SYNVISC
SYNVISC-ONE
ANTI-INFECTIVES
ANTIBACTERIALS
§ CEPHALOSPORINS
cefaclor
cefdinir
cephalexin
SUPRAX
§ ERYTHROMYCINS /
MACROLIDES
azithromycin
clarithromycin
clarithromycin ext-rel
erythromycins
§ FLUOROQUINOLONES
ciprofloxacin ext-rel
ciprofloxacin tablet
levofloxacin
AVELOX
CIPRO SUSPENSION
§ PENICILLINS
amoxicillin
amoxicillin-clavulanate
dicloxacillin
penicillin VK
§ TETRACYCLINES
doxycycline hyclate
minocycline
tetracycline
§ ANTIFUNGALS
fluconazole
itraconazole
terbinafine tablet
ANTIVIRALS
§ HEPATITIS C AGENTS
ribavirin
INCIVEK
VICTRELIS
§ HERPES AGENTS
acyclovir
valacyclovir
§ INFLUENZA AGENTS
amantadine
rimantadine
RELENZA
TAMIFLU
§ MISCELLANEOUS
clindamycin
metronidazole
nitrofurantoin
sulfamethoxazole-
trimethoprim
CARDIOVASCULAR
§ ACE INHIBITORS
fosinopril
lisinopril
quinapril
ramipril
§ ACE INHIBITOR /
DIURETIC COMBINATIONS
fosinopril-
hydrochlorothiazide
lisinopril-
hydrochlorothiazide
quinapril-
hydrochlorothiazide
§ ANGIOTENSIN II
RECEPTOR ANTAGONISTS /
DIURETIC COMBINATIONS
eprosartan
irbesartan / irbesartan-
hydrochlorothiazide
losartan / losartan-
hydrochlorothiazide
BENICAR / BENICAR HCT
DIOVAN / DIOVAN HCT
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
For specific information, visit
www.caremark.com
or contact a CVS Caremark Customer Care representative.
MICARDIS /
MICARDIS HCT
ANTILIPEMICS
§ BILE ACID RESINS
cholestyramine
WELCHOL
CHOLESTEROL
ABSORPTION INHIBITORS
ZETIA
§ FIBRATES
fenofibrate
ANTARA
LIPOFEN
TRICOR
TRILIPIX
§ HMG-CoA REDUCTASE
INHIBITORS /
COMBINATIONS
atorvastatin
fluvastatin
lovastatin
pravastatin
simvastatin
CRESTOR
LESCOL XL
VYTORIN
NIACINS / COMBINATIONS
NIASPAN
SIMCOR
§ BETA-BLOCKERS
atenolol
carvedilol
metoprolol
metoprolol succinate ext-rel
nadolol
propranolol
propranolol ext-rel
BYSTOLIC
COREG CR
§ CALCIUM CHANNEL
BLOCKERS
amlodipine
diltiazem ext-rel
nifedipine ext-rel
verapamil ext-rel
§ CALCIUM CHANNEL
BLOCKER / ANTILIPEMIC
COMBINATIONS
amlodipine-atorvastatin
§ DIGITALIS GLYCOSIDES
digoxin
DIRECT RENIN INHIBITORS /
DIURETIC COMBINATIONS
TEKTURNA /
TEKTURNA HCT
DIRECT RENIN INHIBITOR /
CALCIUM CHANNEL
BLOCKER COMBINATIONS
TEKAMLO
DIRECT RENIN INHIBITOR /
CALCIUM CHANNEL
BLOCKER / DIURETIC
COMBINATIONS
AMTURNIDE
§ DIURETICS
furosemide
hydrochlorothiazide
metolazone
spironolactone-
hydrochlorothiazide
torsemide
triamterene-
hydrochlorothiazide
CENTRAL NERVOUS
SYSTEM
ANTIDEPRESSANTS
§ SELECTIVE SEROTONIN
REUPTAKE INHIBITORS
(SSRIs)
citalopram
escitalopram
fluoxetine
paroxetine
paroxetine ext-rel
sertraline
VIIBRYD
§ SEROTONIN
NOREPINEPHRINE
REUPTAKE INHIBITORS
(SNRIs)
2
venlafaxine
venlafaxine ext-rel
CYMBALTA
PRISTIQ
§ MISCELLANEOUS
AGENTS
bupropion
bupropion ext-rel
mirtazapine
trazodone
§ HYPNOTICS,
NONBENZODIAZEPINES
zolpidem
zolpidem ext-rel
MIGRAINE
§ SELECTIVE SEROTONIN
AGONISTS
naratriptan
sumatriptan
MAXALT
SUMAVEL DOSEPRO
ZOMIG
SELECTIVE SEROTONIN
AGONIST / NONSTEROIDAL
ANTI-INFLAMMATORY
DRUG (NSAID)
COMBINATIONS
TREXIMET
MULTIPLE SCLEROSIS
AGENTS
AVONEX
BETASERON
COPAXONE
ENDOCRINE AND
METABOLIC
ANDROGENS
ANDRODERM
AXIRON
FORTESTA
ANTIDIABETICS
§ BIGUANIDES
metformin
metformin ext-rel
§ BIGUANIDE /
SULFONYLUREA
COMBINATIONS
glipizide-metformin
DIPEPTIDYL PEPTIDASE-4
(DPP-4) INHIBITORS
JANUVIA
TRADJENTA
DIPEPTIDYL PEPTIDASE-4
(DPP-4) INHIBITOR /
BIGUANIDE COMBINATIONS
JANUMET
JANUMET XR
JENTADUETO
INCRETIN MIMETIC AGENTS
BYDUREON
VICTOZA
INSULINS
APIDRA
HUMULIN R U-500
LANTUS
LEVEMIR
NOVOLIN
NOVOLOG
NOVOLOG MIX
INSULIN SENSITIZERS
ACTOS
INSULIN SENSITIZER /
BIGUANIDE COMBINATIONS
ACTOPLUS MET
INSULIN SENSITIZER /
SULFONYLUREA
COMBINATIONS
DUETACT
§ MEGLITINIDES
nateglinide
PRANDIN
§ SULFONYLUREAS
glimepiride
glipizide
glipizide ext-rel
SUPPLIES
ACCU-CHEK STRIPS AND
KITS
3
BD INSULIN SYRINGES
AND NEEDLES
ONETOUCH STRIPS AND
KITS
3
CALCIUM REGULATORS
§ BISPHOSPHONATES
alendronate
ibandronate
ACTONEL
ATELVIA
§ CALCITONINS
calcitonin-salmon
PARATHYROID HORMONES
FORTEO
CONTRACEPTIVES
§ MONOPHASIC
ethinyl estradiol-
drospirenone
BEYAZ
LO LOESTRIN FE
LOESTRIN 24 FE
§ TRIPHASIC
ethinyl estradiol-
norgestimate
ORTHO TRI-CYCLEN LO
FOUR PHASE
NATAZIA
§ EXTENDED CYCLE
ethinyl estradiol-
levonorgestrel
TRANSDERMAL
ORTHO EVRA
VAGINAL
NUVARING
ESTROGENS
§ ORAL
estradiol
estropipate
PREMARIN
§ TRANSDERMAL
estradiol
DIVIGEL
EVAMIST
VIVELLE-DOT
VAGINAL
PREMARIN CREAM
VAGIFEM
§ ESTROGEN /
PROGESTINS, ORAL
estradiol-norethindrone
PREMPHASE
PREMPRO
FERTILITY REGULATORS
OVULATION STIMULANTS,
GONADOTROPINS
FOLLISTIM AQ
HUMAN GROWTH
HORMONES
HUMATROPE
NORDITROPIN
§ PHOSPHATE BINDER
AGENTS
calcium acetate
FOSRENOL
PHOSLYRA
RENVELA
§ PROGESTINS, ORAL
medroxyprogesterone
progesterone, micronized
SELECTIVE ESTROGEN
RECEPTOR MODULATORS
EVISTA
§ THYROID SUPPLEMENTS
levothyroxine
SYNTHROID
GASTROINTESTINAL
§ H
2
RECEPTOR
ANTAGONISTS
ranitidine
§ PROTON PUMP
INHIBITORS
lansoprazole
omeprazole
omeprazole-sodium
bicarbonate capsule
pantoprazole
DEXILANT
NEXIUM
GENITOURINARY
§ BENIGN PROSTATIC
HYPERPLASIA
alfuzosin ext-rel
doxazosin
finasteride
tamsulosin
terazosin
AVODART
RAPAFLO
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
For specific information, visit
www.caremark.com
or contact a CVS Caremark Customer Care representative.
§ URINARY
ANTISPASMODICS
oxybutynin
oxybutynin ext-rel
tolterodine
trospium
GELNIQUE
VESICARE
HEMATOLOGIC
§ ANTICOAGULANTS
warfarin
PRADAXA
XARELTO
§ PLATELET AGGREGATION
INHIBITORS
clopidogrel
AGGRENOX
BRILINTA
EFFIENT
IMMUNOLOGIC
AGENTS
BIOLOGIC DISEASE-
MODIFYING AGENTS
ENBREL
HUMIRA
NUTRITIONAL
§ PRENATAL VITAMINS
prenatal vitamins
CITRANATAL
RESPIRATORY
ANAPHYLAXIS TREATMENT
AGENTS
EPIPEN
EPIPEN JR
§ ANTICHOLINERGICS
SPIRIVA
§ ANTICHOLINERGIC / BETA
AGONIST COMBINATIONS
ipratropium-albuterol
inhalation solution
COMBIVENT RESPIMAT
BETA AGONISTS,
INHALANTS
§ SHORT ACTING
albuterol
PROAIR HFA
PROVENTIL HFA
LONG ACTING
ARCAPTA NEOHALER
FORADIL
SEREVENT
§ LEUKOTRIENE RECEPTOR
ANTAGONISTS
montelukast
zafirlukast
§ NASAL ANTIHISTAMINES
azelastine
ASTEPRO
§ NASAL STEROIDS
flunisolide
fluticasone
triamcinolone
NASONEX
STEROID / BETA AGONIST
COMBINATIONS
ADVAIR
DULERA
SYMBICORT
§ STEROID INHALANTS
budesonide inhalation
suspension
ASMANEX
PULMICORT FLEXHALER
QVAR
TOPICAL
DERMATOLOGY
§ ACNE
adapalene
benzoyl peroxide
clindamycin solution
clindamycin-benzoyl
peroxide
erythromycin solution
erythromycin-benzoyl
peroxide
tretinoin
ACANYA
DIFFERIN
DUAC
EPIDUO
RETIN-A MICRO
VELTIN
§ ACTINIC KERATOSIS
fluorouracil
imiquimod
CARAC
PICATO
SOLARAZE
ZYCLARA
§ ANTIPSORIATICS
calcipotriene
OXSORALEN-ULTRA
SORIATANE
SORILUX
TAZORAC
CORTICOSTEROIDS
§ Low Potency
desonide
hydrocortisone
§ Medium Potency
mometasone
triamcinolone
§ High Potency
desoximetasone
fluocinonide
§ Very High Potency
clobetasol
§ ROSACEA
metronidazole
sulfacetamide-sulfur
FINACEA
METROGEL
ORACEA
OPHTHALMIC
§ ANTIALLERGICS
azelastine
cromolyn sodium
ALREX
LASTACAFT
PATADAY
§ ANTI-INFECTIVES
ciprofloxacin
erythromycin
gentamicin
levofloxacin
ofloxacin
sulfacetamide
tobramycin
MOXEZA
VIGAMOX
§ ANTI-INFECTIVE /
ANTI-INFLAMMATORY
COMBINATIONS
neomycin-polymyxin B-
bacitracin-hydrocortisone
neomycin-polymyxin B-
dexamethasone
tobramycin-
dexamethasone
TOBRADEX ST
ZYLET
ANTI-INFLAMMATORIES
§ NONSTEROIDAL
diclofenac
ketorolac
BROMDAY
§ STEROIDAL
dexamethasone
DUREZOL
LOTEMAX
§ BETA-BLOCKERS,
NONSELECTIVE
timolol maleate solution
BETIMOL
BETA-BLOCKERS,
SELECTIVE
BETOPTIC S
§ CARBONIC ANHYDRASE
INHIBITORS
dorzolamide
AZOPT
§ CARBONIC ANHYDRASE
INHIBITOR / BETA-
BLOCKER COMBINATIONS
dorzolamide-timolol
COSOPT PF
§ PROSTAGLANDINS
latanoprost
TRAVATAN Z
ZIOPTAN
§ SYMPATHOMIMETICS
brimonidine
ALPHAGAN P
SYMPATHOMIMETIC / BETA-
BLOCKER COMBINATIONS
COMBIGAN
QUICK REFERENCE DRUG LIST
A
ACANYA
ACCU-CHEK STRIPS AND
KITS
3
ACTONEL
ACTOPLUS MET
ACTOS
acyclovir
adapalene
ADVAIR
AGGRENOX
albuterol
alendronate
alfuzosin ext-rel
ALPHAGAN P
ALREX
amantadine
amlodipine
amlodipine-atorvastatin
amoxicillin
amoxicillin-clavulanate
AMTURNIDE
ANDRODERM
ANTARA
APIDRA
ARCAPTA NEOHALER
ASMANEX
ASTEPRO
ATELVIA
atenolol
atorvastatin
AVELOX
AVINZA
AVODART
AVONEX
AXIRON
azelastine
azithromycin
AZOPT
B
BD INSULIN SYRINGES
AND NEEDLES
BENICAR
BENICAR HCT
benzoyl peroxide
BETASERON
BETIMOL
BETOPTIC S
BEYAZ
BRILINTA
brimonidine
BROMDAY
budesonide inhalation
suspension
bupropion
bupropion ext-rel
BYDUREON
BYSTOLIC
C
calcipotriene
calcitonin-salmon
calcium acetate
CARAC
carvedilol
cefaclor
cefdinir
CELEBREX
cephalexin
cholestyramine
CIPRO SUSPENSION
ciprofloxacin
ciprofloxacin ext-rel
ciprofloxacin tablet
citalopram
CITRANATAL
clarithromycin
clarithromycin ext-rel
clindamycin
clindamycin solution
clindamycin-benzoyl
peroxide
clobetasol
clopidogrel
codeine-acetaminophen
COMBIGAN
COMBIVENT RESPIMAT
COPAXONE
COREG CR
COSOPT PF
CRESTOR
cromolyn sodium
CYMBALTA
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
For specific information, visit
www.caremark.com
or contact a CVS Caremark Customer Care representative.
D
desonide
desoximetasone
dexamethasone
DEXILANT
diclofenac
dicloxacillin
DIFFERIN
digoxin
diltiazem ext-rel
DIOVAN
DIOVAN HCT
DIVIGEL
dorzolamide
dorzolamide-timolol
doxazosin
doxycycline hyclate
DUAC
DUETACT
DULERA
DUREZOL
E
EFFIENT
ENBREL
EPIDUO
EPIPEN
EPIPEN JR
eprosartan
erythromycin
erythromycin solution
erythromycin-benzoyl
peroxide
erythromycins
escitalopram
estradiol
estradiol-norethindrone
estropipate
ethinyl estradiol-
drospirenone
ethinyl estradiol-
levonorgestrel
ethinyl estradiol-
norgestimate
EVAMIST
EVISTA
EXALGO
F
fenofibrate
fentanyl transdermal
FINACEA
finasteride
fluconazole
flunisolide
fluocinonide
fluorouracil
fluoxetine
fluticasone
fluvastatin
FOLLISTIM AQ
FORADIL
FORTEO
FORTESTA
fosinopril
fosinopril-
hydrochlorothiazide
FOSRENOL
furosemide
G
GELNIQUE
gentamicin
glimepiride
glipizide
glipizide ext-rel
glipizide-metformin
H
HUMATROPE
HUMIRA
HUMULIN R U-500
hydrochlorothiazide
hydrocodone-
acetaminophen
hydrocortisone
hydromorphone
I
ibandronate
imiquimod
INCIVEK
ipratropium-albuterol
inhalation solution
irbesartan
irbesartan-
hydrochlorothiazide
itraconazole
J
JANUMET
JANUMET XR
JANUVIA
JENTADUETO
K
KADIAN
ketorolac
L
lansoprazole
LANTUS
LASTACAFT
latanoprost
LESCOL XL
LEVEMIR
levofloxacin
levothyroxine
LIPOFEN
lisinopril
lisinopril-
hydrochlorothiazide
LO LOESTRIN FE
LOESTRIN 24 FE
losartan
losartan-
hydrochlorothiazide
LOTEMAX
lovastatin
M
MAXALT
medroxyprogesterone
meloxicam
metformin
metformin ext-rel
metolazone
metoprolol
metoprolol succinate ext-rel
METROGEL
metronidazole
MICARDIS
MICARDIS HCT
minocycline
mirtazapine
mometasone
montelukast
morphine
morphine ext-rel
morphine suppository
MOXEZA
N
nadolol
naproxen
naratriptan
NASONEX
NATAZIA
nateglinide
neomycin-polymyxin B-
bacitracin-hydrocortisone
neomycin-polymyxin B-
dexamethasone
NEXIUM
NIASPAN
nifedipine ext-rel
nitrofurantoin
NORDITROPIN
NOVOLIN
NOVOLOG
NOVOLOG MIX
NUCYNTA
NUCYNTA ER
NUVARING
O
ofloxacin
omeprazole
omeprazole-sodium
bicarbonate capsule
ONETOUCH STRIPS AND
KITS
3
OPANA ER
ORACEA
ORTHO EVRA
ORTHO TRI-CYCLEN LO
OXSORALEN-ULTRA
oxybutynin
oxybutynin ext-rel
oxycodone
oxycodone-acetaminophen
OXYCONTIN
P
pantoprazole
paroxetine
paroxetine ext-rel
PATADAY
penicillin VK
PENNSAID
PHOSLYRA
PICATO
PRADAXA
PRANDIN
pravastatin
PREMARIN
PREMARIN CREAM
PREMPHASE
PREMPRO
prenatal vitamins
PRISTIQ
PROAIR HFA
progesterone, micronized
propranolol
propranolol ext-rel
PROVENTIL HFA
PULMICORT FLEXHALER
Q
quinapril
quinapril-
hydrochlorothiazide
QVAR
R
ramipril
ranitidine
RAPAFLO
RELENZA
RENVELA
RETIN-A MICRO
ribavirin
rimantadine
S
SEREVENT
sertraline
SIMCOR
simvastatin
SOLARAZE
SORIATANE
SORILUX
SPIRIVA
spironolactone-
hydrochlorothiazide
sulfacetamide
sulfacetamide-sulfur
sulfamethoxazole-
trimethoprim
sumatriptan
SUMAVEL DOSEPRO
SUPRAX
SYMBICORT
SYNTHROID
SYNVISC
SYNVISC-ONE
T
TAMIFLU
tamsulosin
TAZORAC
TEKAMLO
TEKTURNA
TEKTURNA HCT
terazosin
terbinafine tablet
tetracycline
timolol maleate solution
TOBRADEX ST
tobramycin
tobramycin-
dexamethasone
tolterodine
torsemide
TRADJENTA
tramadol
tramadol ext-rel
TRAVATAN Z
trazodone
tretinoin
TREXIMET
triamcinolone
triamterene-
hydrochlorothiazide
TRICOR
TRILIPIX
trospium
V
VAGIFEM
valacyclovir
VELTIN
venlafaxine
venlafaxine ext-rel
verapamil ext-rel
VESICARE
VICTOZA
VICTRELIS
VIGAMOX
VIIBRYD
VIMOVO
VIVELLE-DOT
VOLTAREN GEL
VYTORIN
W
warfarin
WELCHOL
X
XARELTO
Z
zafirlukast
ZETIA
ZIOPTAN
zolpidem
zolpidem ext-rel
ZOMIG
ZYCLARA
ZYLET
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
For specific information, visit
www.caremark.com
or contact a CVS Caremark Customer Care representative.
PREFERRED ALTERNATIVES LIST
DRUG NAME(S)
PREFERRED ALTERNATIVE(S)*
ACIPHEX
lansoprazole, omeprazole
,
omeprazole-
sodium bicarbonate capsule, pantoprazole,
DEXILANT, NEXIUM
ADVICOR
SIMCOR
ALORA
estradiol
, DIVIGEL, EVAMIST, VIVELLE-DOT
ALTOPREV
atorvastatin, fluvastatin, lovastatin, pravastatin,
simvastatin
, CRESTOR, LESCOL XL, VYTORIN
ALVESCO
ASMANEX, PULMICORT FLEXHALER, QVAR
ANDROGEL
ANDRODERM, AXIRON, FORTESTA
ANGELIQ
estradiol-norethindrone
, PREMPHASE, PREMPRO
ARMOUR THYROID
levothyroxine
,
SYNTHROID
ASCENSIA STRIPS AND KITS
ACCU-CHEK STRIPS AND KITS
3
, ONETOUCH
STRIPS AND KITS
3
ATACAND, ATACAND HCT
eprosartan, irbesartan, irbesartan-
hydrochlorothiazide, losartan, losartan-
hydrochlorothiazide,
BENICAR, BENICAR HCT,
DIOVAN, DIOVAN HCT, MICARDIS, MICARDIS HCT
ATROVENT HFA
SPIRIVA
AXERT
naratriptan, sumatriptan
, MAXALT, ZOMIG
AZELEX
erythromycin solution
BECONASE AQ
flunisolide, fluticasone
,
triamcinolone,
NASONEX
BENZAC AC, BENZAC W
adapalene, clindamycin solution
,
clindamycin-
benzoyl peroxide
,
erythromycin solution
,
erythromycin-benzoyl peroxide
,
tretinoin
, ACANYA,
DIFFERIN, DUAC, EPIDUO, RETIN-A MICRO,
VELTIN
BENZAGEL
adapalene, clindamycin solution
,
clindamycin-
benzoyl peroxide
,
erythromycin solution
,
erythromycin-benzoyl peroxide
,
tretinoin
, ACANYA,
DIFFERIN, DUAC, EPIDUO, RETIN-A MICRO,
VELTIN
BENZIQ
adapalene, clindamycin solution
,
clindamycin-
benzoyl peroxide
,
erythromycin solution
,
erythromycin-benzoyl peroxide
,
tretinoin
, ACANYA,
DIFFERIN, DUAC, EPIDUO, RETIN-A MICRO,
VELTIN
CARDURA XL
alfuzosin ext-rel, doxazosin, tamsulosin
,
terazosin,
RAPAFLO
CENESTIN
estradiol, estropipate,
PREMARIN
CLINDAGEL
erythromycin solution
COMBIVENT
COMBIVENT RESPIMAT
DESQUAM E, DESQUAM X
adapalene, clindamycin solution
,
clindamycin-
benzoyl peroxide
,
erythromycin solution
,
erythromycin-benzoyl peroxide
,
tretinoin
, ACANYA,
DIFFERIN, DUAC, EPIDUO, RETIN-A MICRO,
VELTIN
DETROL LA
oxybutynin ext-rel, tolterodine, trospium,
GELNIQUE,
VESICARE
DORAL
zolpidem
,
zolpidem ext-rel
DUEXIS
VIMOVO
DYNACIRC CR
amlodipine, nifedipine ext-rel
DRUG NAME(S)
PREFERRED ALTERNATIVE(S)*
EDARBI, EDARBYCLOR
eprosartan, irbesartan, irbesartan-
hydrochlorothiazide, losartan,
losartan-
hydrochlorothiazide,
BENICAR, BENICAR HCT,
DIOVAN, DIOVAN HCT, MICARDIS, MICARDIS HCT
EDLUAR
zolpidem, zolpidem ext-rel
ENABLEX
oxybutynin ext-rel, tolterodine, trospium,
GELNIQUE,
VESICARE
ENJUVIA
estradiol, estropipate,
PREMARIN
ESTRACE CREAM
PREMARIN CREAM, VAGIFEM
ESTRASORB
estradiol,
DIVIGEL, EVAMIST, VIVELLE-DOT
ESTRING
PREMARIN CREAM, VAGIFEM
ESTROGEL
estradiol,
DIVIGEL, EVAMIST, VIVELLE-DOT
FEMRING
PREMARIN CREAM, VAGIFEM
FEMTRACE
estradiol
,
estropipate
,
PREMARIN
FENOGLIDE
fenofibrate
,
ANTARA, LIPOFEN,
TRICOR, TRILIPIX
FIRST TESTOSTERONE
ANDRODERM, AXIRON, FORTESTA
FLECTOR
diclofenac, meloxicam, naproxen
FLOVENT, FLOVENT HFA
ASMANEX, PULMICORT FLEXHALER, QVAR
FORTAMET
metformin, metformin ext-rel
FOSAMAX PLUS D
alendronate, ibandronate,
ACTONEL, ATELVIA
FREESTYLE STRIPS AND KITS
4
ACCU-CHEK STRIPS AND KITS
3
, ONETOUCH
STRIPS AND KITS
3
FROVA
naratriptan, sumatriptan
, MAXALT, ZOMIG
GENOTROPIN
HUMATROPE, NORDITROPIN
GLUMETZA
metformin, metformin ext-rel
HUMALOG
APIDRA, NOVOLOG
HUMALOG MIX 50/50
NOVOLOG MIX 70/30
HUMALOG MIX 75/25
NOVOLOG MIX 70/30
HUMULIN
NOVOLIN
INNOPRAN XL
atenolol
,
carvedilol, metoprolol,
metoprolol succinate ext-rel, nadolol, propranolol,
propranolol ext-rel
, BYSTOLIC, COREG CR
INTERMEZZO
zolpidem, zolpidem ext-rel
ISTALOL
timolol maleate solution
, BETIMOL
KOMBIGLYZE XR
JANUMET, JANUMET XR, JENTADUETO
LIVALO
atorvastatin, fluvastatin, lovastatin, pravastatin,
simvastatin,
CRESTOR, LESCOL XL, VYTORIN
LUMIGAN
latanoprost,
TRAVATAN Z, ZIOPTAN
LUNESTA
zolpidem, zolpidem ext-rel
MAXAIR
PROAIR HFA, PROVENTIL HFA
MENEST
estradiol
,
estropipate
, PREMARIN
MENOSTAR
estradiol
, DIVIGEL, EVAMIST, VIVELLE-DOT
NUTROPIN, NUTROPIN AQ
HUMATROPE, NORDITROPIN
OLEPTRO
trazodone
OLUX-E
clobetasol propionate foam
OMNARIS
flunisolide, fluticasone, triamcinolone
, NASONEX
OMNITROPE
HUMATROPE, NORDITROPIN
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document.
For specific information, visit
www.caremark.com
or contact a CVS Caremark Customer Care representative.
DRUG NAME(S)
PREFERRED ALTERNATIVE(S)*
ONGLYZA
JANUVIA, TRADJENTA
OXYTROL
4
oxybutynin ext-rel, tolterodine, trospium,
GELNIQUE,
VESICARE
PATANASE
azelastine
, ASTEPRO
PEXEVA
citalopram
,
escitalopram, fluoxetine
,
paroxetine
,
paroxetine ext-rel
,
sertraline
,
VIIBRYD
PRECISION XTRA STRIPS AND
KITS
ACCU-CHEK STRIPS AND KITS
3
, ONETOUCH
STRIPS AND KITS
3
PRED MILD
dexamethasone
, DUREZOL, LOTEMAX
PREFERAOB
CITRANATAL
PREFEST
estradiol-norethindrone
,
PREMPHASE, PREMPRO
QNASL
flunisolide, fluticasone, triamcinolone,
NASONEX
RELION INSULIN
NOVOLIN INSULIN
RELPAX
naratriptan, sumatriptan
, MAXALT, ZOMIG
RHINOCORT AQUA
flunisolide, fluticasone, triamcinolone
, NASONEX
RIOMET
metformin, metformin ext-rel
ROZEREM
zolpidem, zolpidem ext-rel
RYZOLT
tramadol ext-rel
SAIZEN
HUMATROPE, NORDITROPIN
SANCTURA XR
4
oxybutynin ext-rel, tolterodine, trospium
, GELNIQUE,
VESICARE
DRUG NAME(S)
PREFERRED ALTERNATIVE(S)*
SKELID
alendronate
,
ACTONEL
STRIANT
ANDRODERM, AXIRON, FORTESTA
SURE-TEST STRIPS AND KITS
ACCU-CHEK STRIPS AND KITS
3
, ONETOUCH
STRIPS AND KITS
3
TESTIM
ANDRODERM, AXIRON, FORTESTA
TEVETEN, TEVETEN HCT
eprosartan, irbesartan, irbesartan-
hydrochlorothiazide, losartan, losartan-
hydrochlorothiazide
, BENICAR, BENICAR HCT,
DIOVAN, DIOVAN HCT, MICARDIS, MICARDIS HCT
TEV-TROPIN
HUMATROPE, NORDITROPIN
TOVIAZ
oxybutynin ext-rel, tolterodine, trospium
, GELNIQUE,
VESICARE
TRIGLIDE
fenofibrate,
ANTARA, LIPOFEN, TRICOR, TRILIPIX
TRUE CARE STRIPS AND KITS,
TRUETEST STRIPS AND KITS,
TRUETRACK STRIPS AND KITS
ACCU-CHEK STRIPS AND KITS
3
, ONETOUCH
STRIPS AND KITS
3
VANOS
clobetasol
VENTOLIN HFA
PROAIR HFA, PROVENTIL HFA
VERAMYST
flunisolide, fluticasone, triamcinolone
, NASONEX
XOPENEX HFA
PROAIR HFA, PROVENTIL HFA
ZETONNA
flunisolide, fluticasone, triamcinolone,
NASONEX
ZYFLO, ZYFLO CR
montelukast, zafirlukast
You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information.
FOR YOUR INFORMATION:
Generics should be considered the first line of prescribing.
This drug list represents a summary of prescription coverage. It is not inclusive and does not
guarantee coverage. Any brand drug for which a generic product becomes available may be designated as a non-preferred product. Specific prescription benefit plan design may not cover
certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay for specific products on the list. Unless
specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS and generic products in lowercase
italics
. Generics listed in therapeutic
categories are for representational purposes only. This is not an all-inclusive list. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list
will be consistent with the category and use where listed. Log in to
www.caremark.com
to check coverage and copay information for a specific medicine.
*
The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.
§ Generics are available in this class and should be considered the first line of prescribing.
1
Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription
price, a fixed amount or other charge, with the balance, if any, paid by a Plan.
2
Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment Recommendations.
3
An Accu-Chek or OneTouch blood glucose meter will be provided at no charge by the manufacturer to those individuals currently using a meter other than Accu-Chek or OneTouch. For
more information on how to obtain a blood glucose meter, call toll-free: 1-800-588-4456. Members must have CVS Caremark Mail Service Pharmacy benefits to qualify.
4
A medical exception process is in place for specific clinical circumstances that may require continued coverage for one of these specific drugs: Freestyle diabetic test strips, Oxytrol and
Sanctura XR. If your doctor believes you have a specific clinical need for one of these drugs, he or she should fax a medical exception request to 1-866-443-1172.
Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information.
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 prescriber.
©2013 Caremark Rx, L.L.C. All rights reserved. 15045-1-0113 v2
www.caremark.com