1st Quarter 2020 High, Standard and High Deductible Health ...

1st Quarter 2021

High, Standard, High Deductible Health Plan (HDHP) Specialty Pharmacy Drug List

If you are a plan member or health care provider, please contact Specialty Customer Care at 1-800-237-2767 or visit

.

Drug Name

Drug Form

Preferred or Non- Preauth Preauth

Limited

Preferred

Required Reviewer Distribution

Exclusive to

CVS Specialty

abacavir (tablet, solution)

Oral

Preferred

X

abiraterone acetate (tablet)

Oral

Preferred

X

OA

X

IV/SQ

Non-Preferred

X

CVS

X

X

Actemra (IV solution, PFS,

ACTpen)

Actimmune (solution for

injection)

Adagen

SQ

Non-Preferred

X

CVS/OA

Injection

Preferred

X

CVS

Adakveo

Injection

Non-Preferred

X

CVS

X

IV

Non-Preferred

X

OA

X

Adcirca (tablet)

Oral

Non-Preferred

X

CVS

X

adefovir

Oral

Preferred

Adempas

Oral

Preferred

X

CVS

X

Advate

IV

Non-Preferred

X

CVS

X

Adynovate

IV

Preferred

X

CVS

X

Afinitor

Oral

Preferred

X

OA

X

Afstyla

IV

Non-Preferred

X

CVS

X

Aldurazyme

IV

Non-Preferred

X

CVS

X

Alferon N

Injection

Non-Preferred

X

CVS/OA

X

Aliqopa

Adcetris (powder for inj)

X

X

Injection

Preferred

X

OA

Alphanate

IV

Non-Preferred

X

CVS

X

AlphaNine SD

IV

Non-Preferred

X

CVS

X

Alprolix

IV

Non-Preferred

X

CVS

X

Alunbrig

Oral

Preferred

X

OA

X

Alyq

Oral

Preferred

X

CVS

X

ambrisentan

Oral

Preferred

X

CVS

X

Ampyra

Oral

Non-Preferred

X

CVS

X

Apokyn

Injection

Non-Preferred

X

CVS

X

Aptivus

Oral

Non-Preferred

IV

Non-Preferred

X

CVS

X

Aranesp

IV/Injection

Non-Preferred

X

CVS/OA

X

Arcalyst

Injection

Non-Preferred

X

CVS

X

Arzerra

IV

Non-Preferred

X

OA

X

Asparlas

IV

Non-Preferred

X

OA

Oral

Non-Preferred

X

CVS

Aralast NP

Astagraf XL

atazanavir sulfate

X

X

X

Oral Powder

Preferred

X

Atripla

Oral

Preferred

X

Aubagio

Oral

Preferred

X

Austedo

Oral

Non-Preferred

Avastin

IV

Non-Preferred

Aveed

Injection

Avonex

Injection

Avsola

azacitidine

CVS

X

X

CVS

X

X

CVS/OA

X

Non-Preferred

X

CVS

X

Non-Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

IV/Injection

Preferred

X

OA

Balversa

Oral

Preferred

X

OA

Baraclude (tablet)

Oral

Non-Preferred

X

CVS

X

Baraclude (solution)

X

X

Oral

Preferred

X

CVS

X

Injection

Non-Preferred

X

OA

X

Bebulin

IV

Non-Preferred

X

CVS

X

Beleodaq

IV

Non-Preferred

X

OA

X

Belrapzo

IV

Non-Preferred

X

OA

X

Bendeka

IV

Non-Preferred

X

OA

X

BeneFIX

IV

Non-Preferred

X

CVS

X

Benlysta

IV

Non-Preferred

X

CVS

X

Bavencio

Beovu

Injection

Non-Preferred

X

CVS

X

Berinert

IV

Non-Preferred

X

CVS

X

Besponsa

IV

Preferred

X

OA

X

Betaseron

Injection

Preferred

X

CVS

X

?2020 CVS Specialty. All rights reserved. 75-50648A 121720

Page 1 of 10

Bethkis

Inhalent

Preferred

X

CVS

X

bexarotene

Oral

Preferred

X

OA

X

Biktarvy

Oral

Preferred

Bivigam

Injection

Non-Preferred

X

CVS/OA

X

Blincyto

IV

Non-Preferred

X

OA

X

bortezomib

X

IV

Non-Preferred

X

OA

X

bosentan

Oral

Preferred

X

CVS

X

Bosulif

Oral

Preferred

X

OA

X

Braftovi

Oral

Preferred

X

OA

Buphenyl

Oral

Non-Preferred

X

CVS

X

IV/SQ

Non-Preferred

X

CVS

X

Cabometyx

Oral

Preferred

X

CVS

Calquence

Oral

Preferred

X

OA

capecitabine

Oral

Preferred

X

OA

Caprelsa

Oral

Preferred

X

OA

X

Carbaglu

Oral

Preferred

X

CVS

X

Cablivi

Carimune NF

X

X

X

X

IV

Non-Preferred

X

CVS/OA

Cayston

Inhalant

Preferred

X

CVS

CellCept

Oral, IV

Non-Preferred

X

CVS

X

Ceprotin

IV

Non-Preferred

X

CVS

X

Cerdelga

Oral

Preferred

X

CVS

X

Cerezyme

IV

Preferred

X

CVS

X

Cholbam

Oral

Non-Preferred

X

CVS

Cimduo

Oral

Non-Preferred

X

CVS

X

Cimzia

Injection

Non-Preferred

X

CVS

X

Oral

Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

cinacalcet

Cinqair

Cinryze

X

X

X

IV

Non-Preferred

X

CVS

X

Coagadex

Injection

Preferred

X

CVS

X

Combivir

Oral

Non-Preferred

Cometriq

Oral

Preferred

X

OA

X

Complera

Oral

Non-Preferred

X

CVS

X

Copaxone

Injection

Non-Preferred

X

CVS

X

Copegus

Oral

Non-Preferred

X

CVS

Copiktra

Oral

Preferred

X

OA

Corifact

IV

Non-Preferred

X

CVS

X

Cosentyx

Injection

Preferred

X

CVS

X

Oral

Non-Preferred

X

OA

X

Crixivan

Oral

Non-Preferred

Crysvita

Injection

Non-Preferred

X

CVS

X

Cuvitru

Injection

Non-Preferred

X

CVS/OA

X

Oral

Preferred

Injection

Preferred

X

OA

X

X

Cotellic

cyclosporine

Cyramza

X

X

X

X

X

Cystadane

Oral

Preferred

X

CVS

Cystagon

Oral

Non-Preferred

X

CVS

Cystaran

Opthalmic

Preferred

X

CVS

Cytogam

IV

Non-Preferred

Dacogen

IV

Non-Preferred

X

OA

X

Daklinza

Oral

Non-Preferred

X

CVS

X

Darzalex

IV

Non-Preferred

X

OA

X

Daurismo

Oral

Non-Preferred

X

OA

X

decitabine

IV

Preferred

X

OA

X

deferasirox

Oral

Preferred

X

CVS

X

IV

Preferred

X

CVS

X

Delstrigo

Oral

Non-Preferred

X

CVS

X

Descovy

Oral

Preferred

X

CVS

X

Desferal

Injection

Non-Preferred

X

CVS

X

didanosine

dimethyl fumarate DR

capsules

dofetilide

Oral

Preferred

Oral

Preferred

X

CVS

X

Oral

Preferred

X

CVS

X

Doptelet

Oral

Preferred

X

CVS

X

Dovato

Oral

Non-Preferred

X

CVS

X

Duopa

Oral

Preferred

X

CVS

Dupixent

IV

Preferred

X

CVS

Edurant

Oral

Preferred

deferoxamine

?2020 CVS Specialty. All rights reserved. 75-50648A 121720

X

X

X

X

X

X

X

Page 2 of 10

efavirenz

Oral

Preferred

Injection

Non-Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

Elelyso

Injection

Non-Preferred

X

CVS

X

Eligard

Injection

Preferred

X

CVS/OA

X

Egrifta

Elaprase

X

Eloctate

IV

Non-Preferred

X

CVS

Emflaza

Oral

Non-Preferred

X

CVS

IV

Non-Preferred

X

OA

Oral

Preferred

Empliciti

emtricitabine/tenofovir

disoproxil fumarate tablets

Emtriva

Oral

Preferred

Enbrel

Injection

Preferred

Endari

Oral

X

X

X

X

X

X

CVS

X

OA

X

Non Covered Benefit

Enhertu

IV

Non-Preferred

entecavir

Oral

Preferred

IV

Non-Preferred

X

CVS

X

Oral, Injection

Non-Preferred

X

CVS

X

Oral

Preferred

X

CVS

X

X

CVS

X

Entyvio

Envarsus XR

Epclusa

Epidiolex

X

X

Oral

Non-Preferred

Epivir

Oral, Solution

Non-Preferred

Epivir HBV

Oral, Solution

Non-Preferred

X

CVS

X

Epogen

IV

Non-Preferred

X

CVS/OA

X

epoprostenol sodium

IV

Preferred

X

CVS

X

Epzicom

Oral

Non-Preferred

erlotinib hydrochloride

Oral

Preferred

X

OA

IV

Non-Preferred

X

OA

X

Erivedge

Oral

Preferred

X

OA

X

Erleada

Oral

Preferred

X

OA

X

Injection

Preferred

X

OA

Oral

Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

Injection

Non-Preferred

X

CVS

X

Oral

Preferred

Oral

Preferred

X

OA

X

IV

Non-Preferred

X

OA

X

Erbitux

Erwinaze

Esbriet

Esperoct

Evenity

everolimus 0.25mg, 0.5mg,

0.75mg

everolimus 2.5mg, 5mg,

7.5mg

Evomela

X

X

X

X

Evotaz

Oral

Preferred

Exjade

Oral

Non-Preferred

X

CVS

Exondys 51

Injection

Preferred

X

CVS

Extavia

Injection

Non-Preferred

X

CVS

X

Eylea

Injection

Non-Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

Farydak

Oral

Non-Preferred

X

OA

X

Fasenra

Injection

Preferred

X

CVS

X

Feiba NF

Injection

Non-Preferred

X

CVS

Ferriprox

Oral

Preferred

X

CVS

Fibryga

IV

Non-Preferred

X

CVS

X

Firazyr

Injection

Preferred

X

CVS

X

Firmagon

Injection

Non-Preferred

X

OA

X

IV

Non-Preferred

X

CVS/OA

X

Fabrazyme

Flebogamma

Flebogamma DIF

X

X

X

X

X

IV

Non-Preferred

X

CVS/OA

X

Injection

Non-Preferred

X

CVS

X

Folotyn

IV

Non-Preferred

X

OA

X

Forteo

Injection

Preferred

X

CVS

X

Oral

Preferred

Fulphila

Injection/IV

Non-Preferred

X

CVS/OA

X

Fusilev

IV

Non-Preferred

X

OA

X

Fuzeon

Injection

Preferred

X

CVS

X

GamaSTAN

Injection

Non-Preferred

X

CVS/OA

X

GamaSTAN S/D

Injection

Non-Preferred

X

CVS/OA

X

Gammagard Liquid

Injection

Non-Preferred

X

CVS/OA

X

Gammagard S/D

Injection

Non-Preferred

X

CVS/OA

X

Gammaked

Injection

Non-Preferred

X

CVS/OA

X

Gammaplex

Injection

Non-Preferred

X

CVS/OA

X

Gamunex C

Injection

Non-Preferred

X

CVS/OA

X

Gattex

Injection

Non-Preferred

X

CVS

X

Flolan

fosamprenavir

?2020 CVS Specialty. All rights reserved. 75-50648A 121720

X

Page 3 of 10

Gazyva

IV

Non-Preferred

Gengraf

Oral

Preferred

Injection

Non-Preferred

Genvoya

Oral

Preferred

Gilenya

Oral

Gilotrif

Givlaari

Glassia

Genotropin

X

OA

X

X

X

CVS

Preferred

X

CVS

Oral

Non-Preferred

X

OA

X

Injection

Non-Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

glatiramer acetate

Injection

Preferred

X

CVS

X

GLATOPA

Injection

Preferred

X

CVS

X

Gleevec

Oral

Non-Preferred

X

OA

X

Granix

Injection

Non-Preferred

X

CVS/OA

X

H.P. Acthar Gel

Injection

Non-Preferred

X

CVS

X

Haegarda

Injection

Non-Preferred

X

CVS

X

Halaven

Injection

Non-Preferred

X

OA

X

Harvoni

Oral

Preferred

X

CVS

X

Helixate FS

X

X

X

IV

Non-Preferred

X

CVS

X

Hemlibra

Injection

Non-Preferred

X

CVS

X

Hemofil M

IV

Non-Preferred

X

CVS

X

HepaGam B

Injection

Non-Preferred

Oral

Non-Preferred

X

CVS

X

Herceptin

Injection

Non-Preferred

X

OA

X

Herceptin Hylecta

Hepsera

X

Injection

Non-Preferred

X

OA

Hetlioz

Oral

Preferred

X

CVS

Hizentra

Injection

Non-Preferred

X

CVS/OA

X

Humate-P

Injection

Non-Preferred

X

CVS

X

Humatrope

Injection

Non-Preferred

X

CVS

X

Injection

Preferred

X

CVS

X

Oral/Injection

Non-Preferred

X

CVS/OA

X

X

CVS

X

Humira

Hycamtin

X

X

hydroxyprogesterone caproate

Injection

Preferred

HyperHEP B

Injection

Non-Preferred

X

HyperRHO S/D

Injection

Non-Preferred

X

HyQvia

Injection

Non-Preferred

X

CVS/OA

X

Ibrance

Oral

Preferred

X

OA

X

Injection

Preferred

X

CVS

Oral

Preferred

X

OA

IV

Non-Preferred

X

CVS

X

Idhifa

Oral

Non-Preferred

X

CVS

X

Ilaris

Injection

Non-Preferred

X

CVS

X

Ilumya

Injection

Non-Preferred

X

CVS

X

Iluvien

icatibant acetate

Iclusig

Idelvion

X

X

Injection

Non-Preferred

imatinib mesylate

Oral

Preferred

X

OA

X

Imbruvica

Oral

Preferred

X

OA

Imfinzi

IV

Non-Preferred

X

OA

Imlygic

Injection

Non-Preferred

X

OA

X

X

X

X

X

Inbrija

Inhalant

Preferred

X

CVS

Increlex

Injection

Non-Preferred

X

CVS

X

Inflectra

IV

Non-Preferred

X

CVS

X

Infugem

Injection

Preferred

X

OA

Inlyta

Oral

Non-Preferred

X

OA

X

Inrebic

Oral

Non-Preferred

X

OA

X

X

CVS/OA

X

OA

Intelence

Oral

Preferred

Intron A

Injection

Non-Preferred

Invirase

Oral

Non-Preferred

Iressa

Oral

Preferred

Isentress

Oral

Preferred

Istodax

Injection

Non-Preferred

X

OA

X

Ixempra

Injection

Non-Preferred

X

OA

X

Ixinity

Inection

Non-Preferred

X

CVS

X

Jadenu

Oral

Non-Preferred

X

CVS

X

Jakafi

Oral

Non-Preferred

X

OA

X

Jevtana

Injection

Non-Preferred

X

OA

X

Jivi

Injection

Preferred

X

CVS

X

Juluca

Oral

Non-Preferred

X

CVS

X

Juxtapid

Oral

Non-Preferred

X

CVS

X

Jynarque

Oral

Preferred

X

CVS

X

?2020 CVS Specialty. All rights reserved. 75-50648A 121720

X

X

X

X

X

Page 4 of 10

Kadcyla

Injection

Non-Preferred

X

OA

X

Kalbitor

Injection

Non-Preferred

X

CVS

X

Kaletra solution

Oral

Non-Preferred

Kaletra tablets

Oral

Preferred

Kalydeco

Oral

Non-Preferred

X

Kanjinti

Injection

Non-Preferred

X

OA

X

Kanuma

Injection

Non-Preferred

X

CVS

X

Keveyis

Oral

Preferred

X

CVS

Kevzara

Injection

Preferred

X

CVS

X

Keytruda

Injection

Non-Preferred

X

OA

X

Khapzory

IV

Non-Preferred

X

OA

X

Kineret

Injection

Non-Preferred

X

CVS

Kisqali

ORAL

Preferred

X

OA

X

Kisqali Femara

ORAL

Preferred

X

OA

X

Kitabis Pak

Inhalant

Non-Preferred

X

CVS

X

Koate-DVI

IV

Non-Preferred

X

CVS

X

Kogenate FS

X

X

CVS

X

X

X

IV

Preferred

X

CVS

Korlym

Oral

Preferred

X

CVS

Kovaltry

IV

Non-Preferred

X

CVS

X

Krystexxa

Injection

Non-Preferred

X

CVS

X

Oral

Non-Preferred

X

CVS

X

Injection

Non-Preferred

X

CVS

X

OA

Kuvan

Kynamro

Kyprolis

X

X

X

Injection

Non-Preferred

Oral, Solution

Preferred

X

lamivudine HBV

Oral

Preferred

X

lamivudine-zidovudine

Oral

Preferred

X

Injection

Preferred

X

lamivudine

Lartruvo

ledipasvir/sofosbuvir

CVS

X

X

Oral

Preferred

X

CVS

X

Lemtrada

IV

Non-Preferred

X

CVS

X

Lenvima

Oral

Preferred

X

OA

X

Letairis

Oral

Non-Preferred

X

CVS

X

Leukine

Injection

Non-Preferred

X

CVS/OA

X

leuprolide acetate kit

Injection

levoleucovorin calcium

Injection

Preferred

OA

X

Oral

Non-Preferred

Lexiva

Non Covered Benefit

X

X

Libtayo

IV

Preferred

X

OA

Lonsurf

Oral

Non-Preferred

X

OA

lopinavir ritonavir solution

Oral

Preferred

Lorbrena

Oral

Non-Preferred

X

OA

X

Lucentis

Injection

Non-Preferred

X

CVS

X

IV

Non-Preferred

X

CVS

X

Lumoxiti

Injection

Non-Preferred

X

OA

X

Lupaneta Pack

Injectable

Non-Preferred

X

CVS

X

Lupron Depot 11.25mg

Injection

Non-Preferred

X

CVS/OA

X

Lucentis

Injection

Non-Preferred

X

CVS

X

Lupron Depot 22.5mg

Injection

Non-Preferred

X

CVS/OA

X

Lupron Depot 3.75mg

Injection

Non-Preferred

X

CVS/OA

X

Lupron Depot 30mg

Injection

Non-Preferred

X

CVS/OA

X

Lupron Depot 45mg

Injection

Non-Preferred

X

CVS/OA

X

Lupron Depot 7.5mg

Injection

Non-Preferred

X

CVS/OA

X

Oral

Preferred

X

OA

X

Macugen

IV

Non-Preferred

X

CVS

X

Makena

Injection

Non-Preferred

X

CVS

X

Marqibo

Injection

Preferred

Mavenclad

Oral

Non-Preferred

X

CVS

X

Mavyret

Oral

Non-Preferred

X

CVS

X

Mayzent

Oral

Preferred

X

CVS

X

Mekinist

Oral

Non-Preferred

X

OA

Mektovi

Oral

Preferred

X

OA

X

Mepsevii

IV/Injection

Preferred

X

CVS

X

IV

Non-Preferred

Injection

Non-Preferred

X

CVS

X

Lumizyme

Lynparza

MICRhoGAM

Mircera

mitoxantrone

X

X

X

X

X

X

IV

Preferred

X

OA

X

Oral

Non-Preferred

X

CVS

X

Monoclate-P

IV

Non-Preferred

X

CVS

X

Mononine

IV

Non-Preferred

X

CVS

X

Moderiba

?2020 CVS Specialty. All rights reserved. 75-50648A 121720

Page 5 of 10

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