advanced control formulary™ change summary report · lancets lancets endocrine and metabolic/...

Advanced Control Formulary™ Change Summary Report Effective 01-01-2020

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. ©2019 CVS Caremark. All rights reserved. 106-40278A 093019 Pg. 1 of 33

This report highlights all changes (additions, deletions, and removals) to the CVS Caremark® Advanced Control Formulary.

ADDITIONS:

Product

Therapeutic Category/

Subcategory Indication Options/Comments

Brand Agents:

Accu-Chek Lancets lancets

Endocrine and Metabolic/ Antidiabetics/ Supplies

Accu-Chek lancets are supplies that aid in the testing of blood glucose levels in those who have diabetes.

To provide a preferred lancet option for testing blood glucose levels.

Accu-Chek Lancing Devices lancing devices

Endocrine and Metabolic/ Antidiabetics/ Supplies

Accu-Chek lancing devices are supplies that aid in the testing of blood glucose levels in those who have diabetes.

To provide a preferred lancing device option for testing blood glucose levels.

Adempas (riociguat) oral tablet

Cardiovascular/ Pulmonary Arterial Hypertension/ Soluble Guanylate Cyclase Stimulators

Adempas is indicated for the treatment of adults with:

Persistent/recurrent chronic thromboembolic pulmonary hypertension (World Health Organization [WHO] Group 4) after surgical treatment or inoperable chronic thromboembolic pulmonary hypertension to improve exercise capacity and WHO functional class

Pulmonary arterial hypertension (PAH) (WHO Group 1) to improve exercise capacity, improve WHO functional class and to delay clinical worsening.

To provide an option for the treatment of persistent/recurrent chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension.



Product


Subcategory Indication Options/Comments Aimovig (erenumab-aooe) subcutaneous solution for injection

Central Nervous System/ Migraine/ Monoclonal Antibodies

Aimovig is indicated for the preventive treatment of migraine in adults.

To provide an additional option for migraine prophylaxis.

Fasenra (benralizumab) subcutaneous solution for injection

Respiratory/ Severe Asthma Agents

Fasenra is indicated for the add-on maintenance treatment of patients with severe asthma aged 12 years and older, and with an eosinophilic phenotype.

To provide an additional option for the treatment of severe asthma.

Firazyr (icatibant) subcutaneous solution for injection

Hematologic/ Hereditary Angioedema

Firazyr is indicated for treatment of acute attacks of hereditary angioedema in adults 18 years of age and older.

To provide an additional option for the treatment of hereditary angioedema.

Flovent Diskus (fluticasone) inhalation aerosol

Respiratory/ Steroid Inhalants

Flovent Diskus is indicated for maintenance treatment of asthma as prophylactic therapy in patients aged 4 years and older.

To provide an additional inhaled corticosteroid for prophylactic treatment of asthma.

Flovent HFA (fluticasone) inhalation aerosol powder breath-activated


Flovent HFA is indicated for maintenance treatment of asthma as prophylactic therapy in patients aged 4 years and older.


FML S.O.P. (fluorometholone) ophthalmic ointment

Topical/ Ophthalmic/ Anti-Inflammatories/ Steroidal

FML S.O.P. is indicated for the treatment of corticosteroid-responsive inflammation of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe.

To provide an additional ophthalmic corticosteroid option.

Ingrezza (valbenazine) oral capsule, oral therapy pack

Central Nervous System/ Movement Disorders

Ingrezza is indicated for the treatment of adults with tardive dyskinesia.

To provide an additional option for the treatment of tardive dyskinesia.



Product


Subcategory Indication Options/Comments Lynparza (olaparib) oral capsule

Antineoplastic Agents/ Miscellaneous

Lynparza capsule is indicated for the treatment of adult patients with deleterious or suspected deleterious germline BRCA-mutated advanced ovarian cancer who have been treated with three or more prior lines of chemotherapy.

To provide an option for the treatment of ovarian cancer.

Lynparza (olaparib) oral tablet


Lynparza tablet is indicated for:

Ovarian cancer o for the maintenance treatment of

adult patients with deleterious or suspected deleterious germline or somatic BRCA-mutated (gBRCAm or sBRCAm) advanced epithelial ovarian, fallopian tube or primary peritoneal cancer who are in complete or partial response to first-line platinum-based chemotherapy

o for the maintenance treatment of adult patients with recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer, who are in complete or partial response to platinum-based chemotherapy

o for the treatment of adult patients with deleterious or suspected deleterious germline BRCA-mutated (gBRCAm) advanced ovarian cancer who have been treated with

To provide an option for the treatment of ovarian cancer and breast cancer.



Product


Subcategory Indication Options/Comments three or more prior lines of chemotherapy

Breast cancer o in patients with deleterious or

suspected deleterious gBRCAm, human epidermal growth factor receptor 2 (HER2)- negative metastatic breast cancer who have been treated with chemotherapy in the neoadjuvant, adjuvant or metastatic setting

Mayzent (siponimod) oral tablet, oral therapy pack

Central Nervous System/ Multiple Sclerosis Agents

Mayzent is indicated for the treatment of relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

To provide an additional option for the treatment of relapsing forms of multiple sclerosis (MS).

Nubeqa (darolutamide) oral tablet

Antineoplastic Agents/ Hormonal Antineoplastic Agents/ Antiandrogens

Nubeqa is indicated for the treatment of patients with non-metastatic castration-resistant prostate cancer.

To provide an additional option for the treatment of prostate cancer.

Pulmicort Flexhaler (budesonide) inhalation aerosol powder breath-activated


Pulmicort Flexhaler is indicated for maintenance treatment of asthma as prophylactic therapy in patients aged 6 years and older.




Product


Subcategory Indication Options/Comments Rinvoq (upadacitinib) oral extended-release tablet

Immunologic Agents/ Autoimmune Agents/ Rheumatoid Arthritis

Rinvoq is indicated for the treatment of adults with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to methotrexate.

To provide an additional option for the treatment of moderate to severe rheumatoid arthritis.

Rocklatan (netarsudil-latanoprost) ophthalmic solution

Topical/ Ophthalmic/ Rho Kinase Inhibitor / Prostaglandin Combinations

Rocklatan is indicated for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension.

To provide an option for the reduction of elevated intraocular pressure.

Rubraca (rucaparib) oral tablet


Rubraca is indicated:

For the maintenance treatment of adult patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in a complete or partial response to platinum-based chemotherapy

For the treatment of adult patients with deleterious BRCA mutation (germline and/or somatic)-associated epithelial ovarian, fallopian tube, or primary peritoneal cancer who have been treated with two or more chemotherapies.

To provide an option for the treatment of ovarian cancer.

Sunosi (solriamfetol) oral tablet

Central Nervous System/ Narcolepsy

Sunosi is indicated to improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea.

To provide an additional option for improving wakefulness in those with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea.



Product


Subcategory Indication Options/Comments Symproic (naldemedine) oral tablet

Gastrointestinal/ Opioid-Induced Constipation

Symproic is indicated for the treatment of opioid-induced constipation in adult patients with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.

To provide an additional option for the treatment of opioid-induced constipation.

Temixys (lamivudine-tenofovir disoproxil fumarate) oral tablet

Anti-Infectives/ Antiretroviral Agents/ Antiretroviral Combinations

Temixys is indicated in combination with other antiretroviral agents for the treatment of human immunodeficiency virus type 1 (HIV-1) infection in adults and pediatric patients weighing at least 35 kg.

To provide an additional combination agent for the treatment of HIV-1 infection.

Tremfya (guselkumab) subcutaneous solution for injection

Immunologic Agents/ Autoimmune Agents/ Psoriasis

Tremfya is indicated for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

To provide an additional option for the treatment of moderate to severe plaque psoriasis.

Vemlidy (tenofovir alafenamide) oral tablet

Anti-Infectives/ Antivirals/ Hepatitis B Agents

Vemlidy is indicated for the treatment of chronic hepatitis B virus infection in adults with compensated liver disease.

To provide an additional option for the treatment of chronic hepatitis B infection.

Xolair (omalizumab) subcutaneous solution for injection

Respiratory/ Severe Asthma Agents

Xolair is indicated for:

Moderate to severe persistent asthma in patients 6 years of age and older with a positive skin test or in vitro reactivity to a perennial aeroallergen and symptoms that are inadequately controlled with inhaled corticosteroids

To provide an additional option for the treatment of severe asthma and chronic idiopathic urticaria.



Product



Chronic idiopathic urticaria in adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment.

Xtampza ER (oxycodone) oral extended-release abuse-deterrent capsule

Analgesics/ Opioid Analgesics

Xtampza ER is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate in adults.

To provide an additional option for severe pain management.

Xultophy (liraglutide-insulin degludec) subcutaneous solution for injection

Endocrine and Metabolic/ Antidiabetics/ Incretin Mimetic Agent / Insulin Combinations

Xultophy is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

To provide an additional option to improve glycemic control in adults with type 2 diabetes mellitus.

Yonsa (abiraterone) oral tablet

Antineoplastic Agents/ Hormonal Antineoplastic Agents/ Antiandrogens

Yonsa is indicated in combination with methylprednisolone for the treatment of patients with metastatic castration-resistant prostate cancer.

To provide an additional option for the treatment of prostate cancer.

Generic Agents:

aliskiren oral tablet

Cardiovascular/ Direct Renin Inhibitors / Diuretic Combinations

Aliskiren is indicated for the treatment of hypertension in adults and children 6 years of age and older, to lower blood pressure.

To provide a generic direct renin inhibitor option for the treatment of hypertension.

ambrisentan oral tablet

Cardiovascular/ Pulmonary Arterial Hypertension/ Endothelin Receptor Antagonists

Ambrisentan is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1):

To improve exercise ability and delay clinical worsening

To provide a generic endothelin receptor antagonist option for the treatment of pulmonary arterial hypertension.



Product



In combination with tadalafil to reduce the risks of disease progression and hospitalization for worsening PAH, and to improve exercise ability.

atazanavir oral capsule

Anti-Infectives/ Antiretroviral Agents/ Protease Inhibitors

Atazanavir is indicated for use in combination with other antiretroviral agents for the treatment of HIV-1 infection for patients 6 years and older weighing at least 15 kg.

To provide a generic protease inhibitor option for the treatment of HIV-1 infection.

azelaic acid topical gel

Topical/ Dermatology/ Rosacea

Azelaic acid gel is indicated for topical treatment of the inflammatory papules and pustules of mild to moderate rosacea.

To provide an additional generic option for the treatment of rosacea.

bosentan oral tablet


Bosentan is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) in adults to improve exercise ability and to decrease clinical worsening.

To provide a generic endothelin receptor antagonist option for the treatment of pulmonary arterial hypertension.

clindamycin topical gel

Topical/ Dermatology/ Acne/ Topical

Clindamycin gel is indicated in the treatment of acne vulgaris.

To provide an additional generic option for the treatment of acne vulgaris.

doxylamine-pyridoxine oral delayed-release tablet

Gastrointestinal/ Antiemetics

Doxylamine-pyridoxine is indicated for the treatment of nausea and vomiting of pregnancy in women who do not respond to conservative management.

To provide a generic option for the treatment of nausea and vomiting in women during pregnancy.

erlotinib oral tablet

Antineoplastic Agents/ Kinase Inhibitors

Erlotinib is indicated for:

The treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal

To provide a generic option for the treatment of metastatic non-small cell lung cancer or pancreatic cancer.



Product


Subcategory Indication Options/Comments growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test receiving first-line, maintenance, or second or greater line treatment after progression following at least one prior chemotherapy regimen

First-line treatment of patients with locally advanced, unresectable or metastatic pancreatic cancer, in combination with gemcitabine.

isosorbide dinitrate oral tablet

Cardiovascular/ Nitrates Isosorbide dinitrate is indicated for the prevention of angina pectoris due to coronary artery disease.

To provide a generic oral nitrate option for the prevention of angina.

loteprednol ophthalmic suspension


Loteprednol is indicated for the:

Treatment of steroid responsive inflammatory conditions of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe such as allergic conjunctivitis, acne rosacea, superficial punctate keratitis, herpes zoster keratitis, iritis, cyclitis, selected infective conjunctivitis, when the inherent hazard of steroid use is accepted to obtain an advisable diminution in edema and inflammation

To provide an additional generic ophthalmic anti-inflammatory option.



Product



Treatment of post-operative inflammation following ocular surgery.

pimecrolimus topical cream

Topical/ Dermatology/ Atopic Dermatitis/ Topical

Pimecrolimus is indicated as second-line therapy for the short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

To provide an additional generic option for the topical treatment of atopic dermatitis.

scopolamine transdermal transdermal patch


Scopolamine transdermal is indicated in adults for the prevention of:

Nausea and vomiting associated with motion sickness

Post-operative nausea and vomiting (PONV) associated with recovery from anesthesia and/or opiate analgesia and surgery.

To provide an additional generic option for the prevention of nausea and vomiting.

tenofovir disoproxil fumarate oral tablet

Anti-Infectives/ Antiretroviral Agents/ Nucleotide Reverse Transcriptase Inhibitors

Tenofovir disoproxil fumarate is indicated:

In combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients 2 years of age and older weighing at least 10 kg

To provide a generic nucleotide reverse transcriptase inhibitor option for the treatment of HIV-1 infection or chronic hepatitis B infection.



Product



For the treatment of chronic hepatitis B in adults and pediatric patients 12 years and older.

DELETIONS:

Product



Brand Agents:

Abstral (fentanyl citrate) sublingual tablet


Abstral is indicated for the management of breakthrough pain in cancer patients 18 years of age and older who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain.

Availability of additional options for managing breakthrough pain in cancer patients. Preferred options on the Advanced Control Formulary include fentanyl transmucosal lozenge and Subsys (fentanyl sublingual spray).

Aralast NP (alpha-1 proteinase inhibitor) intravenous solution for injection

Respiratory/ Alpha-1 Antitrypsin Deficiency Agents

Aralast NP is indicated for chronic augmentation therapy in adults with clinically evident emphysema due to severe congenital deficiency of alpha1-antitrypsin inhibitor.

Availability of another option for the treatment of emphysema due to an inherited disorder known as alpha1-antitrypsin deficiency. The preferred option on the Advanced Control Formulary is Prolastin-C (alpha-1 proteinase inhibitor).

Glassia (alpha-1 proteinase inhibitor) intravenous solution for injection

Respiratory/ Alpha-1 Antitrypsin Deficiency Agents

Glassia is indicated for chronic augmentation and maintenance therapy in adults with clinically evident emphysema

Availability of another option for the treatment of emphysema due to an inherited disorder known as alpha1-antitrypsin deficiency.



Product


Subcategory Indication Options/Comments due to severe hereditary deficiency of alpha1-antitrypsin inhibitor.

The preferred option on the Advanced Control Formulary is Prolastin-C (alpha-1 proteinase inhibitor).

Letairis (ambrisentan) oral tablet


Letairis is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1):

To improve exercise ability and delay clinical worsening

In combination with tadalafil to reduce the risks of disease progression and hospitalization for worsening PAH, and to improve exercise ability.

Availability of other endothelin receptor antagonist options for the treatment of pulmonary arterial hypertension. Preferred options on the Advanced Control Formulary include ambrisentan, bosentan, and Opsumit (macitentan).

Nexavar (sorafenib) oral tablet


Nexavar is indicated for the treatment of:

Unresectable hepatocellular carcinoma

Advanced renal cell carcinoma

Locally recurrent or metastatic, progressive, differentiated thyroid carcinoma refractory to radioactive iodine treatment.

Availability of other options for the treatment of hepatocellular carcinoma, renal cell carcinoma, or thyroid carcinoma. Preferred options on the Advanced Control Formulary include Cabometyx (cabozantinib), Sutent (sunitinib), and Votrient (pazopanib).

Retin-A Micro (tretinoin microsphere) topical gel microsphere


Retin-A Micro is indicated for topical treatment of acne vulgaris.

Availability of other options for the treatment of acne vulgaris. Preferred options on the Advanced Control Formulary include adapalene, benzoyl peroxide, clindamycin gel, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, Epiduo (adapalene-benzoyl peroxide), and Tazorac (tazarotene).



Product


Subcategory Indication Options/Comments Reyataz (atazanavir) oral capsule, oral packet

Anti-Infectives/ Antiretroviral Agents/ Protease Inhibitors

Reyataz is indicated for use in combination with other antiretroviral agents for the treatment of HIV-1 infection for patients 3 months and older weighing at least 5 kg.

Availability of other protease inhibitor options for the treatment of HIV-1 infection. Preferred options on the Advanced Control Formulary include atazanavir and Prezista (darunavir).

Safyral (ethinyl estradiol-drospirenone-levomefolate) oral tablet

Endocrine and Metabolic/ Contraceptives/ Monophasic

Safyral is indicated for use by women to:

Prevent pregnancy

Raise folate levels in women who choose to use an oral contraceptive for contraception.

Availability of generic monophasic oral contraceptive options. Preferred options on the Advanced Control Formulary include ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, and ethinyl estradiol-norethindrone acetate-iron.

Tarceva (erlotinib) oral tablet


Tarceva is indicated for:

The treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 (L858R) substitution mutations as detected by an FDA-approved test receiving first-line, maintenance, or second or greater line treatment after progression following at least one prior chemotherapy regimen

First-line treatment of patients with locally advanced, unresectable or metastatic pancreatic cancer, in combination with gemcitabine.

Availability of other options for the treatment of metastatic non-small cell lung cancer or pancreatic cancer. Preferred options on the Advanced Control Formulary include erlotinib and Iressa (gefitinib).



Product


Subcategory Indication Options/Comments Tekturna (aliskiren) oral tablet

Cardiovascular/ Direct Renin Inhibitors / Diuretic Combinations

Tekturna is indicated for the treatment of hypertension in adults and children 6 years of age and older, to lower blood pressure.

Availability of a generic direct renin inhibitor option for the treatment of hypertension. The preferred option on the Advanced Control Formulary is aliskiren.

Tracleer (bosentan) oral tablet, oral soluble tablet


Tracleer is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1):

In adults to improve exercise ability and to decrease clinical worsening

In pediatric patients aged 3 years and older with idiopathic or congenital PAH to improve pulmonary vascular resistance (PVR), which is expected to result in an improvement in exercise ability.

Availability of other endothelin receptor antagonist options for the treatment of pulmonary arterial hypertension. Preferred options on the Advanced Control Formulary include ambrisentan, bosentan, and Opsumit (macitentan).

Viread (tenofovir disoproxil fumarate) oral tablet, oral powder

Anti-Infectives/ Antiretroviral Agents/ Nucleotide Reverse Transcriptase Inhibitors

Viread is indicated:

In combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients 2 years of age and older weighing at least 10 kg

For the treatment of chronic hepatitis B in adults and pediatric patients 12 years and older.

Availability of a generic nucleotide reverse transcriptase inhibitor option for the treatment of HIV-1 infection or chronic hepatitis B infection. The preferred option on the Advanced Control Formulary is tenofovir disoproxil fumarate.



REMOVALS:

Product



Brand Agents:

Aldara (imiquimod) topical cream

Topical/ Dermatology/ Actinic Keratosis

Aldara is indicated for the topical treatment of:

Clinically typical, nonhyperkeratotic, nonhypertrophic actinic keratoses (AKs) on the face or scalp in immunocompetent adults

Biopsy-confirmed, primary superficial basal cell carcinoma in immunocompetent adults; maximum tumor diameter of 2.0 cm on trunk, neck, or extremities (excluding hands and feet), only when surgical methods are medically less appropriate and patient follow-up can be reasonably assured

External genital and perianal warts/condyloma acuminata in patients 12 years or older.

Availability of a generic option for the topical treatment of actinic keratosis, superficial basal cell carcinoma, or external genital and perianal warts/condyloma acuminata. The preferred option on the Advanced Control Formulary is imiquimod.

Alrex (loteprednol) ophthalmic suspension


Alrex is indicated for the temporary relief of the signs and symptoms of seasonal allergic conjunctivitis.

Availability of generic ophthalmic options for treating seasonal allergic conjunctivitis. Preferred options on the Advanced Control Formulary include azelastine, cromolyn sodium, and olopatadine.



Product


Subcategory Indication Options/Comments Asmanex (mometasone) inhalation aerosol powder


Asmanex is indicated for maintenance treatment of asthma as prophylactic therapy in patients 4 years of age and older.

Availability of other inhaled corticosteroid for prophylactic treatment of asthma. Preferred options on the Advanced Control Formulary include Arnuity Ellipta (fluticasone furoate), Flovent Diskus (fluticasone propionate), Flovent HFA (fluticasone propionate, CFC-free aerosol), Pulmicort Flexhaler (budesonide), and Qvar RediHaler (beclomethasone breath-activated aerosol).

Asmanex HFA (mometasone) inhalation aerosol powder breath-activated


Asmanex HFA is indicated for maintenance treatment of asthma as prophylactic therapy in patients 12 years of age and older.

Availability of other inhaled corticosteroid for prophylactic treatment of asthma. Preferred options on the Advanced Control Formulary include Arnuity Ellipta (fluticasone furoate), Flovent Diskus (fluticasone propionate), Flovent HFA (fluticasone propionate, CFC-free aerosol), Pulmicort Flexhaler (budesonide), and Qvar RediHaler (beclomethasone breath-activated aerosol).

Ativan (lorazepam) intravenous solution for injection

Central Nervous System/ Antianxiety/ Benzodiazepines

Ativan is indicated for:

The treatment of status epilepticus

In adult patients for pre-anesthetic medication, producing sedation (sleepiness or drowsiness), relief of anxiety, and a decreased ability to recall events related to the day of surgery.

Availability of generic benzodiazepine options. Preferred options on the Advanced Control Formulary include diazepam injection and lorazepam injection.

Ativan (lorazepam) oral tablet

Central Nervous System/ Antianxiety/ Benzodiazepines

Ativan is indicated for the management of anxiety disorders or for the short-term relief

Availability of generic benzodiazepine options.



Product


Subcategory Indication Options/Comments of the symptoms of anxiety or anxiety associated with depressive symptoms.

Preferred options on the Advanced Control Formulary include alprazolam, clonazepam, diazepam, lorazepam, and oxazepam.

Atralin (tretinoin) topical gel


Atralin is indicated for topical treatment of acne vulgaris.


Avonex (interferon beta-1a) intramuscular solution for injection


Avonex is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

Availability of other options for the treatment of relapsing forms of multiple sclerosis (MS). Preferred options on the Advanced Control Formulary include glatiramer, Aubagio (teriflunomide), Betaseron (interferon beta-1b), Copaxone (glatiramer), Gilenya (fingolimod), Mayzent (siponimod), Rebif (interferon beta-1a), Tecfidera (dimethyl fumarate delayed-rel), and Tysabri (natalizumab).

BeauRx (dimethicone) topical gel

Topical/ Dermatology/ Scar Treatment

BeauRx has been shown to flatten, soften and smooth scars, relieve the itching and discomfort of scars, as well as reduce the discoloration associated with scars; it is effective for both old and new scars, and may help in the prevention of excessive and abnormal scar formation.

Availability of other options for the management of scarring. Consult doctor for preferred options on the Advanced Control Formulary.



Product


Subcategory Indication Options/Comments Clindagel (clindamycin) topical gel


Clindagel is indicated for topical application in the treatment of acne vulgaris.


Combivent Respimat (ipratropium-albuterol) inhalation aerosol solution

Respiratory/ Anticholinergic / Beta Agonist Combinations / Short Acting

Combivent Respimat is indicated for patients with chronic obstructive pulmonary disease (COPD) on a regular aerosol bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator.

Availability of other anticholinergic-beta agonist option for the treatment of chronic obstructive pulmonary disease (COPD). Preferred options on the Advanced Control Formulary include ipratropium-albuterol inhalation solution, Anoro Ellipta (umeclidinium-vilanterol), and Bevespi Aerosphere (glycopyrrolate-formoterol).

Complera (emtricitabine-rilpivirine-tenofovir disoproxil fumarate) oral tablet


Complera is indicated for use as a complete regimen for the treatment of HIV-1 infection in patients weighing at least 35 kg:

As initial therapy in those with no antiretroviral treatment history and with HIV-1 RNA less than or equal to 100,000 copies/mL at the start of therapy, or

To replace a stable antiretroviral regiment in those who are virologically suppressed (HIV-1 RNA <50

Availability of other complete regimen options for the treatment of HIV-1 infection. Preferred options on the Advanced Control Formulary include Atripla (efavirenz-emtricitabine-tenofovir disoproxil fumarate), Biktarvy (bictegravir-emtricitabine-tenofovir alafenamide), Genvoya (elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide), Odefsey (emtricitabine-rilpivirine-tenofovir alafenamide), Symfi (efavirenz-lamivudine-tenofovir disoproxil fumarate), Symfi Lo (efavirenz-lamivudine-tenofovir disoproxil



Product


Subcategory Indication Options/Comments copies/mL) on a stable antiretroviral regimen for at least 6 months with no treatment failure and no known substitutions associated with resistance to the individual components of Complera.

fumarate), and Triumeq (abacavir-dolutegravir-lamivudine).

Cuprimine (penicillamine) oral capsule

Immunologic Agents/ Disease-Modifying Antirheumatic Drugs (DMARDs)

Cuprimine is indicated in the treatment of Wilson's disease, cystinuria, and in patients with severe, active rheumatoid arthritis who have failed to respond to an adequate trial of conventional therapy.

Availability of other options for the treatment of Wilson’s disease, cystinuria, and severe, active rheumatoid arthritis. Consult doctor for preferred options on the Advanced Control Formulary.

Cycloset (bromocriptine) oral tablet

Endocrine and Metabolic/ Antidiabetics/ Miscellaneous

Cycloset is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Availability of other options for the management of type 2 diabetes mellitus. Consult doctor for preferred options on the Advanced Control Formulary.

Diastat (diazepam) rectal gel

Central Nervous System/ Anticonvulsants

Diastat is indicated for the management of selected, refractory, patients with epilepsy, on stable regimens of AEDs, who require intermittent use of diazepam to control bouts of increased seizure activity.

Availability of a generic rectal benzodiazepine option. The preferred options on the Advanced Control Formulary is diazepam rectal gel.

Durolane (sodium hyaluronate) intraarticular injection

Analgesics/ Viscosupplements

Durolane is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-

Availability of other viscosupplements for osteoarthritis. Preferred options on the Advanced Control Formulary include Gel-One (sodium hyaluronate), Gelsyn-3



Product


Subcategory Indication Options/Comments pharmacological therapy or simple analgesics, e.g. acetaminophen.

(sodium hyaluronate), Supartz FX (sodium hyaluronate), and Visco-3 (sodium hyaluronate).

Elidel (pimecrolimus) topical cream

Topical/ Dermatology/ Atopic Dermatitis/ Topical

Elidel is indicated as second-line therapy for the short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable.

Availability of other options for the treatment of mild to moderate atopic dermatitis. Preferred options on the Advanced Control Formulary include pimecrolimus, tacrolimus, and Eucrisa (crisaborole).

EpiCeram (dimethicone-petrolatum) topical emulsion

Topical/ Dermatology/ Emollients

EpiCeram is used to treat dry skin conditions and to manage and relieve the burning and itching experienced with various types of dermatoses, including atopic dermatitis, irritant contact dermatitis, and radiation dermatitis.

Availability of generic options for managing and relieving the burning and itching experienced with various types of skin conditions. Preferred options on the Advanced Control Formulary include desonide and hydrocortisone.

Flarex (fluorometholone acetate) ophthalmic suspension


Flarex is indicated for use in the treatment of steroid responsive inflammatory conditions of the palpebral and bulbar conjunctiva, cornea, and anterior segment of the eye.

Availability of other ophthalmic anti-inflammatory options. Preferred options on the Advanced Control Formulary include dexamethasone, loteprednol, prednisolone acetate 1%, and FML S.O.P. (fluorometholone).

Hysingla ER (hydrocodone)


Hysingla ER is indicated for the management of pain severe enough to require daily, around-the-clock, long-term

Availability of other long-acting options for pain management.



Product


Subcategory Indication Options/Comments oral extended-release abuse-deterrent tablet

opioid treatment and for which alternative treatment options are inadequate.

Preferred options on the Advanced Control Formulary include fentanyl transdermal, methadone, morphine ext-rel, Embeda (morphine-naltrexone ext-rel), Nucynta ER (tapentadol ext-rel), and Xtampza ER (oxycodone ext-rel).

Isordil (isosorbide dinitrate) oral tablet

Cardiovascular/ Nitrates Isordil is indicated for the prevention of angina pectoris due to coronary artery disease.

Availability of a generic oral nitrate option for the prevention of angina. The preferred option on the Advanced Control Formulary is isosorbide dinitrate.

Istalol (timolol maleate) ophthalmic solution

Topical/ Ophthalmic/ Beta-Blockers/ Nonselective

Istalol is indicated for the treatment of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma.

Availability of other ophthalmic beta-blocker options for the reduction of elevated intraocular pressure. Preferred options on the Advanced Control Formulary include timolol maleate solution, Betimol (timolol hemihydrate), and Betoptic S (betaxolol).

KamDoy (emulsion) topical emulsion

Topical/ Dermatology/ Emollients

KamDoy is indicated to manage and relieve the burning and itching experienced with various types of dermatoses, including atopic and allergic contact dermatitis.

Availability of generic options for managing and relieving the burning and itching experienced with various types of skin conditions. Preferred options on the Advanced Control Formulary include desonide and hydrocortisone.

Lo Loestrin Fe (ethinyl estradiol-norethindrone acetate-iron) oral tablet

Endocrine and Metabolic/ Contraceptives/ Biphasic

Lo Loestrin Fe is indicated for use by women to prevent pregnancy.

Availability of other combination oral contraceptives. Preferred options on the Advanced Control Formulary include ethinyl estradiol-drospirenone, ethinyl estradiol-drospirenone-levomefolate, ethinyl estradiol-



Product


Subcategory Indication Options/Comments levonorgestrel, ethinyl estradiol-norethindrone acetate-iron, and ethinyl estradiol-norgestimate.

Lotemax (loteprednol) ophthalmic gel, ointment


Lotemax gel and ointment are indicated for the treatment of postoperative inflammation and pain following ocular surgery.


Lotemax (loteprednol) ophthalmic suspension


Lotemax suspension is indicated for the:

Treatment of steroid responsive inflammatory conditions of the palpebral and bulbar conjunctiva, cornea and anterior segment of the globe such as allergic conjunctivitis, acne rosacea, superficial punctate keratitis, herpes zoster keratitis, iritis, cyclitis, selected infective conjunctivitis, when the inherent hazard of steroid use is accepted to obtain an advisable diminution in edema and inflammation

Treatment of post-operative inflammation following ocular surgery.


Lotemax SM (loteprednol) ophthalmic gel


Lotemax SM is indicated for the treatment of post-operative inflammation and pain following ocular surgery.

Availability of other ophthalmic anti-inflammatory options.



Product


Subcategory Indication Options/Comments Preferred options on the Advanced Control Formulary include dexamethasone, loteprednol, prednisolone acetate 1%, and FML S.O.P. (fluorometholone).

Luzu (luliconazole) topical cream

Topical/ Dermatology/ Antifungals

Luzu is indicated for the topical treatment of interdigital tinea pedis, tinea cruris, and tinea corporis caused by the organisms Trichophyton rubrum and Epidermophyton floccosum.

Availability of generic options for the treatment of interdigital tinea pedis, tinea cruris, and tinea corporis. Preferred options on the Advanced Control Formulary include ciclopirox, clotrimazole, econazole, ketoconazole, luliconazole, and oxiconazole.

Mestinon (pyridostigmine) oral tablet, oral syrup

Central Nervous System/ Myasthenia Gravis

Mestinon is indicated for the treatment of myasthenia gravis.

Availability of generic options for the treatment of myasthenia gravis. Preferred options on the Advanced Control Formulary include pyridostigmine and pyridostigmine ext-rel.

Migranal (dihydroergotamine) intranasal solution

Central Nervous System/ Migraine/ Ergotamine Derivatives

Migranal is indicated for the acute treatment of migraine headaches with or without aura.

Availability of other options for the acute treatment of migraine headaches. Preferred options on the Advanced Control Formulary include eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, and Zomig Nasal Spray (zolmitriptan).

Ortho D (folic acid-cholecalciferol) oral capsule

Nutritional/Supplements/ Vitamins and Minerals/ Folic Acid / Combinations

Ortho D is used for the dietary management of patients with unique nutritional needs requiring increased folate levels and Vitamin D supplementation due to Vitamin D deficiency and other nutritional supplementation.

Availability of a generic supplementation option. The preferred option on the Advanced Control Formulary is folic acid.



Product


Subcategory Indication Options/Comments Oxsoralen-Ultra (methoxsalen) oral capsule

Topical/ Dermatology/ Antipsoriatics

Oxsoralen-Ultra is indicated for the symptomatic control of severe, recalcitrant, disabling psoriasis not adequately responsive to other forms of therapy and when the diagnosis has been supported by biopsy.

Availability of other options for severe psoriasis. Preferred options on the Advanced Control Formulary include acitretin and methoxsalen.

OxyContin (oxycodone) oral extended-release abuse-deterrent tablet


OxyContin is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate in:

Adults; and

Opioid-tolerant pediatric patients 11 years of age and older who are already receiving and tolerate a minimum daily opioid dose of at least 20 mg oxycodone orally or its equivalent.

Availability of other long-acting options for pain management. Preferred options on the Advanced Control Formulary include fentanyl transdermal, methadone, morphine ext-rel, Embeda (morphine-naltrexone ext-rel), Nucynta ER (tapentadol ext-rel), and Xtampza ER (oxycodone ext-rel).

Pazeo (olopatadine) ophthalmic solution

Topical/ Ophthalmic/ Antiallergics

Pazeo is indicated for the treatment of ocular itching associated with allergic conjunctivitis.

Availability of generic ophthalmic options for treating seasonal allergic conjunctivitis. Preferred options on the Advanced Control Formulary include azelastine, cromolyn sodium, and olopatadine.

Plegridy (peginterferon beta-1a) subcutaneous solution for injection


Plegridy is indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

Availability of other options for the treatment of relapsing forms of multiple sclerosis (MS). Preferred options on the Advanced Control Formulary include glatiramer, Aubagio (teriflunomide), Betaseron (interferon beta-1b), Copaxone (glatiramer), Gilenya



Product


Subcategory Indication Options/Comments (fingolimod), Mayzent (siponimod), Rebif (interferon beta-1a), Tecfidera (dimethyl fumarate delayed-rel), and Tysabri (natalizumab).

ProAir HFA (albuterol sulfate) inhalation aerosol solution

Respiratory/ Beta Agonists, Inhalants/ Short Acting

ProAir HFA is indicated for:

Treatment or prevention of bronchospasm in patients 4 years of age and older with reversible obstructive airway disease

Prevention of exercise-induced bronchospasm in patients 4 years of age and older.

Availability of generic short-acting beta-agonist options for the management of asthma. Preferred options on the Advanced Control Formulary include albuterol sulfate CFC-free aerosol and levalbuterol tartrate CFC-free aerosol.

ProAir RespiClick (albuterol sulfate) inhalation aerosol powder breath-activated

Respiratory/ Beta Agonists, Inhalants/ Short Acting

ProAir RespiClick is indicated for:

Treatment or prevention of bronchospasm in patients 4 years of age and older with reversible obstructive airway disease

Prevention of exercise-induced bronchospasm in patients 4 years of age and older.

Availability of generic short-acting beta-agonist options for the management of asthma. Preferred options on the Advanced Control Formulary include albuterol sulfate CFC-free aerosol and levalbuterol tartrate CFC-free aerosol.

Proctocort (hydrocortisone) rectal cream

Gastrointestinal/ Inflammatory Bowel Disease/ Rectal Agents

Proctocort cream is indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses.

Availability of other rectal options for the treatment of inflammatory bowel disease. Preferred options on the Advanced Control Formulary include hydrocortisone enema, mesalamine suppository, mesalamine suspension, and Cortifoam (hydrocortisone acetate).



Product


Subcategory Indication Options/Comments Proctocort (hydrocortisone) rectal suppository


Proctocort suppository is indicated for use in inflamed hemorrhoids, post-irradiation (factitial) proctitis; as an adjunct in the treatment of chronic ulcerative colitis; cryptitis; and other inflammatory conditions of anorectum and pruritus ani.

Availability of other rectal options for the treatment of inflammatory bowel disease. Preferred options on the Advanced Control Formulary include hydrocortisone enema, mesalamine suppository, mesalamine suspension, and Cortifoam (hydrocortisone acetate).

Qtern (dapagliflozin-saxagliptin) oral tablet

Endocrine and Metabolic/ Antidiabetics/ Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor / Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations

Qtern is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Availability of another combination SGLT2/DPP-4 inhibitor combination option for improving glycemic control in adults with type 2 diabetes mellitus. The preferred option on the Advanced Control Formulary is Glyxambi (empagliflozin-linagliptin).

Recedo (polysiloxane-silicon dioxide) topical gel


Recedo is intended for the management of old and new hypertrophic or keloid scarring resulting from burns, general surgical procedures or trauma wounds.

Availability of a generic option for the management of scarring. The preferred option on the Advanced Control Formulary is imiquimod.

Sil-K Pad (silicone gel matrix) topical pad


Sil-K Pad is intended for non-invasive management of old and new hypertrophic or keloid scars resulting from burns, surgical procedures or trauma wounds.

Availability of a generic option for the management of scarring. The preferred option on the Advanced Control Formulary is imiquimod.

Stribild (elvitegravir-cobicistat-emtricitabine-


Stribild is indicated as a complete regimen

For the treatment of HIV-1 infection in adults and pediatric patients 12 years of age and older weighing at least 35 kg

Availability of other complete regimen options for the treatment of HIV-1 infection.



Product


Subcategory Indication Options/Comments tenofovir disoproxil fumarate) oral tablet

who have no antiretroviral treatment history, or

To replace the current antiretroviral regimen in those who are virologically suppressed (HIV-1 RNA less than 50 copies/mL) on a stable antiretroviral regimen for at least 6 months with no history of treatment failure and no known substitutions associated with resistance to the individual components of Stribild.

Preferred options on the Advanced Control Formulary include Atripla (efavirenz-emtricitabine-tenofovir disoproxil fumarate), Biktarvy (bictegravir-emtricitabine-tenofovir alafenamide), Genvoya (elvitegravir-cobicistat-emtricitabine-tenofovir alafenamide), Odefsey (emtricitabine-rilpivirine-tenofovir alafenamide), Symfi (efavirenz-lamivudine-tenofovir disoproxil fumarate), Symfi Lo (efavirenz-lamivudine-tenofovir disoproxil fumarate), and Triumeq (abacavir-dolutegravir-lamivudine).

Syprine (trientine) oral capsule

Endocrine and Metabolic/ Miscellaneous

Syprine is indicated in the treatment of patients with Wilson's disease who are intolerant of penicillamine.

Availability of other options for the treatment of Wilson’s disease. Consult doctor for preferred options on the Advanced Control Formulary.

Timoptic Ocudose (timolol maleate) ophthalmic solution

Topical/ Ophthalmic/ Beta-Blockers/ Nonselective

Timoptic Ocudose is indicated in the treatment of elevated intraocular pressure in patients with ocular hypertension or open-angle glaucoma.

Availability of other ophthalmic beta-blocker options for the reduction of elevated intraocular pressure. Preferred options on the Advanced Control Formulary include timolol maleate solution, Betimol (timolol hemihydrate), and Betoptic S (betaxolol).

Transderm Scop (scopolamine) transdermal patch


Transderm Scop is indicated in adults for the prevention of:

Nausea and vomiting associated with motion sickness

Availability of generic options for the treatment of nausea and vomiting. Preferred options on the Advanced Control Formulary include meclizine and scopolamine transdermal.



Product



Post-operative nausea and vomiting associated with recovery from anesthesia and/or opiate analgesia and surgery.

Uceris Foam (budesonide) rectal foam


Uceris foam is indicated for the induction of remission in patients with active mild to moderate distal ulcerative colitis extending up to 40 cm from the anal verge.

Availability of other rectal agents for the treatment of mild to moderate distal ulcerative colitis. Preferred options on the Advanced Control Formulary include hydrocortisone enema, mesalamine suppository, mesalamine suspension, and Cortifoam (hydrocortisone acetate).

Uceris Tablet (budesonide) oral extended-release tablet

Gastrointestinal/ Inflammatory Bowel Disease/ Oral Agents

Uceris tablet is indicated for the induction of remission in patients with active, mild to moderate ulcerative colitis.

Availability of other oral agents for the treatment of mild to moderate ulcerative colitis. Preferred options on the Advanced Control Formulary include balsalazide, sulfasalazine, sulfasalazine delayed-rel, Apriso (mesalamine ext-rel), and Pentasa (mesalamine ext-rel).

Vanos (fluocinonide) topical cream

Topical/ Dermatology/ Corticosteroids/ Very High Potency

Vanos is indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid responsive dermatoses in patients 12 years of age or older.

Availability of a generic high-potency corticosteroid for the relief of inflammatory and pruritic conditions. The preferred option on the Advanced Control Formulary is clobetasol cream.

Verzenio (abemaciclib) oral tablet


Verzenio is indicated:

In combination with an aromatase inhibitor as initial endocrine-based therapy for the treatment of

Availability of other options for the treatment of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer.



Product


Subcategory Indication Options/Comments postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer

In combination with fulvestrant for the treatment of women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer with disease progression following endocrine therapy

As monotherapy for the treatment of adult patients with HR-positive, HER2-negative advanced or metastatic breast cancer with disease progression following endocrine therapy and prior chemotherapy in the metastatic setting.

Preferred options on the Advanced Control Formulary include Ibrance (palbociclib) and Kisqali (ribociclib).

VESIcare (solifenacin succinate) oral tablet

Genitourinary/ Urinary Antispasmodics

VESIcare is indicated for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency.

Availability of other options for the treatment of overactive bladder. Preferred options on the Advanced Control Formulary include darifenacin ext-rel, oxybutynin ext-rel, solifenacin, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, Myrbetriq (mirabegron), and Toviaz (fesoterodine).



Product


Subcategory Indication Options/Comments Zelapar (selegiline) orally disintegrating tablet

Central Nervous System/ Antiparkinsonian Agents

Zelapar is indicated as an adjunct in the management of patients with Parkinson’s disease being treated with levodopa/carbidopa who exhibit deterioration in the quality of their response to this therapy.

Availability of generic options for the adjunctive management of Parkinson’s disease. Preferred options on the Advanced Control Formulary include rasagiline and selegiline.

Zontivity (vorapaxar) oral tablet

Hematologic/ Platelet Aggregation Inhibitors

Zontivity is indicated for the reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) or with peripheral arterial disease (PAD).

Availability of other options for the reduction of thrombotic cardiovascular events. Consult doctor for preferred options on the Advanced Control Formulary.

Zovirax (acyclovir) oral capsule, oral tablet, oral suspension

Anti-Infectives/ Antivirals/ Herpes Agents

Zovirax is indicated for:

The acute treatment of herpes zoster (shingles)

The treatment of initial episodes and the management of recurrent episodes of genital herpes

The treatment of chickenpox (varicella).

Availability of generic antiviral options. Preferred options on the Advanced Control Formulary include acyclovir and valacyclovir.

Zovirax (acyclovir) topical cream


Zovirax cream is indicated for the treatment of recurrent herpes labialis (cold sores) in immunocompetent adults and adolescents 12 years of age and older.


Zovirax (acyclovir) topical ointment


Zovirax ointment is indicated in the management of initial genital herpes and in limited non-life-threatening mucocutaneous herpes simplex virus infections in immunocompromised patients.




Product


Subcategory Indication Options/Comments Zylet (tobramycin-loteprednol) ophthalmic suspension

Topical/ Ophthalmic/ Anti-Infective/ Anti-Inflammatory Combinations

Zylet is indicated for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists.

Availability of other ophthalmic anti-infective and anti-inflammatory products. Preferred options on the Advanced Control Formulary include neomycin-polymyxin B-bacitracin-hydrocortisone, neomycin-polymyxin B-dexamethasone, tobramycin-dexamethasone, TobraDex Ointment (tobramycin-dexamethasone), and TobraDex ST (tobramycin-dexamethasone).

OTHER:

Product


Subcategory Indication Options/Comments Cyclophosphamide (cyclophosphamide) oral capsule

Antineoplastic Agents/ Alkylating Agents

Cyclophosphamide is indicated for the treatment of:

Malignant Diseases: malignant lymphomas (Hodgkin’s disease, lymphocytic lymphoma, mixed-cell type lymphoma, histiocytic lymphoma, Burkitt’s lymphoma); multiple myeloma, leukemias, mycosis fungoides, neuroblastoma, adenocarcinoma of ovary, retinoblastoma, breast carcinoma

Minimal Change Nephrotic Syndrome in Pediatric Patients: biopsy proven

Brand product is changing to generic status. Previous brand listing will now be reflected as generic.



Product


Subcategory Indication Options/Comments minimal change nephrotic syndrome in pediatric patients who failed to adequately respond to or are unable to tolerate adrenocorticosteroid therapy.

Kevzara (sarilumab) subcutaneous solution for injection

Immunologic Agents/ Autoimmune Agents/ Rheumatoid Arthritis

Kevzara is indicated for treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to one or more disease-modifying antirheumatic drugs (DMARDs).

Kevzara is now only preferred after two preferred agents have been tried.

Simponi (golimumab) subcutaneous solution for injection

Immunologic Agents/ Autoimmune Agents/ Ulcerative Colitis

Simponi is indicated for the treatment of adult patients with:

Moderately to severely active rheumatoid arthritis (RA) in combination with methotrexate

Active psoriatic arthritis (PsA) alone, or in combination with methotrexate

Active ankylosing spondylitis (AS)

Moderate to severe ulcerative colitis (UC) with an inadequate response or intolerant to prior treatment or requiring continuous steroid therapy o inducing and maintaining clinical

response o improving endoscopic appearance

of the mucosa during induction o inducing clinical remission

Now excluded for ulcerative colitis. Note: Simponi remains excluded for ankylosing spondylitis, psoriatic arthritis, and rheumatoid arthritis.



Product


Subcategory Indication Options/Comments o achieving and sustaining clinical

remission in induction responders

Taltz (ixekizumab) subcutaneous solution for injection

Immunologic Agents/ Autoimmune Agents/ Ankylosing Spondylitis

Taltz is indicated for the treatment of adults with:

Moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy

Active psoriatic arthritis

Active ankylosing spondylitis.

Now excluded for ankylosing spondylitis. Note: Taltz remains preferred for psoriasis and excluded for psoriatic arthritis.

Xeljanz (tofacitinib) oral tablet

Immunologic Agents/ Autoimmune Agents/ Ulcerative Colitis

Xeljanz is indicated for:

Treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response or intolerance to methotrexate

Treatment of adult patients with active psoriatic arthritis who have had an inadequate response or intolerance to methotrexate or other disease-modifying antirheumatic drugs (DMARDs)

Treatment of adult patients with moderately to severely active ulcerative colitis.

Now preferred for ulcerative colitis after failure of Humira (adalimumab). Note: Xeljanz remains preferred for rheumatoid arthritis and excluded for psoriatic arthritis.

advanced control formulary™ change summary report · lancets lancets endocrine and metabolic/...

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