Specialty Comprehensive Drug List

[Pages:17]January 2022

Updated Quarterly

CVS Specialty? Pharmacy Distribution Drug List

Providing one of the broadest offerings of specialty pharmaceuticals in the industry

The CVS Specialty Pharmacy Distribution Drug List is a guide of medications available and distributed through CVS Specialty. Our goal is to help make your life better. With more than 40 years of experience, CVS Specialty provides quality care and service. Our network of pharmacies includes certifications and accreditations from the Joint Commission, Utilization Review Accreditation Commission (URAC), the National Association of Boards of Pharmacy (NABP) and the Accreditation Commission for Health Care (ACHC). These nationally recognized symbols reflect an organization's commitment to meet highest standards of quality, compliance and safety. This list is updated quarterly. Below brand-name products are in CAPS, and generic products are shown in lowercase italics.

Prospective Patients: Ready to get started? Enroll to get your medications from CVS Specialty .

Health Care Providers: Visit the CVS Specialty website to download enrollment forms or call 1-800-237-2767 (TTY: 711).

Therapy Class

Acromegaly

Alcohol/Opioid Dependency Allergen Immunotherapy Alpha-1 Antitrypsin Deficiency Amyloidosis Anemia

Asthma

Atopic Dermatitis Bone Disorders ? Other Botulinum Toxins Cardiac Disorders

Brand Name

BYNFEZIA PEN SANDOSTATIN SANDOSTATIN LAR SOMATULINE DEPOT SOMAVERT SUBLOCADE VIVITROL ORALAIR PALFORZIA

ARALAST NP GLASSIA ZEMAIRA ONPATTRO VYNDAMAX VYNDAQEL ARANESP EPOGEN PROCRIT REBLOZYL RETACRIT CINQAIR DUPIXENT FASENRA NUCALA XOLAIR

DUPIXENT VOXZOGO DYSPORT MYOBLOC XEOMIN ARCALYST TIKOSYN

Generic Name

octreotide acetate (SANDOSTATIN)

dofetilide (TIKOSYN)

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 1 of 17

January 2022

Updated Quarterly

Therapy Class

Brand Name

Coagulation Disorders

CEPROTIN

Contraceptives

KYLEENA

LILETTA

MIRENA NEXPLANON

SKYLA

Cryopyrin-Associated Periodic Syndromes

ARCALYST ILARIS

Cystic Fibrosis

BETHKIS

BRONCHITOL

CAYSTON KITABIS PAK

PULMOZYME TOBI

TOBI PODHALER

Endocrine Disorders ? Other

CORTROPHIN

Electrolyte Disorders

SAMSCA

Enzyme Deficiency Disorders - Other

Gastrointestinal Disorders ? Other

GATTEX

MYTESI OCALIVA

SOLESTA

Gout

KRYSTEXXA

Growth Hormone & Related Disorders EGRIFTA

EGRIFTA SV GENOTROPIN

HUMATROPE INCRELEX

MACRILEN NORDITROPIN

NUTROPIN AQ

OMNITROPE SAIZEN

SEROSTIM SKYTROFA

ZOMACTON ZORBTIVE

Hematopoietics

MOZOBIL

Hemophilia, Von Willebrand Disease ADVATE

& Related Bleeding Disorders

ADYNOVATE

AFSTYLA ALPHANATE

ALPHANINE SD ALPROLIX

BENEFIX COAGADEX

CORIFACT ELOCTATE

ESPEROCT FEIBA

FIBRYGA

Generic Name

tobramycin (BETHKIS) tobramycin nebulizer (TOBI)

tolvaptan (SAMSCA) nitisinone

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 2 of 17

Therapy Class

Hemophilia, Von Willebrand Disease & Related Bleeding Disorders (cont.)

Hepatitis

Brand Name

HEMLIBRA HEMOFIL M HUMATE-P IDELVION IXINITY JIVI KOATE KOATE-DVI KOGENATE FS KOVALTRY MONONINE NOVOEIGHT NOVOSEVEN RT NUWIQ OBIZUR PROFILNINE PROFILNINE SD REBINYN RECOMBINATE RIASTAP RIXUBIS SEVENFACT STIMATE TRETTEN VONVENDI WILATE XYNTHA BARACLUDE EPCLUSA EPIVIR HBV HARVONI HEPSERA INTRON A LEDIPASVIR-SOFOSBUVIR MAVYRET PEGASYS PEGINTRON SOFOSBUVIR/VELPATASVIR SOVALDI VEMLIDY VIEKIRA PAK VIREAD VOSEVI ZEPATIER

January 2022

Updated Quarterly

Generic Name

adefovir dipivoxil (HEPSERA) entecavir (BARACLUDE) lamivudine hbv (EPIVIR HBV) ribavirin caps ribavirin tabs tenofovir disoproxil fumarate (VIREAD)

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 3 of 17

January 2022

Updated Quarterly

Therapy Class

Hereditary Angioedema Hormonal Therapies

Human Immunodeficiency Virus

Brand Name

BERINERT CINRYZE FIRAZYR HAEGARDA KALBITOR RUCONEST TAKHZYRO AVEED ELIGARD FENSOLVI FIRMAGON LUPRON LUPRON DEPOT NATPARA SUPPRELIN LA TRELSTAR ZOLADEX APTIVUS ATRIPLA BIKTARVY CABENUVA CIMDUO COMBIVIR COMPLERA CRIXIVAN DELSTRIGO DESCOVY DOVATO EDURANT EMTRIVA EPIVIR EPZICOM EVOTAZ FUZEON GENVOYA INTELENCE INVIRASE ISENTRESS JULUCA KALETRA LEXIVA NORVIR ODEFSEY PIFELTRO PREZCOBIX PREZISTA RESCRIPTOR RETROVIR RETROVIR IV REYATAZ RUKOBIA

Generic Name

icatibant acetate (FIRAZYR)

leuprolide acetate (LUPRON)

abacavir tab (ZIAGEN) abacavir-lamivudine (EPZICOM) abacavir sulfate-lamivudine-zidovudine

(TRIZIVIR) atazanavir sulfate (REYATAZ) didanosine (VIDEX, VIDEX EC) efavirenz (SUSTIVA) efavirenz-emtricitabine-tenofovir df

(ATRIPLA) efavirenz-lamivudine-tenofovir df

(SYMFI, SYMFI LO) emtricitabine (EMTRIVA) emtricitabine-tenofovir df

(TRUVADA) etravirine (INTELENCE) fosamprenavir (LEXIVA) lamivudine (EPIVIR) lamivudine-zidovudine (COMBIVIR) lopinavir-ritonavir (KALETRA) nevirapine (VIRAMUNE, VIRAMUNE XR) ritonavir (NORVIR) stavudine tenofovir disoproxil fumarate (VIREAD) zidovudine (RETROVIR)

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 4 of 17

Therapy Class

Human Immunodeficiency Virus (cont.)

Immune Deficiencies & Related Disorders

Brand Name

SELZENTRY STRIBILD SUSTIVA SYMFI SYMFI LO SYMTUZA TEMIXYS TIVICAY TRIUMEQ TRIZIVIR TROGARZO TRUVADA TYBOST VIDEX VIDEX EC VIDEX SOL VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD ZIAGEN ASCENIV BIVIGAM CUTAQUIG CUVITRU CYTOGAM FLEBOGAMMA DIF GAMASTAN GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX C HEPAGAM B HIZENTRA HYPERHEP B S/D HYPERRHO S/D HYQVIA MICRHOGAM NABI-HB OCTAGAM PANZYGA PRIVIGEN RHOGAM RHOPHYLAC VARIZIG WINRHO SDF XEMBIFY

January 2022

Updated Quarterly

Generic Name

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 5 of 17

January 2022

Updated Quarterly

Therapy Class

Infectious Disease ? Other Infertility

Inflammatory Bowel Disease

Iron Overload Lysosomal Storage Disorders

Mental Health Conditions Migraine Movement Disorders

Brand Name

ACTIMMUNE ALFERON N NUZYRA XENLETA CETROTIDE CHORIONIC GONADOTROPIN FOLLISTIM AQ GANIRELIX ACETATE GONAL-F MENOPUR NOVAREL OVIDREL PREGNYL

AVSOLA CIMZIA ENTYVIO HUMIRA INFLECTRA INFLIXIMAB REMICADE RENFLEXIS SIMPONI ARIA STELARA IV TYSABRI XELJANZ ZEPOSIA DESFERAL EXJADE JADENU ALDURAZYME CERDELGA CEREZYME CYSTAGON ELAPRASE ELELYSO FABRAZYME KANUMA LUMIZYME NAGLAZYME NEXVIAZYME VIMIZIM VPRIV SPRAVATO ZULRESSO ZYPREXA RELPREVV AIMOVIG AJOVY EMGALITY APOKYN AUSTEDO DUOPA

Generic Name

deferasirox (EXJADE, JADENU) deferiprone deferoxamine (DESFERAL) miglustat

droxidopa (NORTHERA) tetrabenazine (XENAZINE)

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 6 of 17

January 2022

Updated Quarterly

Therapy Class

Movement Disorders (cont.) Multiple Sclerosis

Neurological Disorders Neuromuscular Neutropenia

Ocular Disorders

Brand Name

INGREZZA KYNMOBI NORTHERA NOURIANZ NUPLAZID RADICAVA SOLIRIS XENAZINE AMPYRA AUBAGIO AVONEX BAFIERTAM BETASERON COPAXONE CORTROPHIN EXTAVIA GILENYA KESIMPTA LEMTRADA MAVENCLAD MAYZENT OCREVUS PLEGRIDY PONVORY REBIF TECFIDERA TYSABRI VUMERITY ZEPOSIA ADUHELM VYVGART FULPHILA GRANIX LEUKINE NEULASTA NEUPOGEN NIVESTYM NYVEPRIA UDENYCA ZARXIO ZIEXTENZO BEOVU DURYSTA EYLEA ILUVIEN LUCENTIS MACUGEN OZURDEX RETISERT SUSVIMO TEPEZZA

Generic Name

dalfampridine ER (AMPYRA) dimethyl fumarate (TECFIDERA) glatiramer acetate (COPAXONE,

glatopa) mitoxantrone hcl

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 7 of 17

January 2022

Updated Quarterly

Therapy Class

Ocular Disorders (cont.) Oncology ? Injectable

Brand Name

VISUDYNE ABRAXANE ADCETRIS AKYNZEO IV ARZERRA ASPARLAS AVASTIN BAVENCIO BELEODAQ BELRAPZO BENDAMUSTINE HCL BENDEKA BESPONSA BLINCYTO BORTEZOMIB CYRAMZA DACOGEN DARZALEX DARZALEX FASPRO EMPLICITI ENHERTU ERBITUX ERWINAZE EVOMELA FOLOTYN GAZYVA HALAVEN HERCEPTIN HERCEPTIN HYLECTA HERZUMA IMFINZI INTRON A ISTODAX IXEMPRA JEMPERLI JEVTANA KADCYLA KANJINTI KEYTRUDA KHAPZORY KYPROLIS LUMOXITI MARGENZA MVASI MYLOTARG OGIVRI ONCASPAR ONTRUZANT OPDIVO PADCEV PERJETA

Generic Name

azacitidine (VIDAZA) decitabine (DACOGEN) levoleucovorin calcium mitoxantrone hcl temsirolimus (TORISEL) valrubicin (VALSTAR) zoledronic acid

Specialty and non-specialty products distributed by CVS Specialty, as well as products covered by a member's prescription or medical benefit plan, may

change from time to time. In addition, a member's specific benefit plan design may not cover certain products or categories, regardless of their

appearance on this document. Call CVS Specialty at 1-800-237-2767 (TTY: 711) for specific medications available through CVS Specialty. Listing is subject

to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical

manufacturers not affiliated with CVS Specialty. Fax: 1-800-323-2445; e-Prescribe: CVS Specialty Pharmacy.

?2022 CVS Specialty. All rights reserved. 75-CTC14953E January 2022 v01202022 CVS Specialty Pharmacy Distribution Drug List

Page 8 of 17

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