VCVS c:aremark""
`
`CVS Caremark®
`
`Value Formulary
`Effective as of 10/01/2016
`
`Page 1 of 50
`
`AstraZeneca Exhibit 2219
`Mylan v. AstraZeneca
`IPR2015-01340
`
`

`

`Value Formulary
`
`Effective 1EIr'01I201Ei
`
`INTRODUCTION ..................................................................................................................................................................................................... ..4
`PREFACE ............................................................................................................................................................................................................... ..‘I
`
`PHARMACY AND THERAPEUTICS [P&T] COMMITTEE .......'..'..:.'.........................................................................................................................II
`DRUG LIST PRODUCT
`
`SPECIALTY MEDICATIONS.........................................
`PLAN
`
`-I-J
`
`.
`
`..........................
`
`PREVENTIVE SERVICES................................
`....... ..
`
`....................................................... ..
`
`|'IIOTlCE.....
`
`ANALGES|CS..........................
`
`ANALGESICS. OTHER
`
`
`OPIOID ANALGESICS .... ..
`
`VISCOSUPPLEMENTS
`ANTI-INFECTIVES
`
`ANTIBACTERIALS
`ANTIF UNGALS .....................
`
`ANTIRETROVIRAL AGENTS
`ANTITUBERCULAR AGENTS __
`. . , . . ..
`ANTIVIRALS . . . . . . . . . . . ... . . . .. . . . . . .. . . . . .
`MISCELLANEOUS ..................................................................................................................................................................................... ..
`
`
`
`toEnbobabnbobn'-.13-.1
`
`
`
`ORAL HORMONAL ANTINEOPLASTIC AGENTS ........ ._
`
`ORAL NON-HORMONAL ANTINEOPLASTIC AGENTS.
`MISCELLANEOUS ..................................................................................................................................................................................... ..
`
`ACE INHIBITORS................................................................................. ..
`
`ACE INHIBITORICALCIUM CHANNEL BLOCKER COMBINATIONS ..
`
`. . . . . . . . . . . . . . . . . .
`ACE INHIBITORIOIURETIC COMBINATIONS . . . . . . . . . . . . . . . . .... . . .. . . . . ... . . . . . . .
`. . ..
`
`ADRENOLYTICS. CENTRAL.. . . .... . . . . . . . .. . . . . . .
`. . . . .. . . . . . . . . . . . .. . . . . . .
`. . . . . . . . . . . . . . . ... . . ..
`ALDOSTERONE RECEPTOR ANTAGONISTS ............................................... ..
`
`ANGIOTENSIN II RECEPTOR ANTAGONISTSIDIURETIC COMB|NAT|ONS..
`
`ANTIARRHYTHMICS ..........................................................................................
`
`..
`ANT|L|PEMICS.............
`
`BETA-BLOCKERS ..................................................................................................................................................................................... ..
`BETA-BLOCKERIOIURETIC
`CALCIUM CHANNEL BLOCKERS ................... ..
`
`DIGITALIS GLYCOSIDES ............ ..
`DIURETICS ............................................................................................... .:.............................
`
`NEPRILYSIN INHIBITORIANGIOTENSIN II RECEPTOR ANTAGONIST COMB! NATIONS ..
`..... ..
`..... ..
`. . . . . ..
`. . . . . ..
`
`
`
`
`
`PULMONARY ARTERIAL HYPERTENSION . . . . .
`MISCELLANEOUS . . .
`.
`. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
`CENTRAL NERVOUS SYSTEM.
`ANTIANXIETY ................. ..
`ANTICONVULSANTS ..
`ANTIDEMENTIA ......... ..
`ANTIDEPRESSANTS
`ANTIPARKINSONIAN AGENTS
`ANTIPSYCHOTICS .................................................... ..
`
`ATTENTION DEFICIT HYPERACTIVITY DISORDER
`
`
`
`
`©2016 CVS Caremark. A1l righls reserved. 108-259548 100116
`Your plwacy is important to us. Our employees are Irained regarding the appropriate way lo handle your private heallh Information.
`
`Page 2 of 50
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`

`

`MIGRAINE........................
`
`MOOD STABILIZERS
`
`MULTIPLE SCLEROSIS AGENTS
`
`MUSCULOSKELETAL THERAPY AGENTS ..
`
`MYASTHENIA GRAVIS
`
`
`PSYCHOTHERAPEUTIC-MISCELLANEOUS ...... ..
`
`MISCELLANEOUS.............................................
`
`ENDOCRINE AND METABOLIC
`
`ANDROGENS
`
`ANTIDIABETICS ..................
`
`CALCIUM REGULATORS
`CONTRACEPTIVES
`
`ENOOMETRIOSIS
`
`ESTROGENS.......................
`
`ESTROGENIPROGESTINS.
`GLUCOCORTICOIDS
`
`GLUCOSE ELEVATING AGENTS. ..
`
`HUMAN GROWTH
`
`HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS
`
`PHOSPHATE BINDERAGENTS
`
`SELECTIVE ESTROGEN RECEPTOR MODULATORS.
`
`TI-IYROID AGENTS
`
`VASOPRESSINS
`
`MISCELLANEOUS.
`
`GASTROINTESTINAL
`
`ANTIDIARRHEALS .
`ANTIEI-‘IETICS ...........
`
`ANTISPASMODICS ...... ..
`
`CHOLELITHOLYTICS ................. ..
`
`Hz RECEPTOR ANTAGON|STS........
`..
`
`INFLAMMATORY BOWEL DISEASE ..,.
`
`IRRITABLE SOWEL SYNDROME
`
`
`
`
`
`
`l\Jh)bJh.)l\3I\)l"s)h.3l*Jl\3l\Jl\.IH0!\-Jh.3h.)!\)h-3hu)I\.3l\)|\-Jl\Jf\3|\)l\')h.}hJl\J;|-BI'|n.'lI"n)lN-'|I\.'|l\.3hr.‘lI'\.'lI'\..'ll\)"'*-l"'|-u-1""-1""-4""-l“'|-JO'}CflD')O'IG'}C3UIO1C.l'I{.}1U'!CJ1K.fl\'.flU101(.n-5'0-h-CAJIJJHJTNJPHJI\)—‘v—*~—|-5-5-I‘-‘-5
`
`
`
`
`
`caratscncntotocnnoaauocacoaoaama:"--J‘-.1"--J"--4
`
`..
`OPIOID-INDUCED CONSTIPATION
`........... ..
`PANCREATIC
`............................................................................................................................ ..
`
`PROSTAGLANDINS
`
`PROTON PUMP INHIBITORS.
`
`SALIVA STIMULANTS ................ ..
`
`STEROIDS, RECTAL .....-
`..
`
`
`SENIGN PROSTATIC I-IYPERPLASIA..
`URINARY ANTISPASMODICS
`VAGINAL ANTI-INFECTIVES ..... ..
`
`
`
`..
`
`
`ANTICOAGULANTS
`PLATELET AGGREGATION INHIBITORS
`PLATELET SYNTHESIS INHIBITORS .... ..
`
`
`
`BIOLOGIC DISEASE-MODIFYING
`DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS)
`
`IMMUNOSUPPRESSANTS
`
`
`..
`..
`\ .
`NUTR|TIONAUSUPPLEMENTS....
`..
`
`ELECTROLYTES . . . . , . . . . . . . . ...
`. . . .. . . ..
`..
`
`
`
`
`©2015 CVS Caremark. AI! Iighls reserved. 1065259548 100116
`Your privacy is Eruponant to us. Our empIoyee5 are Irained regarding the appropriate way to handle your private health Infommalion.
`
`Page 3 of 50
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`Page 3 of 50
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`

`

`RESPIRATORY
`ANAPHYLAXIS TREATMENT AGENTS
`
`ANTICHOLINERGICS ...............................................
`....... _.
`
`ANTICHOLINERGICIBETA AGONIST COMB!NATlONS.....
`
`ANTIHISTAMINES, LOW SEDATlNG...............................
`
`ANTIHISTAMINES. NONSEDATING...................
`ANTIHISTAMJNES, SEDATING ...................................................................................................................................... ..
`
`ANTIHISTAMJNBDECONGESTANT COMB|NAT|ONS.,.
`
`ANTITUSSIVES.......................................................... ..
`
`ANTITUSSIVE COMBINATIONS...
`
`BETA AGONISTS ........................ ..
`CYSTIC FIBROSIS ............................................ ..
`
`LEUKOTRIENE RECEPTOR ANTAGONISTS
`NASAL ANTIHISTAMINES ................................ ..
`
`NASAL STEROIDS ........................................ ..
`
`STEROIDIBETA AGONIST COMBINATIONS.
`
`STEROID INHALANTS .................................. ..
`
`XANTHINES
`
`MISCELLANEOUS...
`
`TOPICAL
`DERMATOLOGY................................... ..
`MOUTHFTHROATIDENTAL AGENTS
`OPHTHALMIC
`
`OTIC ............... ..
`
`
`
`
`
`
`-2:::Ln):86$EESBESN3%.-_-_-_-_-_-——c::c:n:n:u:u:;c:.e:.
`
`@201 E CVS Caremark. All rights reserved. 105-259548 100116
`Your privacy is fmponanl lo us. Our employees are trained regarding the appropriate way to handle your private heallh infomwlion.
`
`Page 4 of 50
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`Page 4 of 50
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`

`

`INTRODUCTTON
`
`We are pleased to provide the 2016 Value Formuiary as a useful reference and informational tool. This
`document can assist practitioners in selecting clinically appropriate and cos-t—efiective products for their
`patients.
`
`The drugs represented have been reviewed by a National Pharmacyand Therapeutics {F'&T) Committee and
`are approved for inclusion. The document is reflective of current medical practice as of the date of review.
`
`The information contained in ttiis document and its appendices is provided solely for the convenience of
`medical providers. We do not.warrant or assure accuracy of such information nor is it intended to be
`comprehensive in nature. This document is not intended to be a substitute for the knowledge, expertise, skill
`and judgment of the medical provider in his or her choice of prescription drugs. All the information in the
`document is provided as a reference for drug therapy selection. Specific drug selection for an individual
`patient rests solely with the presoriber.
`
`The document is subject to state-specific regulations and rules, including, but not limited to. those regarding
`generic substitution, controlled substance schedules. preference for brands and mandatory generics
`whenever applicable.
`
`We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in
`whole or in part. on the informafron contained herein. The medical provider should consult the drug
`manufacturers product literature or standard references for more detailed information.
`
`National guidelines can be found on the National Guideline Clearinghouse site at
`http:liw'irrw.guideline.gov, on the websites listed under each therapeutic class and on the sites listed in the
`Websites section of this publication.
`
`PREFACE
`
`The document is organized bysections. Each section is divided by therapeutic drug class primarily defined
`by mechanism of action. Products are listed by generic name with brand name for reference only. Unless. the
`cited drug is available as an injectable or an exception is specifically noted, generally. all applicable dosage
`forms and strengths of the drug cited are included in the document.
`
`Drugs represented in this document may have varying cost to the plan member based on the plan‘s benefit
`structure. Generic medications typically are available at the lower cost. brand"-name medications on the
`document will generally cost more than generics. Generics should be considered the first fine of prescribing
`subject to applicable rules.
`
`PHARMACY P-ND THERAPEUTICS (P8:-T) COMMITTEE
`
`The services of an independent National Pharmacy and Therapeutics Committee ("P&T Committee’) are
`utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory
`body of clinical professionals from across the United States. The PET Committee's voting members include
`physicians, pharmacists, a pharmaooeconomist and a medical ethicist, all of whom have a broad background
`ofolinlcal and academic expertise regarding prescription drug- Employees with significant clinical expertise
`are invited to meet with the P&T Committee, but no CVS Carernarli employee may vote on issues before the
`P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts
`of interest with any pharmaceutical manufacturers.
`
`DRUG LIST PRODUCT DESCRIPTIONS
`
`To assist in understanding which specific -strengths and dosage forms on the document are covered, examples
`are noted below. The general principles shown in the examples can usually be extended to other entries in the
`document. Any exceptions are noted.
`
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`
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`

`

`Listed products on the document generally include all strengths and all oral dosage forms of the cited
`product.
`texapro
`escrtalopram
`Oral tablets, oral solution-and all strengths of Lexapro would be included in this listing.
`
`Nasal sprays require a separate entry.
`sornainipran nasal spray
`
`_
`
`_
`
`Oral disintegrating tablets require a separate entry.
`ondanserron oraiiy disintegrating tabs
`
`lrjectalzrle dosage forms require a separate entry.
`sumatriptan inf
`
`lnrilrex
`
`Zofiran DDT
`
`imitrex
`
`when a strength or dosage form is specified. only the specified strength and dosage form is on the
`document. other strengthsidosage forms, including injeotahle dosage forms of the reference product are
`not.
`
`terbinafine tabs
`
`Larnisil
`
`The tablets formulation is listed on the document. but the oral granules are not.
`
`Extended-release and delayed-release products require their own entry.
`melfonnin
`Glucopnage
`The immediate-release product listing of Gluoophage alone would not include the extended-release
`product Gluoophage XR.
`
`Giucophage XR
`metformin ext-nei
`A separate entry for Glucophage XR continue that the extended-release product is on the document.
`
`Dosage forms on the document will be consistent with the category and use where listed.
`
`Conisporin
`neomycin/poiymyxin Bfhyttroconisone
`Since Cortisporin is listed only in the OTIC section, it is limited to the one solution and suspension. From this
`entry the topical cream cannot be assumed to be on the list unless there is an entry for this product in the
`DERMATOLOGY section of tltedocumenl.
`
`GEN ERIC SUBSTITUTION
`
`Generic substitution is a phannacy action whereby a generic version is dispensed rather than a prescribed
`brand-name product. Boldface type indicates generic availability. However. not all strengths or dosage
`forms of the generic name in boldface type may be generically available. In most instances, a brand-name
`drug for which a generic product becomes available will become rron~formulary, with the generic product
`covered in its place, upon release of the generic product onto the market. However, the document is subject
`to slate specific regulations and ‘rules regarding generic substitution and mandatory generic rules apply
`where appropriate.
`
`Generic. drugs are usually priced lower than their brand-name-equivalents. Prescription generic dnlgs are:
`
`-
`
`0
`
`Approved by the US". Food and Drug Adminislrafion for safety and effectiveness. and are
`manufactured under the same strict standards that apply to brand-name drugs.
`Tested in "humans to assure the generic is absorbed into the bloodstream in a similar rate and
`extent compared‘ to the brand-name drug (bioequivalenoe). Generics may be different from the
`brand in size. color and inactive ingredients. but this does not alter their effectiveness or ability to
`be absorbed just like the brand-name drug.
`* Manufactured in the same strength and dosage form as the brand-name drugs.
`
`when a generic drug is substituted for a brand-name drug. You can expect the generic to produce the same
`clinical effect and safety profile as the brand-name drug [therapeutic eqoivatence).
`
`@2015 Bus caren1ar1r.AlIrighIs reserved. 108-259543 100116
`Your privacy is important to us. Our emptoyees are trained regarding the appropriate way to handle your private heatlh Iniomauon.
`
`Page 6 of 50
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`Page 6 of 50
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`

`S-F'ECiALT‘r' MEDICATIONS
`
`A new, rapidly growing category of drugs, specialty medications are the result of continued advances in drug
`development technology and design. They are created to target and treat complex chronic or genetic medical
`conditions and include bioenglneered proteins. blood-derived products and complex molecules. The
`therapeutic categories listed below include products that are covered as part of the Specialty benefit.
`
`Acromegaly
`AloohollOpioid Dependency
`Allergic Asthma
`Alpha-1 Antitrypsin Deficiency
`Anemia
`Botulinum Toxins [non-cosmetic use only}
`Cardiac Disorders
`
`Contraceptives
`Cryopyrin-Associated Periodic Syndromes
`Cystic Fibrosis
`Dupuytren's Contractors
`Gastrointestinal Disorders-Other
`Gout
`Growth Hormone Si Related Disorders
`Hematopoietics
`Hemophilia. Von Willebrand Disease &
`Related Bleeding Disorders
`Hepatitis
`Hereditary Angioedema
`HIV Medications
`
`Hormonal Therapies
`immune Deficiencies 8: Related Disorders
`
`immune (Idiopathic) Thrombocytopenic Purpura
`infectious Disease
`
`inflammatory Bowel Disease
`
`Specialty Guideline Management (SGM)
`
`Iron Overload
`Lipid Disorders
`Lysosomal Storage Disorders
`Movement Disorders
`Multiple Sclerosis
`Neulropenia
`Oncology — lnjectable
`Oncology — Ora|l'Topical
`Osteoarthritis
`
`Osteoporosis
`Pain Management
`Paroxysmal Nocturnal Hemogloblnuria
`Phenyllretonuria
`Pre-Term Birth
`Psoriasis
`
`Pulmonary Arterial Hypertension
`Renal Disease
`
`Respiratory Syncytial Virus
`Retinal Disorders
`Rheumatoid Arthritis
`Seizure Disorders
`
`Systemic Lupus Erythematosus
`Transplant
`Urea Cycle Disorders
`
`SGM is our utilization management program that helps ensure appropriate utilization for specialty
`medications based on currently accepted evidence—based medicine guidelines. The utilization management
`program is available for therapeutic areas dispensed by our specialty pharmacies. SGM is designed to help
`ensure safety and etticacy while preventing off-guideline utilization. Medications which may be included in
`the SGM program are identified in the document as "SP" for your reference. For additional information,
`please refer to vrww.cvsspecialty.com or to submit a prior authorization. please call
`866-314-5506.
`
`PLAN DESIGN
`
`The document represents a closed forrnulary plan design. Certain medications on the list are covered if
`utilization management criteria are met li.e., Step Therapy, F’_rior Authorization, Quantity Limits, etc];
`requests for use of such medications outside of their listed criteria will be reviewed for medical necessity. If a
`medication is not listed on the document, a formulary exception may be requested for coverage. Medical
`necessity or formulary exception requests will be reviewed based on drug-specific prior authorization criteria
`or standard non-forrnulary prescription request criteria.
`
`Individual pharmacy benefit plans may impose restrictions or not reimburse some products. In addition, over-
`the-counter [OTC] products, with the exception of insulin and diabetes monitoring products, are usually not
`included in the pharmacy benefit. it covered in the pharmacy benefit, OTC products require a valid
`prescription. OTC products are listed for informational purposes.
`
`Log in to www.caremark.com to check coverage.
`
`mtitta‘ CV5 Caremarlt. All rights reserved. ‘I06-259543 1Elt31l6
`Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health Information
`
`Page 7 of 50
`
`Page 7 of 50
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`

`

`PREVEl\lTllJE SERVICES
`
`The US. Department of Health and Human Services {HHS} has adopted Guidelines for Preventive Services
`under the Affordable Care Act {ACA}. Under the ACA, some pharmacy benefit plans may provide a range of
`preventive services for 50 member cost share. These items may include:
`
`' Aspirin to Prevent Cardiovascular Disease
`
`- Bowel Preparations for Colorectal Cancer Screening
`
`- Fluoride Supplementation in Children
`
`' Folic Acid Supplementation for Women Expecting or Planning to be Pregnant
`
`- Tobacco Use Counseling and Cessation Intervention
`
`- Immunizations
`
`- Women's Health Preventive Services (i .e., birth control, emergency contraception}
`
`Items that may be covered as preventive services under this formulary will not be specifically noted since
`final coverage is determined by the plan sponsor. For additional information regarding preventive services,
`please refer to http:i.-'www.hhs.gov.
`
`LEGEND
`
`AL
`OTC
`
`PA
`
`Qt.
`
`SP
`ST
`boldface
`
`delayed-rel
`
`ext-rel
`
`NOTICE
`
`Age Limit
`Over the counter
`
`Prior Authorization
`
`Quantity Limit
`
`Specialty Drug
`Step Therapy
`Indicates generic availability: boldface may not apply to every strength or dosage form
`under the listed generic name
`Delayed-release (also known as enteric-coated], refer to the reference brand listed for
`clarification
`
`Extended-release (also known as sustained-release). refer to the reference brand listed
`for clarification
`
`The information contained in this document is proprietary. The information may not be copied in whole or in
`part without written permission. ©2016 CVS Caremark. All rights reserved.
`
`This document contains reierences to brand-name prescription drugs that are trademarks or registered
`trademarks of pharmaceutical manufacturers not afliliated with CVS Caremark.
`
`CV8 Caremari: does not operate the websitesiorganizetions listed here. nor is it responsible for the
`availability or reliability of the websites’ content. These listings do not imply or constitute an endorsement,
`sponsorship or recommendation by CVS Caremark.
`
`Please be advised that this document is updated periodically and changes may appear prior to their
`effective date to allow for client notification.
`
`ml} to CV5 Caremark. All rights reserved. 106-259543 1UlJ11fi
`Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
`
`Page 8 of 50
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`Page 8 of 50
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`

`

`ANALGESICS
`
`Practice guidelines of pain management are available at:
`http:tiwww.asahq.org
`
`ANALGESICS, OTHER
`Treatment recommendations for osteoarthritis are available at:
`
`http:r'iwww.rheumatology.org
`
`. _ ._
`
`OTC
`
`acetaminophen
`
`NSAIDS
`
`diclofenac potassium
`diclofenac sodium delayed-rel
`diclofenac sodium ext-rel
`difiunisal
`etodolac
`
`fenoproferl
`flurbigrofen
`ibuprofen
`ibugrofen
`ketogrofen
`ketogrofen ext-rel
`ketorolac
`
`lcetorolac inj
`meloxicam
`nabumetone
`no
`xen
`
`nagoxen delayed-.re|
`nagoxen sodium
`namxen sodium
`oiraprozin
`piroxicam
`sulindac
`tolrnetin
`
`OTC
`
`OTC
`
`GOUT
`
`allogurlnol
`colchicine
`
`grohenecid
`
`OPIOID ANALGESICS
`
`TYLENOL
`
`ADVIL
`
`MOBIC
`
`NAPROSYN
`
`EC-NAPF§0SYl_d_
`ALEVE
`ANAPRDX
`DAYPRO
`FELDENE
`
`ZYLOPRIM
`COLGRYS
`
`Practice Guidelines for Cancer Pain Management fincludes WHO analgesic ladder) are available at:
`http:itwvrw.asahq.org
`htlp:Hwvrw.nccn.org
`
`J
`
`Opioid guidelines in the management oi chronic non-malignant pain are available at:
`htlp:Nwwvv.asipp.orglGuidetines.hln1
`
`QL. PA
`QL
`PA. QL
`QL, PA
`QL
`QL
`QL. PA
`QL
`
`codeine sulfate
`codeineiacetaminoghen
`ientanvl lozenge
`fentanyl transderrnal
`hydrocodonelacetaminomen
`hvdrocodoneiacetaminomen - Vicodin
`hgdromorghone
`levogghanol tartrate
`
`TYLENOL wfCODElNE
`ACTIQ
`DURAGESJC
`NORCO
`
`DILAUDID
`
`@016 CV3 caremark. NI rights reserved. 106-259543 100118
`Your privacy is Important to us Our employees are trained regarding the appropriate way to handle your private health tnfomiatian.
`
`Page 9 of 50
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`Page 9 of 50
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`

`

`QL. PA
`
`QL, PA
`QL, PA
`QL, PA
`QL. PA
`QL. PA
`QL
`QL
`QL
`
`methadone
`
`morphine
`morphine ext-rel
`morphine ext-rel
`morphine supp
`oxycodone
`oirvcodonelacetaminophen
`tramadol
`tramadol ext-re]
`
`‘JISCOSUPPLEMENTS
`
`PA. SP
`PA, SP
`
`sodium hvaluronete
`sodium hvaluronate
`
`ANTI-INFECTIUES
`
`DOLOPHINE
`
`KADIAN
`MS CONTIN
`
`ROXICODONE
`PERCOCET
`ULTRAM
`LILTRAM ER
`
`GEL-ONE
`HYALGAN
`
`Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at:
`http:iivvww.idsociety.org
`
`Hepatitis: CDC recommendations on the treatment of hepatitis are available at:
`http:iiwvvw.cdc.govihepatitisliiesourcesi
`
`Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at:
`http:iiwww.aasld.org
`
`HIWAIDS: Guidelines torthe treatment of HIV patients by the US. Department of Health and Human Services are available at:
`http:H'.vww.aidsinfo.nih.gov
`
`infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at:
`http:iiwww.myamericanheart.org
`
`influenza: Recommendations of the Advisory Committee on immunization Practices are available at:
`http:iiwwvv.cdc.govincidod.-‘diseasesltluitluvtrus.I1tn1
`
`International Travel: CDC recommendations for international travel are available at:
`
`http:liwww.cdc.govitravel
`
`Respiratory Tract Infectioniitntibiotic Useicommunity Acquired Pneurnonialother: Principles of appropriate antibiotic use
`for treatment of nonspecific upper respiratory tract infection in adults are available at:
`l1ttp:.ii'www.cdc.govif|ui
`
`Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at:
`http:.-‘i'www.cdc.govistdltreatmentidetaulthtm
`
`ANTIBACTERIALS
`
`CE[]i1€t|OSf]f]I'ifl'S
`First Generation
`cefadroxil
`
`cephalexin
`
`Second Generation
`
`cefprozil
`ceturoxime airetil
`
`Third Generation
`cefdinir
`
`cefpodoxime
`
`KEFLEX
`
`CEFTIN
`
`VANTIN
`
`©9015 CV5 Caremarin All rights reserved. 105-259543 1ClEl1t6
`Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your privale health intorrnation.
`
`Page 10 of 50
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`

`

`Li 3:? mm aayuii15it.'1.Jc:ro|i(Jes.
`azithromycin
`ctarithromgcin
`ciarithromycin ext-rel
`erythromycin delayed-rel
`elythromycin ethylsuccinate
`erythromycin stearate
`fidaxomicin
`
`PA
`
`Fiu:Jrr:qLtino|mtes
`ciprofloxacin
`ciprofloxacin ext-rel
`Ieunflmtacin
`moxifloxacin
`
`Pcnicillins
`
`arnoxicillin
`amuxicilliniclavulanate
`amoxiciiliniclavulanate ext-rel
`
`" "
`
`_
`dicloxacillin
`
`penicillin VK
`
`Tell‘:-Jqgrjiines
`doxycycline hyclate
`doxgcgcline hgctale tabs
`doxycgcline monuhgdrate susp
`minocycline
`minocycline ext-rel
`tetracycline
`
`ANTIFUNGALS
`clotrimazule troches
`fiuconazole
`
`grisepfutvin microsize
`itraconazole
`
`nystatin
`gosaconazole
`terbinafme tabs
`vonconazole
`
`ANTIRETROVIRAL AGENTS
`
`AI1Ii1‘etI'o'..rira| Adiuuants
`cobicistat
`
`Antiretrljtmal Contbinations
`
`abacaviridolutegraviritamivudine
`abacavirilamivudine
`abacaviriiamiuudineizidouudine
`atazanaviricohicistat
`darunaviricobicistat
`efavirenzlemtricitabineitennfovir
`
`elvitegraviricobicistatlemtricitabinertenofovir
`elvitegrauiricobicislatfemtricitabineitenofovir alafenamide
`emtricitabinefrilpivinneitenofovir
`emtricitabineitenoiovir
`
`ZITHROMAX
`BIAXIN
`
`_ __
`E.E.S.
`E RYTHROCIN
`DIFICID
`
`_______
`CIPRO
`
`LEVAQUIN
`AVELOX
`
`AUGMENTIN
`AUGMENTIN XR
`
`VIBRAMYCIN
`
`VIBRAMYCIN
`MINOCIN
`
`DIFLUCAN
`
`SPORANOX
`
`NOXAFIL
`LAMISIL
`VFEND
`
`TYBOST
`
`TRIUM EQ
`EPZICOM
`TRIZIVIR
`EVOTAZ
`PREZCOBIX
`ATRIPLA
`
`STRIBILD
`GENVOYA
`COMPLERA
`TRUVADA
`
`©2016 CV5 Caren1ark.A1l rights reserved. 106-259543 100116
`Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
`
`Page 11 of 50
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`Page 11 of 50
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`

`

`Iamivudineizidovudine
`
`COMBIVIR
`
`ifiiiuterrmkiriu Rs.-cc Zliili Ant;-3L oni:5i:a
`
`maraviroc
`SELZENTRY
`
`Integrase inhibitors
`dolutegravir
`eivilegravir
`raliegravir
`
`'
`
`Nair-riucieoside Reverse Transcriglase |'|‘il1ibIiIJi"$
`efavirenz
`eiravirine
`
`neviragine
`nevirapine ext-rel
`rilpivirine
`
`Nucleoside Reverse Transerigiase inhibitors
`abacavir
`
`didanosine delayed-rel
`didanoslne seln
`emtriciiabine
`lamivudine
`slavudine
`ziclovudine
`
`Niicleniide Reverse Trarisrzripiase inhibitors
`lenofovir
`
`Protease Inhibitors
`atazanavir
`darunavir
`
`foaamgrenavir
`Iuginaviriritanavir
`ritonavir
`
`ANTITUBERCULAR AGENTS
`
`cagreomgcin
`cyclusefine
`elharnbutol
`ethionamide
`isoniazid
`
`isoniazidirifampin
`isoniazid-rifampiri wipyrazinamide
`ggrazinamide
`rifamgin
`rifageniine
`slreglamgciri sulfate
`
`TIVICAY
`VITEKTA
`ISENTRESS
`
`SUSTWA
`INTELENCE
`
`VIRAMUNE
`VIRAMUNE XR
`EDU RANT
`
`ZIAGEN
`
`VIDEX EC
`VIDEX
`EMTRIVA
`EPIVIR
`ZERIT
`RETROVIR
`
`VIREAD
`
`REYATAZ
`PREZISTA
`
`LEXIVA
`KALETRA
`NORVIR
`
`CAPASTAT SULFATE
`
`MYAM BUTOL
`TRECATOR
`
`RIFAMATE
`RIFATER
`
`RIFADIN
`PRIFTIN
`
`ANTIVIRALS
`
`Cvioinegaiovirus Agents
`vaigancicluvir e VALCYTE
`
`©2016 CV5 Caremadt All righls reserved. 106-259543 100116
`Your privacy is important to us. Our employees are lrained regarding Ihe appropnale way to handle yuur private heallh Information.
`
`"I
`
`I
`
`Page 12 of 50
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`

`

`Hepotiiis Agcnls
`Hegaritfs B
`
`enlecavir
`lamivudine
`
`Hegarifls C
`PA. SP
`PA, SP
`PA. SP
`PA. SP
`PA, SP
`PA, SP
`
`ledigasvirisofosbuvir
`ribavirin cage
`ribavirin cage - Rihasghere
`ribavirin oral coin
`ribavirin tabs
`sofoebuvir
`
`'- "
`
`Heroes Agents
`acfiiovir
`famciclovir
`
`valagclovir
`
`Influenza Agents
`QL. PA
`oeeitamivir
`CIL. PA
`zanamivir
`
`MISCELLANEOUS
`albendazole
`
`PA
`
`PA
`
`PA
`
`atovaguone
`clindamgcin
`dagsone
`ivennectin
`Iinezolid
`
`linezolid ini
`melronidazole
`nitazoxanide
`nilrofurantoiI1 ext-rel
`
`nitrofurantoin macrogslals
`rifahutin
`
`rifaximin 550 mg
`sulfamethoxazolehrimethogrim
`suifamethoxazoleitrimelhogrim DS
`tinidazole
`
`BARACLUDE
`EPIVIR-HBV
`
`HARVONI
`REBETOL
`
`REBETOL
`COPEGUS
`SOVALDI
`
`ZOVIRAX
`FAMUIR
`
`VALTREX
`
`TAMIFLU
`RELENZA
`
`ALBENZA
`
`MEPRON
`CLEOCIN
`
`STROMECTOL
`ZYVOX
`
`ZYVOX
`FLAGYL
`ALINIA
`MACROBID
`
`MACRODANTIN
`MYCOBUTIN
`
`XIFAXAN 550 mg
`
`TINDAMAX
`
`
`ST, PA
`vancomgcin
`VANCOCIN
`
`ANTINEOPLASTIC AGENTS
`
`Clinicai practice guideiinee in oncology are availabie at
`hItp:ifwww.asco.or9
`http:i.iwww.nccn.org
`
`Most oncology medications are eligible for coverage and some may require prior authorizaiion. Please call the Customer Care
`phone number located on the prescription ID card for coverage determination.
`
`ORAL HORMDNAL ANTINEOPLASTIC AGENTS
`
`Antiandrogens
`PA. SP
`abiraterone
`bicalutamide
`
`PA. SP
`
`enzaluiamide
`ilutamide
`
`ZYTIGA
`
`XTANDI
`
`@2015 CV5 Caremarlc All nghls reserved. 106-259543 100116
`Your privacy is irnpeltanl 1:: us. Our employees are trained regarding the appropriate way to handle your private heaflh information.
`
`Page 13 of 50
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`

`nilulamide
`
`l‘mlr:‘;~;1rml:rr5lScle1;lr-Jo Eslrogon l'\‘r.~r:r:plor' P.-lorirlirrr 2'.
`fulvestrant
`tamoxifen
`loremlfene
`
`Aromalase Inhibitors
`anaslrozole
`exemestane
`letrozole
`
`Progosllns
`
`megestrol acetate
`
`ORAL NON-HORMONAL ANTINEOPLASTIC AGENTS
`
`Alkylaling agents
`allrelamine
`busulfan
`chlorambucil
`
`cgcloghosghamide cags
`estramusline
`lomusline
`
`PA, SP
`
`rnelghalan
`temozolomide
`
`Anrimetaboliles
`
`PA. SP
`
`cagecitabine
`mercaglogurirre
`thioguanine
`
`lrnmunomodulators
`PA. SP
`lenaliclomide
`PA. SP
`gomalidomide
`PA, SP
`thalidomide
`
`Kinaso Inhibitors
`PA. SP
`afatlnib
`PA, SP
`axllinib
`PA. SP
`bosulinib
`PA. SP
`cabozaniinib
`PA. SP
`cerilinib
`PA. SP
`crizolinib
`PA. SP
`dabrafenib
`PA. SP
`dasatinih
`PA. SP
`erlolinib
`PA. SP
`everolimus
`PA. SP
`ibrulinib
`PA. SP
`idelalisib
`
`PA. SP
`PA. SP
`PA. SP
`PA, SP
`PA. SP
`PA, SP
`PA. SP
`
`imatinib mesylate
`Iapatinib
`lenvalinib
`nilotinib
`Qalbociclib
`Qazoganib
`gonalinib
`
`MLANDRON
`
`FASLOD EX
`
`FARESTON
`
`ARIMIDEX
`AROMASIN
`FEMARA
`
`MEGACE
`
`HEXALEN
`MYLERAN
`LEUKERAN
`
`EMCYT
`GLEOSTINE
`
`ALKERAN
`TEMODAR
`
`XELODA
`
`REVLIMID
`POMALYST
`THALOMID
`
`GlLOTR|F
`IN LYTA
`BOSULIF
`COMETRIQ
`ZYKAEHA
`XAL KORE
`TAFlNLAR
`SPRYCEL
`TARC EVA
`AFTNITOR
`IMBRUVICA
`ZYDELIG
`
`GLEEVEC
`TYKERB
`LENVIMA
`TASIGNA
`IBRANCE
`VOTRIENT
`ICLUSIG
`
`©2016 CV5 Caremant All nghls reserved. 106-2595-1B 1001 16
`Your privacy is imporlanl 10 us. Our employees are trained regarding the appropriate way to handle your private health information.
`
`13
`
`Page 14 of 50
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`

`PIX. SP
`PA, SP
`PA, SP
`PA, SP
`PA. SP
`PA. SP
`PA. SP
`
`regorafenib
`ruxolitinib
`sorafenib
`sunilinib
`trametinib
`vandelanib
`vemurafenib
`
`Togoisomerase Inhibitors
`logoteoan cage
`
`MISCELLANEOUS
`
`PA, SP
`
`PA. SP
`PA, SP
`
`PA. SP
`
`PA. SP
`PA. SP
`
`bexarotene cage
`etogoside cags
`hydroxyurea
`mitotane
`
`olagarib
`ganobinoetat
`grocarbazine
`tretinoin cags
`uridine triaoelale
`venetoclax
`
`vismodeglb
`vorinostal
`
`CARDIOVASCULAR
`
`'
`
`STI‘-JARGA
`JAKAFI
`NEXAVAR
`SUTENT
`MEKINIST
`CAPRELSA
`ZELBORAF
`
`HYCAMTIN
`
`TARGRETIN
`
`HYDREA
`LYSODREN
`
`LYNPARZA
`FARYDAK
`MATULANE
`
`VISTOGARD
`VENCLEXTA
`
`ERIVEDGE
`ZOLINZA
`
`The Eighth Report of the Joint National Committee on Prevention. Detection, Evaluation and Treatment of High Blood Pressure
`is available at:
`
`htlp:l'flamaJamanetworkcomlarticle.aspx?articleid=179149?
`
`Guidelines for the evaluation and management of cardiovascular diseases in adults are available at
`http:lfwww.acc.org
`hllp:Hvi.rvrw.heartfailureguidelineorg
`hnp:.iMww.myamericanhean.org
`
`ACE INHIBITORS
`Guidelines for the use of ACE inhibitors are available at:
`
`htlpfljamajamanetworlr.comlarticle.aspx?arlicleid=1}'91497
`http:ll‘professionaI.diabeles.org
`http:ll‘www.acc.org
`http:flwww.m3ramericanheart.org
`
`e¢3l1f_°l"
`enala|:_lIil
`'
`VASOTEC
`
`gerindogril
`_
`ACEON
`ramigril
`ALTACE
`trandolagril
`MAVIK
`
`ACE INHIBITORICALCIUM CHANNEL BLOCKER COMBINATIONS
`
`amlodiginelbenazggril
`
`LOTREL
`
`ACE INHIBITORIDIURETIC COMBINATIONS
`caglom'll'h}{drochlorothiazide
`enalagrillhgdrochlorothiazide
`Iisinogrilmydrochlorothiazide
`
`VASERETK3
`ZESTORETIC
`
`©2016 CV5 Caramarlt All rights reserved. 106259548 100116
`Your privacyis important to us. Our employees are trained regarding the appropriate way to handle your private heallh lnlorrriellon.
`
`Page 15 of 50
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`

`ADRENOLYTICS. CENTRAL
`clonidine
`clonidine transdermal
`
`ALDOSTERONE RECEPTOR ANTAGONISTS
`
`eplerenone
`splronolactone
`
`CATAPRES
`CATfi.PRES-TTS
`
`INSPRA
`ALDACTONE
`
`ANGIOTENSIN ll RECEPTOR ANTAGONISTSIDIURETIC COMBINATIONS
`
`Guidelines for the use of angiotensiri ll receptor antagonists in various patient populations are available at:
`http:l'{iamaJamar1etworlc.comlartir:le.aspx?artic|eid=179149?
`httpJiprofessional.diabetes.org
`
`irbesartan
`
`irhesartanihgdrochlorothiazicle
`losartan
`
`losartanihydrochlorothiazide
`valsartan
`
`valsartanlhggdrochtorothiazide
`
`AVAPRO
`
`AVALIDE
`COZAAR
`
`HYZAAR
`DIOVAN
`
`DIOVAN HCT
`
`ANTIARRHYTHMICS
`Guidelines for the use of antiarrhythmios and cardiac glycosides in various patient populations are available at:
`ht[p:r'i'www.ace.org
`
`PA. SP
`
`acebutolol
`amiodarone
`amtodarone - Pacerone
`
`disopygrnide
`disopyramide ext-rel
`dofetilide
`flecainide
`ihutilide
`
`propafenone
`propafenone errt-rel
`sotalol
`sotaloi
`
`SECTRAL
`CORDARONE
`
`NORPACE
`NORFAGE CR
`TlKOSYN
`
`CORVERT
`
`RYTHMOL
`RYTI-IMOL SR
`BETAPACE
`BETAPACE AF