| Acanya | clindamycin phosphate/benzoyl peroxide gel | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Accuneb | albuterol sulfate nebulization solution | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Short-Acting Beta Agonists - Oral Inh |
| Acthar | corticotropin gel | 8/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Seizure Disorders |
| Actimmune | interferon gamma-1B solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Infectious Disease |
| Adagen | pegademase bovine solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Adcetris | brentuximab vedotin solution reconstituted | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Adderall | amphetamine-dextroamphetamine tablet | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Adempas | riociguat tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension Agents |
| Advair Diskus and HFA | fluticasone propionate and salmeterol xinafoate aerosol and aerosolpowder | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | LABA/Corticosteroid |
| Advate | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Afinitor | everolimus tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Afstyla | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Akne-Mycin | erythromycin ointment | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Akynzeo | netupitant and palonosetron capsules | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Albenza | albendazole | 10/1/2017 | Requires Prior Approval, Subject to Quantity Limits | | Anthelmintic |
| Aldurazyme | laronidase solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Alferon-N | interferon alpha-n3 | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Infectious Disease |
| Aloxi | palonosetrom hci solution | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Alphanate | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Ampyra | dalfampridine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Anadrol-50 | oxmehtolone tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Anabolic Steroids |
| Androderm | testosterone transdermal patch | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Androgel | testosterone topical gel | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Android | methyltestosterone, oral capsule | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Androxy | fluoxymesterone, oral tablet | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Anzemet | dolasetron | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Apokyn | apomorphine hycrochloride solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Movement Disorders |
| Aralast | alpha-1 proteinase inhibitor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Alpha-1 Antitrypsin Deficiency |
| Aranesp | darbepoetin solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Anemia |
| Arcalyst | rilonacept for subcutaneous [SC] injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cryopyrin Associated Periodic Synd (CAPS) |
| Arcapta | indacaterol capsule | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Long-Acting Beta Agonists (LABA) |
| Arzerra | ofatumumab concentrate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Aubagio | teriflunomide tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Avastin | bevacizumab solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Age-Related Macular Degen/Oncology |
| Avastin | bevacizumab solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinal Disorders/Oncology |
| Aveed | testosterone undecanoate injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Axert | almotriptan | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Axiron | testosterone topical solution | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Azacitidine | Azacitidine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Azelex | azelaic acid cream | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Bavencio | | 8/1/2017 | | | Oncology |
| Beleodaq | belinostat solution reconstituted | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Belviq | lorcaserin hydrocholoride tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Benlysta | belimumab solution reconstituted | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Systemic Lupus Erythematosus |
| Benzphetamine | Benzphetamine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Berinert | C1 esterase inhibitor [human] for IV | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hereditary Angioedema |
| Betaseron | interferon beta-1b for subcutaneous [SC] injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Bethkis | tobramycin (oral inhalation) nebulization solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cystic Fibrosis |
| Bevespi | Glycopyrrolate; Formoterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | LABA/Anticholinergic |
| Biltricide | praziquantel | 10/1/2017 | Requires Prior Approval, Subject to Quantity Limits | | |
| Binosto | alendronate effervescent tablets | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Bisphosphanates |
| Blincyto | Blinatumomab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Bontril PDM | phendmetrazine tartrate tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Bontril SR | phendimetrazine tartrate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Bosulif | bosutinib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Botox | onabotulinumtoxin A | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Botulinum Toxins |
| Breo Ellipta | Fluticasone; Vilanterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | LABA/Corticosteroid |
| Brovana | Arformoterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Long-Acting Beta Agonists (LABA) |
| Bunavail | buprenorphine/naloxone buccal films | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Antagonists |
| Buphenyl | sodium phenylbutyrate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Urea Cycle Disorders |
| Buprenorphine | Buprenorphine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Antagonists |
| Buprenorphine/Naloxone | Buprenorphine/Naloxone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Antagonists |
| Butorphanol Nasal Spray | Butorphanol Nasal Spray | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics |
| Cambia | diclofenac potassium powder for oral solution | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | COX-2/NSAIDs |
| Caprelsa (Vandetanib) | vandetanib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Carbaglu | carglumic acid | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Urea Cycle Disorders |
| Cayston | aztreonam | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cystic Fibrosis |
| Ceprotin | protein C | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Coagulation Disorders |
| Cerezyme | imiglucerase | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Cesamet | nabilone | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Cetrotide | cetrorelix | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Cholbam | cholic acid | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | GI Disorders |
| Cialis 2.5 and 5 mg | tadalafil | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | BPH |
| Ciclodan Kit | ciclopirox topical solution 8% moisturize | 10/1/2017 | Requires Prior Approval | | Topical Antifungals |
| Cinryze | C1 esterase inhibitor (IV) | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hereditary Angioedema |
| Claravis | isotretinoin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Isotretinoins |
| Clindagel | clindamycin phosphate gel | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Clomiphene | clomiphene citrate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Non-Specialty |
| CNL8 Nail Kit | ciclopirox topical solution 8% nail lacquer remover swabs / emery board | 10/1/2017 | Requires Prior Approval | | Topical Antifungals |
| Cometriq | Cabozantinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Compounded Products | - | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Compounded Products |
| Concerta | methylphenidate extended-release tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Contrave | naltrexone Hcl/buproprion Hcl ER tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Copaxone | glatiramer acetate injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Corifact | antihemophilic factor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Corlanor | ivabradine tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Misc CV Agents |
| Crinone | progesterone, vaginal | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Non-Specialty |
| Cuprimine | penicillamine | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Chelating Agent |
| Cyramza | Ramucirumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Cystagon | mepivacaine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Cystaran | Cysteamine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Daraprim | pyrimethamine tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiparasitic |
| Darzalex | daratumumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Daytrana | methylphenidate transdermal system | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Decitabine | Decitabine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Delatestryl | testosterone enanthate injection | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Depo-Testosterone | testosterone cypionate injection | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Desferal (Deferoxamine) | deferoxamine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Iron Overload |
| Desoxyn | methamphetamine tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Dextroamphetamine | Dextroamphetamine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Didrex | benzphetamine hydrochloride tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Diethylpropion | Diethylpropion | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Differin | adapalene | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Dificid | fidaxomicin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Macrolide Antibiotics |
| Doral | quazepam | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Dronabinol | Dronabinol | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Dulera | Formoterol; mometasone | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | LABA/Corticosteroid |
| Dupixent | | 8/1/2017 | Requires Prior Approval | | Eczema |
| Dyanavel XR | amphetamine extended release | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Dysport | AbobotulinumtoxinA | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Botulinum Toxins |
| Egrifta | tesamorelin injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | HIV |
| Elaprase | Idursulfase | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Elelyso | Taliglucerase Alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Elidel | Calcineurin Inhibitor | 10/1/2017 | Requires Prior Approval | | Chelating Agent |
| Eligard | leuprolide | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Emend | aprepitant capsules | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| EMLA | Lidocaine; Prilocaine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Anesthetics - Lidocaine Containing |
| Empliciti | Elotuzumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Emverm | mebendazole | 10/1/2017 | Requires Prior Approval, Subject to Quantity Limits | | Anthelmintic |
| Enbrel | etanercept injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Psoriasis/RA |
| Endometrin | progesterone, vaginal | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Non-Specialty |
| Entresto | sacubitril-valsartan tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Heart Failure |
| Entyvio | Vedolizumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IBS |
| Epclusa | Sofosbuvir | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hepatitis C |
| Epiduo | adapalene/benzoyl peroxide gel | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Epogen | Epoetin Alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Anemia |
| Epoprostenol (Flolan, Veletri) | epoprostenol | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Erbitux | Cetuximab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Erivedge | vismodegib capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Erwinaze | L-asparaginase | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Esbriet | pirfenidone capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Idiopathic Pulmonary Fibrosis |
| Estazolam | estazolam | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Eszopiclone | eszopiclone | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Eucrisa | | 8/1/2017 | Requires Prior Approval, Requires Step Therapy | | Eczema |
| Evekeo | amphetamine sulfate tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Exalgo | hydromorphone hcl extended release tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Exjade | Deferasirox | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Iron Overload |
| Eylea | Aflibercept | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinal Disorders |
| Fabior | tazarotene foam | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Fabrazyme | Agalsidase Beta | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Fanapt | iloperidone | 10/1/2017 | Requires Prior Approval | | Atypical Antipsychotics |
| Feiba | Antihemophilic Factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Fentanyl (Lozenge/Nasal Spray Forms) | fentanyl citrate | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oral/Intranasal Fentanyl Products |
| Fentora | fentanyl buccal tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oral/Intranasal Fentanyl Products |
| Finacea | azelaic acid | 10/1/2017 | Requires Prior Approval | | Rosacea |
| Firazyr | icatibant for subcutaneous [SC] injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hereditary Angioedema |
| Firmagon | Degarelix | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Flector | Diclofenac | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | COX-2/NSAIDs |
| Flurazepam | flurazepam | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Focalin | dexmethylphenidate immediate release tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Focalin XR | dexmethylphenidate extended release tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Follistim AQ | follitropin beta | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Folotyn | Pralatrexate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Foradil | Formoterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Long-Acting Beta Agonists (LABA) |
| Fortamet and Glumetza | | 8/1/2017 | Requires Prior Approval | | |
| Forteo | teriparatide injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Osteoporosis |
| Fortesta | testosterone topical gel | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Fosamax-D | Alendronate | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Bisphosphanates |
| Frova | frovatriptan | 1/1/2017 | Requires Prior Approval, Requires Step Therapy, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Fusilev | Levoleucovorin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Gammaguard | Immune globulin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IVIG |
| Gammaked | immune globulin injection (Human) | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IVIG |
| Gammunex-C | Immune globulin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IVIG |
| Ganirelix acetate | ganirelix acetate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Gattex | Teduglutide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | GI Disorders |
| Gazyva | Obinutuzumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Gel-One | hyaluronate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Osteoarthritis |
| Gilenya | fingolimod capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Gilotrif | afatinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Glassia | Alpha-1-proteinase Inhibitor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Alpha-1 Antitrypsin Deficiency |
| Glatopa | glatiramer acetate injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Granisetron | granisetron | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Granix | Tbo-Filgrastim | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Neutropenia |
| Grastek | timothy grass pollen allergen extract sublingual [SL] tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sublingual Immunotherapy Products |
| H.P. Acthar Gel | | 8/1/2017 | | | Seizure Disorders |
| Halaven | Eribulin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Halcion | Triazolam | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Harvoni | sofosbuvir/ledipasvir tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hepatitis C |
| Hemofil M | Antihemophilic Factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Herceptin | Trastuzumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Hetlioz | tasimelteon capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sleep Disorders |
| Hizentra | immune globulin subcutaneous (Human) | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IVIG |
| Humate-P | Antihemophilic Factor VIII | 10/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Humatrope | somatropin injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Growth Hormone and Related Disorders |
| Humira | adalimumab injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IBS/RA/Psoriasis |
| Hyalgan | Sodium Hyaluronate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Osteoarthritis |
| Hycamtin | Topotecan | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Hysingla | hydrocodone | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Ibrance | Palbociclib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Iclusig | ponatinib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Ilaris | canakinumab for subcutaneous [SC] injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cryopyrin Associated Periodic Synd (CAPS) |
| Imatinib | imatinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Imbruvica | Ibrutinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Imitrex | sumatriptan tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Imlygic | Talimogene Laherparepvec | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Increlex | mecasermin [rDNA origin] injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Growth Hormone and Related Disorders |
| Inlyta | Axitinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Inova | benzoyl peroxide/salicylic acid pad | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Intron A | Interferon Alfa-2b | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Iressa | Gefitinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Istodax | Romidepsin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Ixempra | Ixabepilone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Ixinity | Factor IX Concentrates | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Jakafi | Ruxolitinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Jevtana | Cabazitaxel | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Jublia | efinaconazole topical solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Antifungals |
| Juxtapid | lomitapide capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lipid Disorders |
| Kadcyla | Ado-Trastuzumab emtansine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Kadian | morphine sulfate ER capsules | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Kalbitor | Ecallantide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hereditary Angioedema |
| Kalydeco | ivacaftor tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cystic Fibrosis |
| Kanuma | Sebelipase alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Kerydin | tavaborole topical solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Antifungals |
| Keytruda | Pembrolizumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Koate-DVI | Antihemophilic factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Kogenate FS | Antihemophilic factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Kogenate FS | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Korlym | mifepristone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cushing's Syndrome |
| Kovaltry | Antihemophilic factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Kovaltry | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Krystexxa | Pegloticase | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Gout |
| Kuvan | sapropterin dihydrochloride | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Phenylketonuria (PKU) |
| Kynamro | mipomersen sodium injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lipid Disorders |
| Kyprolis | Carfilzomib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Lazanda | fentanyl nasal spray | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oral/Intranasal Fentanyl Products |
| Lenvima | Lenvatinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Letairis | ambrisentan tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Leukine | leukine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Neutropenia |
| Levalbuterol | levalbuterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Short-Acting Beta Agonists - Oral Inh |
| Lidocaine 5% Ointment | Lidocaine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Anesthetics - Lidocaine Containing |
| Lidocaine Gel - 2% and 4% | Lidocaine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Anesthetics - Lidocaine Containing |
| Lidocaine HCL 4% Solution | Lidocaine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Anesthetics - Lidocaine Containing |
| Lidoderm | lidocaine patch 5% | 10/1/2017 | Requires Prior Approval | | Topical Anesthetics - Lidocaine Containing |
| Lonsurf | Trifluridine; Tipiracil | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Lovaza | omega-3-acid ethyl esters capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Omega-3 Fatty Acids |
| Lucentis | Ranibizumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinal Disorders |
| Lumizyme | Alglucosidase alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Lupaneta | Leuprolide; Norethindrone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Lupron Depot PED (leuprolide acetate) | leuprolide acetate for depot suspension | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Central Precocious Puberty (CPP) |
| Lupron/Leuprolide | leuprolide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Lynparza | Olaparib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Marinol | Dronabinol | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Maxalt | rizatriptan | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Mekinist | trametinib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Menopur | Menotropins | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Metadate CD | methylphenidate extended-release capsules | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Methamphetamine | methamphetamine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Methitest | methyltestosterone tablets | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Methylin | methylphenidate tablets, chewables, oral solution | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Methylphenidate | Methylphenidate | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Methylphenidate ER | Methylphenidate ER | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Methyltestosterone | methyltestosterone | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Metrocream | metronidazole | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Rosacea |
| Metrogel Topical | metronidazole | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Rosacea |
| Migranal | dihydroergotamine nasal spray | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Mirvaso | brimonidine | 10/1/2017 | Requires Prior Approval | | Rosacea |
| Monoclate-P | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Mononine | Factor IX Concentrates | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Morphine Sulfate ER | Morphine Sulfate ER | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Mozobil | Plerixafor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hematopoietics |
| MS Contin | morphine sulfate controlled-release tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Myalept | Metreleptin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lipodystrophy |
| Myobloc | RimabotulinumtoxinB | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Botulinum Toxins |
| Myorisan | Isotretinoin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Isotretinoins |
| Naglazyme | Galsulfase | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Nalfon | Fenoprofen | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | COX-2/NSAIDs |
| Naratriptan | naratriptan | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Natesto | testosterone nasal gel | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Natpara | Parathyroid Hormone Lyophilisate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Neulasta | pegfilgrastim | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Neutropenia |
| Nexavar | sorafenib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Ninlaro | ixazomib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Noritate | metronidazole | 10/1/2017 | Requires Prior Approval | | Rosacea |
| Novarel | human chorionic gonadotropin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| NovoEight | Antihemophilic factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Novoeight | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| NovoSeven | Antihemophilic factor VII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Noxafil | posaconazole | 1/1/2017 | | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antifungal |
| Nplate | Romiplostim | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Idiopathic Thrombocytopenic Purpura (ITP) |
| Nucynta | Tapentadol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pain - Opiod Analgesic |
| Nuvigil | armodafinil tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Narcolepsy (Other) |
| Nuwiq | Antihemophilic factor VIII | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Nuwiq | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Ocrevus | | 8/1/2017 | Requires Prior Approval | | Multiple Sclerosis |
| Octreotide acetate (Sandostatin) | octreotide acetate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Acromegaly |
| Ofev | nintedanib capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Idiopathic Pulmonary Fibrosis |
| Oncaspar | Pegaspargase | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Onexton | Benzoyl Peroxide; Clindamycin | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Opana ER | oxymorphone hcl ER tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Opdivo | Nivolumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Oracea | doxycycline | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Rosacea |
| Oralair | sweet vernal, orchard, perennial rye, timothy, and kentucky blue grass mixed pollens allergen extract SL tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sublingual Immunotherapy Products |
| Orenitram | treprostinil ER tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Orfadin | Nitisinone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Orkambi | lumacaftor/ivacaftor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cystic Fibrosis |
| Otrexup | methotrexate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Psoriasis/RA |
| Ovidrel | human chorionic gonadotropin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Oxandrin | Oxandrolone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Anabolic Steroids |
| Oxycodone ER | Oxycodone ER | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Oxycontin | oxycodone controlled release tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Oxymorphone ER | Oxymorphone ER | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Pedipirox-4 Nail Kit | ciclopirox topical solution 8% nail lacquer remover pads / nail file / with or withour foot powder | 10/1/2017 | Requires Prior Approval | | Topical Antifungals |
| Penlac Nail Lacquer | ciclopirox topical solution 8% | 10/1/2017 | Requires Prior Approval | | Topical Antifungals |
| Performist | Formoterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Long-Acting Beta Agonists (LABA) |
| Perjeta | Pertuzumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Pexeva | Paroxetine | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | SSRIs |
| Phendimetrazine | phendimetrazine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Phentermine | phentermine HCl | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Pliaglis | Lidocaine; Tetracaine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Anesthetics - Lidocaine Containing |
| Pomalyst | Pomalidomide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Pregnyl | human chorionic gonadotropin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Specialty |
| Prilosec Packets | Omeprazole | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Proton Pump Inhibitors |
| Proair HFA and Respiclick | albuterol sulfate | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Short-Acting Beta Agonists - Oral Inh |
| Procentra | dextroamphetamine sulfate liquid | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Procysbi | Cysteamine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Profilnine SD | Factor IX Complex | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Progesterone Vag Gel | progesterone, vaginal | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Non-Specialty |
| Prolastin-C | Alpha-1-proteinase Inhibitor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Alpha-1 Antitrypsin Deficiency |
| Proleukin | Aldesleukin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Promacta | eltrombopag tablets and oral suspension | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Idiopathic Thrombocytopenic Purpura (ITP) |
| Protonix Packets | Pantoprazole | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Proton Pump Inhibitors |
| Protopic | tacrolimus | 10/1/2017 | Requires Prior Approval | | Calcineurin Inhibitor |
| Provigil | modafinil tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Narcolepsy (Other) |
| Prudoxin | doxepin | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Topical Skin Product |
| Pulmozyme | Dornase Alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cystic Fibrosis |
| Quillichew ER | Methylphenidate | 1/1/2017 | | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Quillivant XR | methylphenidate ER oral suspension | 1/1/2017 | | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Ragwitek | short ragweed pollen allergen extract sublingual [SL] tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sublingual Immunotherapy Products |
| Rasuvo | Methotrexate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Psoriasis/RA |
| Ravicti | Glycerol Phenylbutyrate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Urea Cycle Disorders |
| Rebif | interferon beta-1a subcutaneous | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Reclast (zoledronic acid) | zoledronic acid | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Osteoporosis |
| Recombinate | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Regimex | benzphetamine 25 mg tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Relenza | Zanamivir | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Influenza |
| Relpax | eletriptan | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Remodulin | treprostinil injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Repatha | evolocumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lipid Disorders |
| Restasis | Cyclosporine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Ophthalmic Immunomodulators |
| Restoril | Temazepam | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Retin-A | tretinoin cream, gel, liquid | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Revlimid | lenalidomide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Rexulti | brexpipraziole | 10/1/2017 | Requires Prior Approval | | Atypical Antipsychotics |
| Rhofade | oxymetazoline hydrochloride | 10/1/2017 | Requires Prior Approval | | Rosacea |
| Riax | Benzoyl Peroxide | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Ritalin LA | methylphenidate ER tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Rituxan | Rituximab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | RA/Oncology |
| Rixubis | Factor IX Concentrates | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Rosac | Sulfacetamide; Sulfur | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Rosadan | metronidazole | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Rosacea |
| Rosanil | sodium sulfacetamide/sulfur cleanser | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Rubraca | rucaparib | 10/1/2017 | Requires Prior Approval | | Oncology |
| Ruconest | recombinant C1 esterase inhibitor for IV use | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hereditary Angioedema |
| Ruconest | | 8/1/2017 | Requires Prior Approval | | |
| Rydapt | midostaurin | 10/1/2017 | Requires Prior Approval | | Oncology |
| Sabril | Vigabatrin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Seizure Disorders |
| Samsca | Tolvaptan | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Electrolyte disorders |
| Sancuso | granisetron | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Saphris | vraylar | 10/1/2017 | Requires Prior Approval | | Atypical Antipsychotics |
| Saxenda | liraglutide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Sensipar | Cinacalcet | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Renal Disorder |
| Serevent Diskus | Salmeterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Long-Acting Beta Agonists (LABA) |
| Serostim | somatropin injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | HIV |
| Signifor | Pasireotide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Acromegaly/Cushing's Syndrome |
| Solaraze | Diclofenac | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Actinic Keratosis |
| Soliris | Eculizumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Paroxysmal Nocturnal Hemoglobinuria (PNH) |
| Solodyn | minocycline ER tablets | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oral Tetracyclines |
| Somarvert | Pegvisomant | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Acromegaly |
| Somatuline | Lanreotide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Acromegaly |
| Sonata | zaleplon capsules | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Soolantra | ivermectin | 10/1/2017 | Requires Prior Approval | | Rosacea |
| Soriatane | acitretin | 10/1/2017 | Requires Prior Approval | | Psoriasis/RA |
| Sotret | Isotretinoin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Isotretinoins |
| Sovaldi | sofosbuvir tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hepatitis C |
| Sprycel | dasatinib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Stiavig | acyclovir buccal tablet | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | |
| Stimate | Desmopressin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Stivarga | regorafenib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Strattera | atomoxetine capsules | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Strensiq | Asfotase alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Bone Disorders - Other |
| Striant | testosterone buccal system | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Striverdi | Olodaterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Long-Acting Beta Agonists (LABA) |
| Suboxone | buprenorphine/naloxone sublingual films | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Antagonists |
| Subsys | fentanyl sublingual spray | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oral/Intranasal Fentanyl Products |
| Sumadan | sulfacetamide/sulfur wash | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Sumatriptan | sumatriptan | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Sumavel | sumatriptan needle-free injection | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Sumaxin | sulfacetamide/sulfur wash | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Acne Products |
| Supartz | Sodium Hyaluronate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Osteoarthritis |
| Supprelin LA | Histrelin | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Central Precocious Puberty (CPP) |
| Suprenza | phentermine hydrochloride orally disintegrating tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Sutent | Sunitinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Sylatron | peginterferon alfa-2b | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Sylvant | Siltuximab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Synagis | Palivizumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | RSV |
| Synarel | nafarelin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fertility Products - Non-Specialty |
| Synera | Lidocaine; Tetracaine | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Topical Anesthetics - Lidocaine Containing |
| Synribo | Omacetaxine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Syprine | trientine | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Chelating Agent |
| Tafinlar | dabrafenib capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Tagrisso | osimertinib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Tamiflu | Oseltamivir | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Influenza |
| Tarceva | erlotinib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Targretin | Bexarotene | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Tazorac | tazarotene cream, gel | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Techfidera | Dimethyl Fumarate | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Multiple Sclerosis |
| Temozolomide | temozolomide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Testim | testosterone topical gel | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Testopel | testosterone pellets | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Buccal System | testosterone | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Cypionate Inj | testosterone cypionate injection | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Enanthate Inj | testosterone enanthate injection | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Nasal Gel | testosterone nasal | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Patch | testosterone | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Propionate Implant Pellets | testosterone | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Topical Cream | testosterone | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Topical Gel | testosterone | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testosterone Topical Ointment | testosterone | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Testosterone Products |
| Testred | methyltestosterone capsules | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Tetrabenazine | tetrabenazine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Movement Disorders |
| Thalomid | thalidomide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Tikosyn | Dofetilide | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Cardiac Disorder |
| Torisel | Temsirolimus | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Tracleer | bosetan tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Treanda | Bendamustine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Trelstar | Triptorelin | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Tretinoin | tretinoin | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Tretin-X | Tretinoin | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Treximet | sumatriptan/naproxen | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Triglide | Fenofibrate | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Fibrates |
| Trulance | plecanatide | 10/1/2017 | Requires Prior Approval | | GI Disorders |
| Tykerb | lapatinib ditosylate tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Tymlos | abaloparatide | 10/1/2017 | Requires Prior Approval | | Osteoporosis |
| Tysabri | Natalizumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | IBS/RA/Psoriasis |
| Tyvaso | treprostinil inhalation solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Uptravi | selexipag tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Valchlor | Mechlorethamine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Vantas | Histrelin | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Varubi | Rolapitant | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Vascepa | icosapent ethyl capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Omega-3 Fatty Acids |
| Vectibix | Panitumumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Velcade | Bortezomib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Veltin | clindamycin phosphate/tretinoin gel | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Ventavis | iloprost inhalation solution | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pulmonary Arterial Hypertension |
| Vfend | voriconazole | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antifungal |
| Vimizim | Elosulfase alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Vimovo | naproxen/esomeprazole magnesium | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | COX-2/NSAIDs |
| Vivitrol | Naltrexone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Alcohol/Opioid Dependency |
| Vogelxo | testosterone topical gel | 1/1/2018 | Requires Prior Approval | | Testosterone Products |
| Voltaren Gel | diclofenac sodium topical gel 1% | 10/1/2017 | Requires Prior Approval | | Topical Anesthetics - Lidocaine Containing |
| Votrient | Pazopanib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| VPRIV | Velaglucerase Alfa | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Vraylar | cariprazine | 10/1/2017 | Requires Prior Approval | | Atypical Antipsychotics |
| Vyvanse | lisdexamfetamine dimesylate capsules | 1/1/2017 | | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Wilate | antihemophilic factor viii | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Xalkori | crizotinib capsules | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Xartemis XR | Acetaminophen; Oxycodone | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Pain - Opiod Analgesic |
| Xeloda | Capecitabine | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Xenical | orlistat | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiobesity |
| Xeomin | IncobotulinumtoxinA | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Botulinum Toxins |
| Xgeva | Denosumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Ximino | minocycline | 1/1/2017 | | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oral Tetracyclines |
| Xolair | omalizumab injection for subcutaneous [SC] use | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Allergic Asthma |
| Xopenex Neb and Concentrate Sol | Levalbuterol | 1/1/2017 | Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Short-Acting Beta Agonists - Oral Inh |
| Xtampza ER | Oxycodone | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Xyntha | antihemophilic factor viii | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hemophilia |
| Xyntha | Antihemophilic factor VIII | 10/1/2017 | Requires Prior Approval | | Hemophilia |
| Xyrem | sodium oxybate oral solution | 10/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Narcolepsy (Other) |
| Yervoy | Ipilimumab | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zaltrap | Ziv-Aflibercept | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zarxio | filgrastim-sndz injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Neutropenia |
| Zavesca | Miglustat | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Lysosomal Storage Disorders |
| Zejula | | 8/1/2017 | Requires Prior Approval | | Oncology |
| Zelboraf | vemurafenib tablets | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zemaira | Alpha-1-proteinase Inhibitor | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Alpha-1 Antitrypsin Deficiency |
| Zenatane | Isotretinoin | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Isotretinoins |
| Zenzedi | dextroamphetamine tablets | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | ADHD-Narcolepsy Agents |
| Ziana | clindamycin phosphate/tretinoin gel | 1/1/2017 | Requires Prior Approval, Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Retinoids |
| Zipsor | Diclofenac | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | COX-2/NSAIDs |
| Zofran | ondansetron | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Zohydro | Hydrocodone | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Opioid Analgesics - Extended-Release |
| Zoladex | Goserelin | 1/1/2018 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Hormonal Therapies |
| Zolinza | Vorinostat | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zolpidem | zolpidem tartrate | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Sedative-Hypnotics |
| Zometa/Zoledronic Acid | zoledronic acid | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zomig | zolmitriptan | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antimigraine |
| Zonalon | doxepin | 10/1/2017 | Requires Prior Approval, Requires Step Therapy | | Topical Skin Product |
| Zorbtive | somatropin injection | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | GI Disorders |
| Zorvolex | Diclofenac | 1/1/2017 | Requires Step Therapy | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | COX-2/NSAIDs |
| Zuplenz | ondansetron | 1/1/2017 | Requires Prior Approval, Subject to Quantity Limits | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Antiemetics |
| Zydelig | Idelalisib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zykadia | ceritinib | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
| Zytiga | Abiraterone | 1/1/2017 | Requires Prior Approval | For policy information, contact CVS Caremark Customer Service at 888-321-3124 | Oncology |
