CVS Caremark Advanced Control Specialty Formulary Guide

1 January 2026 Advanced Control Specialty Formulary® The CVS Caremark® Advanced Control Specialty Formulary® is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list and does not guarantee coverage. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER Your benefit plan provides you with prescription drug coverage that is administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list the next time you or a covered family member sees a doctor. • Your specific prescription benefit plan design may not cover certain medications, products or categories, regardless of their appearance in this document. Medications and products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered immediately upon release to the market. • Your prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated. • You may be responsible for the full cost of medications and products that are removed from coverage. • For specific information regarding your prescription benefit coverage and cost sharing, or if you have additional questions, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu. • When a generic medication that is equivalent to a brand-name drug is released to the market, in most instances, that brand-name drug will be designated as a non-preferred option. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is medically necessary, consider prescribing a brand name on this list. • The member's prescription benefit plan design may alter coverage of certain products or vary cost sharing amounts based on the condition being treated. • This drug list represents a summary of prescription coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered immediately upon release to the market. • The member's prescription benefit plan may have different cost sharing for specific products on the list. • Unless specifically indicated, drug list products will include all dosage forms.

2 • Log in to Caremark.com to check coverage and cost sharing information for a specific medicine. ANALGESICS VISCOSUPPLEMENTS DUROLANE EUFLEXXA GELSYN-3 ORTHOVISC ANTI-INFECTIVES ANTIRETROVIRAL AGENTS abacavir atazanavir darunavir efavirenz emtricitabine etravirine lamivudine maraviroc nevirapine nevirapine ext-rel ritonavir tenofovir disoproxil fumarate zidovudine APRETUDE ISENTRESS TIVICAY ANTIRETROVIRAL COMBINATION AGENTS abacavir-lamivudine efavirenz-emtricitabine- tenofovir disoproxil fumarate efavirenz-lamivudine-tenofovir disoproxil fumarate emtricitabine-rilpivirine- tenofovir disoproxil fumarate emtricitabine-tenofovir disoproxil fumarate lamivudine-zidovudine lopinavir-ritonavir BIKTARVY CABENUVA CIMDUO DESCOVY DOVATO GENVOYA ODEFSEY SYMTUZA TRIUMEQ HEPATITIS B entecavir lamivudine tenofovir disoproxil fumarate HEPATITIS C ribavirin EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) HARVONI (genotypes 1, 4, 5, 6) VOSEVI ANTINEOPLASTIC AGENTS ALKYLATING AGENTS temozolomide ANTIMETABOLITES capecitabine LONSURF BIOLOGIC RESPONSE MODIFIERS lenalidomide ERIVEDGE THALOMID BIOSIMILARS KANJINTI RUXIENCE TRAZIMERA ZIRABEV HORMONAL ANTINEOPLASTIC AGENTS abiraterone leuprolide acetate ELIGARD ERLEADA NUBEQA XTANDI YONSA KINASE INHIBITORS dasatinib erlotinib everolimus gefitinib imatinib mesylate lapatinib nilotinib pazopanib sorafenib sunitinib ALECENSA ALUNBRIG AUGTYRO BOSULIF BRAFTOVI BRUKINSA CABOMETYX CALQUENCE GAVRETO GOMEKLI IBRANCE IBTROZI INLYTA JAKAFI KISQALI KISQALI FEMARA CO-PACK KOSELUGO LENVIMA MEKINIST MEKTOVI PIQRAY RETEVMO ROZLYTREK RYDAPT SCEMBLIX STIVARGA TAFINLAR TAGRISSO TRUQAP VITRAKVI XOSPATA ZYKADIA MISCELLANEOUS bexarotene KRAZATI LUMAKRAS LYNPARZA ODOMZO VISTOGARD ZEJULA MONOCLONAL ANTIBODIES PHESGO POLYCYTHEMIA VERA BESREMI JAKAFI PROTEASOME INHIBITORS bortezomib NINLARO CARDIOVASCULAR ANTILIPEMICS, PCSK9 INHIBITORS REPATHA MISCELLANEOUS VYNDAMAX PULMONARY ARTERIAL HYPERTENSION ambrisentan bosentan sildenafil tadalafil treprostinil ADEMPAS OPSUMIT OPSYNVI ORENITRAM TADLIQ TYVASO TYVASO DPI UPTRAVI YUTREPIA CENTRAL NERVOUS SYSTEM AMYOTROPHIC LATERAL SCLEROSIS (ALS) RADICAVA ORS ANTIDEPRESSANTS ZURZUVAE ANTIPARKINSONIAN AGENTS INBRIJA ANTISEIZURE AGENTS vigabatrin BOTULINUM TOXINS DAXXIFY DYSPORT XEOMIN MISCELLANEOUS ENSPRYNG

3 MOVEMENT DISORDERS tetrabenazine AUSTEDO INGREZZA MULTIPLE SCLEROSIS AGENTS dimethyl fumarate delayed-rel fingolimod glatiramer teriflunomide AVONEX BAFIERTAM BETASERON COPAXONE 40 MG/ML KESIMPTA MAYZENT OCREVUS REBIF TYSABRI VUMERITY ZEPOSIA MYASTHENIA GRAVIS VYVGART VYVGART HYTRULO NARCOLEPSY/CATAPLEXY LUMRYZ WAKIX XYWAV ENDOCRINE AND METABOLIC ACROMEGALY octreotide acetate kit SOMATULINE DEPOT CALCIUM RECEPTOR AGONISTS cinacalcet CALCIUM REGULATORS, MISCELLANEOUS OSENVELT PROLIA CALCIUM REGULATORS, PARATHYROID HORMONES teriparatide TYMLOS CENTRAL PRECOCIOUS PUBERTY FENSOLVI LUPRON DEPOT-PED SUPPRELIN LA TRIPTODUR CHELATING AGENTS deferasirox deferiprone deferoxamine penicillamine trientine CONTRACEPTIVES KYLEENA MIRENA SKYLA FERTILITY REGULATORS cetrorelix acetate FOLLISTIM AQ GANIRELIX ACETATE PREGNYL HEREDITARY TYROSINEMIA TYPE 1 AGENTS ORFADIN HUMAN GROWTH HORMONES HUMATROPE NORDITROPIN SOGROYA LYSOSOMAL STORAGE DISORDERS NEXVIAZYME LYSOSOMAL STORAGE DISORDERS - FABRY DISEASE ELFABRIO FABRAZYME GALAFOLD LYSOSOMAL STORAGE DISORDERS - GAUCHER DISEASE CERDELGA CEREZYME MISCELLANEOUS betaine mifepristone sapropterin tolvaptan CYSTAGON UREA CYCLE DISORDER carglumic acid sodium phenylbutyrate PHEBURANE GASTROINTESTINAL EOSINOPHILIC ESOPHAGITIS DUPIXENT MISCELLANEOUS IQIRVO GENITOURINARY MISCELLANEOUS tiopronin tiopronin delayed-rel FILSPARI VANRAFIA HEMATOLOGIC BLEEDING DISORDERS AGENTS NOVOSEVEN RT SEVENFACT WILATE HEMATOPOIETIC GROWTH FACTORS ARANESP FULPHILA NIVESTYM NYVEPRIA PROCRIT RETACRIT HEMOPHILIA A AGENTS ADVATE ADYNOVATE AFSTYLA ALTUVIIIO ELOCTATE ESPEROCT JIVI KOGENATE FS KOVALTRY NOVOEIGHT NUWIQ XYNTHA HEMOPHILIA B AGENTS BENEFIX REBINYN PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS EMPAVELI SICKLE CELL DISEASE ENDARI THROMBOCYTOPENIA AGENTS ALVAIZ DOPTELET IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS ORALAIR ALOPECIA AREATA LITFULO OLUMIANT AUTOIMMUNE AGENTS (PHYSICIAN- ADMINISTERED) AVSOLA ILUMYA PYZCHIVA INTRAVENOUS REMICADE SIMPONI ARIA SKYRIZI INTRAVENOUS STELARA INTRAVENOUS TREMFYA INTRAVENOUS YESINTEK INTRAVENOUS AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ALL OTHER CONDITIONS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ANKYLOSING SPONDYLITIS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) RINVOQ AUTOIMMUNE AGENTS (SELF-ADMINISTERED), CROHN'S DISEASE ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENTYVIO SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS

4 TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS AUTOIMMUNE AGENTS (SELF-ADMINISTERED), HIDRADENITIS SUPPURATIVA ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) AUTOIMMUNE AGENTS (SELF-ADMINISTERED), NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS CIMZIA PREFILLED SYRINGE COSENTYX SUBCUTANEOUS RINVOQ AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIASIS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP BIMZELX HYRIMOZ (except NDCs 61314-XXXX-XX) OTEZLA PYZCHIVA SUBCUTANEOUS SKYRIZI SUBCUTANEOUS SOTYKTU STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS AUTOIMMUNE AGENTS (SELF-ADMINISTERED), PSORIATIC ARTHRITIS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) OTEZLA PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS AUTOIMMUNE AGENTS (SELF-ADMINISTERED), RHEUMATOID ARTHRITIS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) KEVZARA ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS RINVOQ XELJANZ XELJANZ XR AUTOIMMUNE AGENTS (SELF-ADMINISTERED), ULCERATIVE COLITIS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENTYVIO SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS VELSIPITY YESINTEK SUBCUTANEOUS ZEPOSIA DISEASE-MODIFYING ANTI- RHEUMATIC DRUGS (DMARDS) RASUVO HEREDITARY ANGIOEDEMA icatibant ORLADEYO RUCONEST TAKHZYRO IMMUNOGLOBULIN CUTAQUIG XEMBIFY IMMUNOSUPPRESSANTS cyclosporine cyclosporine modified everolimus mycophenolate mofetil mycophenolate sodium sirolimus tacrolimus OPHTHALMIC RETINAL DISORDERS BYOOVIZ RESPIRATORY ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ARALAST NP GLASSIA ZEMAIRA CHRONIC OBSTRUCTIVE PULMONARY DISEASE DUPIXENT NUCALA (except lyophilized powder) CHRONIC RHINOSINUSITIS WITH NASAL POLYPS DUPIXENT NUCALA (except lyophilized powder) XOLAIR CYSTIC FIBROSIS tobramycin inhalation solution PULMONARY FIBROSIS AGENTS pirfenidone OFEV SEVERE ASTHMA AGENTS DUPIXENT FASENRA NUCALA (except lyophilized powder) TEZSPIRE XOLAIR TOPICAL DERMATOLOGY, ATOPIC DERMATITIS CIBINQO DUPIXENT EBGLYSS NEMLUVIO RINVOQ DERMATOLOGY, CHRONIC SPONTANEOUS URTICARIA DUPIXENT XOLAIR DERMATOLOGY, PRURIGO NODULARIS DUPIXENT NEMLUVIO MOUTH/THROAT/DENTAL AGENTS MUGARD QUICK REFERENCE DRUG LIST A abacavir abacavir-lamivudine abiraterone ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ADEMPAS ADVATE ADYNOVATE AFSTYLA ALECENSA ALTUVIIIO ALUNBRIG ALVAIZ ambrisentan APRETUDE ARALAST NP ARANESP atazanavir AUGTYRO AUSTEDO AVONEX AVSOLA B BAFIERTAM BENEFIX BESREMI betaine BETASERON bexarotene BIKTARVY BIMZELX bortezomib bosentan

5 BOSULIF BRAFTOVI BRUKINSA BYOOVIZ C CABENUVA CABOMETYX CALQUENCE capecitabine carglumic acid CERDELGA CEREZYME cetrorelix acetate CIBINQO CIMDUO CIMZIA PREFILLED SYRINGE cinacalcet COPAXONE 40 MG/ML COSENTYX SUBCUTANEOUS CUTAQUIG cyclosporine cyclosporine modified CYSTAGON D darunavir dasatinib DAXXIFY deferasirox deferiprone deferoxamine DESCOVY dimethyl fumarate delayed- rel DOPTELET DOVATO DUPIXENT DUROLANE DYSPORT E EBGLYSS efavirenz efavirenz-emtricitabine- tenofovir disoproxil fumarate efavirenz-lamivudine- tenofovir disoproxil fumarate ELFABRIO ELIGARD ELOCTATE EMPAVELI emtricitabine emtricitabine-rilpivirine- tenofovir disoproxil fumarate emtricitabine-tenofovir disoproxil fumarate ENBREL ENDARI ENSPRYNG entecavir ENTYVIO SUBCUTANEOUS EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) ERIVEDGE ERLEADA erlotinib ESPEROCT etravirine EUFLEXXA everolimus everolimus F FABRAZYME FASENRA FENSOLVI FILSPARI fingolimod FOLLISTIM AQ FULPHILA G GALAFOLD GANIRELIX ACETATE GAVRETO gefitinib GELSYN-3 GENVOYA GLASSIA glatiramer GOMEKLI H HARVONI (genotypes 1, 4, 5, 6) HUMATROPE HYRIMOZ (except NDCs 61314-XXXX-XX) I IBRANCE IBTROZI icatibant ILUMYA imatinib mesylate INBRIJA INGREZZA INLYTA IQIRVO ISENTRESS J JAKAFI JIVI K KANJINTI KESIMPTA KEVZARA KISQALI KISQALI FEMARA CO-PACK KOGENATE FS KOSELUGO KOVALTRY KRAZATI KYLEENA L lamivudine lamivudine lamivudine-zidovudine lapatinib lenalidomide LENVIMA leuprolide acetate LITFULO LONSURF lopinavir-ritonavir LUMAKRAS LUMRYZ LUPRON DEPOT-PED LYNPARZA M maraviroc MAYZENT MEKINIST MEKTOVI mifepristone MIRENA MUGARD mycophenolate mofetil mycophenolate sodium N NEMLUVIO nevirapine nevirapine ext-rel NEXVIAZYME nilotinib NINLARO NIVESTYM NORDITROPIN NOVOEIGHT NOVOSEVEN RT NUBEQA NUCALA (except lyophilized powder) NUWIQ NYVEPRIA O OCREVUS octreotide acetate kit ODEFSEY ODOMZO OFEV OLUMIANT OPSUMIT OPSYNVI ORALAIR ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS ORENITRAM ORFADIN ORLADEYO ORTHOVISC OSENVELT OTEZLA P pazopanib penicillamine PHEBURANE PHESGO PIQRAY pirfenidone PREGNYL PROCRIT PROLIA PYZCHIVA INTRAVENOUS PYZCHIVA SUBCUTANEOUS R RADICAVA ORS RASUVO REBIF REBINYN REMICADE REPATHA RETACRIT RETEVMO ribavirin RINVOQ ritonavir ROZLYTREK RUCONEST RUXIENCE RYDAPT S sapropterin SCEMBLIX SEVENFACT sildenafil SIMPONI ARIA sirolimus SKYLA SKYRIZI INTRAVENOUS

6 SKYRIZI SUBCUTANEOUS sodium phenylbutyrate SOGROYA SOMATULINE DEPOT sorafenib SOTYKTU STELARA INTRAVENOUS STELARA SUBCUTANEOUS STIVARGA sunitinib SUPPRELIN LA SYMTUZA T tacrolimus tadalafil TADLIQ TAFINLAR TAGRISSO TAKHZYRO temozolomide tenofovir disoproxil fumarate teriflunomide teriparatide tetrabenazine TEZSPIRE THALOMID tiopronin tiopronin delayed-rel TIVICAY tobramycin inhalation solution tolvaptan TRAZIMERA TREMFYA INTRAVENOUS TREMFYA SUBCUTANEOUS treprostinil trientine TRIPTODUR TRIUMEQ TRUQAP TYMLOS TYSABRI TYVASO TYVASO DPI U UPTRAVI V VANRAFIA VELSIPITY vigabatrin VISTOGARD VITRAKVI VOSEVI VUMERITY VYNDAMAX VYVGART VYVGART HYTRULO W WAKIX WILATE X XELJANZ XELJANZ XR XEMBIFY XEOMIN XOLAIR XOSPATA XTANDI XYNTHA XYWAV Y YESINTEK INTRAVENOUS YESINTEK SUBCUTANEOUS YONSA YUTREPIA Z ZEJULA ZEMAIRA ZEPOSIA zidovudine ZIRABEV ZURZUVAE ZYKADIA

7 PREFERRED OPTIONS FOR EXCLUDED SPECIALTY MEDICATIONS The preferred options listed below are a broad representation of available treatment options and do not necessarily represent clinical equivalency. DRUG NAME(S) PREFERRED OPTION(S) ACTEMRA INTRAVENOUS AVSOLA, REMICADE, SIMPONI ARIA ADCIRCA sildenafil, tadalafil, TADLIQ AFINITOR, AFINITOR DISPERZ everolimus ALPROLIX BENEFIX, REBINYN APOKYN INBRIJA APTIVUS Talk to your doctor ARCALYST Talk to your doctor AUBAGIO dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BAFIERTAM, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA AUSTEDO XR tetrabenazine, AUSTEDO, INGREZZA AVASTIN ZIRABEV BARACLUDE TABLET entecavir, lamivudine, tenofovir disoproxil fumarate BERINERT icatibant, RUCONEST BETHKIS tobramycin inhalation solution BORTEZOMIB bortezomib, NINLARO BOTOX AJOVY, DAXXIFY, DYSPORT, EMGALITY, QULIPTA, XEOMIN BUPHENYL sodium phenylbutyrate, PHEBURANE CARBAGLU carglumic acid CAYSTON tobramycin inhalation solution CETROTIDE cetrorelix acetate, GANIRELIX ACETATE CHORIONIC GONADOTROPIN PREGNYL CIMZIA LYOPHILIZED POWDER AVSOLA, ILUMYA, PYZCHIVA INTRAVENOUS, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS, TREMFYA INTRAVENOUS, YESINTEK INTRAVENOUS CINRYZE ORLADEYO, TAKHZYRO DRUG NAME(S) PREFERRED OPTION(S) COMPLERA efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine- tenofovir disoproxil fumarate, emtricitabine-rilpivirine-tenofovir disoproxil fumarate, BIKTARVY, CABENUVA, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ COPAXONE 20 MG/ML dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BAFIERTAM, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA COPIKTRA BRUKINSA, CALQUENCE COTELLIC MEKINIST, MEKTOVI CUPRIMINE penicillamine CYSTADANE betaine DESFERAL deferasirox, deferiprone, deferoxamine DIACOMIT Talk to your doctor EDURANT efavirenz ELELYSO CERDELGA, CEREZYME EPOGEN ARANESP, PROCRIT, RETACRIT ESBRIET pirfenidone, OFEV EXJADE deferasirox, deferiprone, deferoxamine EXTAVIA dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BAFIERTAM, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA EYLEA BYOOVIZ FEIBA NOVOSEVEN RT, SEVENFACT FERRIPROX deferasirox, deferiprone, deferoxamine FINTEPLA clobazam, clonazepam, lamotrigine, rufinamide, topiramate, topiramate ext-rel FIRAZYR icatibant, RUCONEST FIRMAGON ELIGARD

8 DRUG NAME(S) PREFERRED OPTION(S) FYLNETRA FULPHILA, NYVEPRIA Fyremadel cetrorelix acetate, GANIRELIX ACETATE ganirelix acetate cetrorelix acetate, GANIRELIX ACETATE GEL-ONE DUROLANE, EUFLEXXA, GELSYN-3, ORTHOVISC GENOTROPIN HUMATROPE, NORDITROPIN, SOGROYA GILENYA dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BAFIERTAM, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA GLEEVEC dasatinib, imatinib mesylate, nilotinib, BOSULIF, SCEMBLIX GONAL-F FOLLISTIM AQ GRANIX NIVESTYM HERCEPTIN, HERCEPTIN HYLECTA KANJINTI, TRAZIMERA HERZUMA KANJINTI, TRAZIMERA HYALGAN DUROLANE, EUFLEXXA, GELSYN-3, ORTHOVISC HYQVIA CUTAQUIG, XEMBIFY ICLUSIG dasatinib, imatinib mesylate, nilotinib, BOSULIF, SCEMBLIX IMBRUVICA INFLECTRA BRUKINSA, CALQUENCE AVSOLA, ILUMYA, PYZCHIVA INTRAVENOUS, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS, TREMFYA INTRAVENOUS, YESINTEK INTRAVENOUS INTELENCE etravirine IRESSA erlotinib, gefitinib, TAGRISSO IXINITY BENEFIX, REBINYN JADENU deferasirox, deferiprone, deferoxamine JUXTAPID REPATHA JYNARQUE tolvaptan KALETRA TABLET atazanavir, darunavir, lopinavir-ritonavir KITABIS PAK tobramycin inhalation solution KORLYM mifepristone KUVAN sapropterin KYPROLIS bortezomib, NINLARO DRUG NAME(S) PREFERRED OPTION(S) LEMTRADA dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BAFIERTAM, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA LETAIRIS ambrisentan, bosentan, OPSUMIT LEUKINE NIVESTYM LILETTA KYLEENA, MIRENA, SKYLA LUCENTIS BYOOVIZ LUPRON DEPOT 7.5 MG, 22.5 MG, 30 MG, 45 MG ELIGARD MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI MONOVISC DUROLANE, EUFLEXXA, GELSYN-3, ORTHOVISC MULPLETA DOPTELET MYOBLOC DAXXIFY, DYSPORT, XEOMIN NEULASTA, NEULASTA ONPRO FULPHILA, NYVEPRIA NEUPOGEN NIVESTYM NEXAVAR pazopanib, sorafenib, sunitinib, CABOMETYX, INLYTA, LENVIMA NEXTERONE amiodarone NITYR ORFADIN NORTHERA midodrine NORVIR ritonavir NOVAREL PREGNYL NPLATE ALVAIZ, DOPTELET NUCALA LYOPHILIZED POWDER DUPIXENT, FASENRA, NUCALA (except lyophilized powder), TEZSPIRE, XOLAIR NUTROPIN AQ HUMATROPE, NORDITROPIN, SOGROYA OCALIVA IQIRVO OCTAGAM Talk to your doctor OGIVRI KANJINTI, TRAZIMERA OMNITROPE HUMATROPE, NORDITROPIN, SOGROYA ORENCIA INTRAVENOUS AVSOLA, REMICADE, SIMPONI ARIA OVIDREL PREGNYL PEGASYS Talk to your doctor PERJETA PHESGO

9 DRUG NAME(S) PREFERRED OPTION(S) PRALUENT REPATHA PREZISTA atazanavir, darunavir PROCYSBI CYSTAGON PROLASTIN-C ARALAST NP, GLASSIA, ZEMAIRA PROMACTA ALVAIZ, DOPTELET RAVICTI sodium phenylbutyrate, PHEBURANE REMODULIN treprostinil RENFLEXIS AVSOLA, ILUMYA, PYZCHIVA INTRAVENOUS, REMICADE, SIMPONI ARIA, SKYRIZI INTRAVENOUS, STELARA INTRAVENOUS, TREMFYA INTRAVENOUS, YESINTEK INTRAVENOUS REVATIO sildenafil, tadalafil, TADLIQ REVLIMID lenalidomide REYATAZ atazanavir, darunavir RIABNI RUXIENCE RITUXAN RUXIENCE RIXUBIS BENEFIX, REBINYN RUBRACA LYNPARZA, ZEJULA SABRIL vigabatrin SANDOSTATIN LAR octreotide acetate kit, SOMATULINE DEPOT SELZENTRY maraviroc SIGNIFOR LAR octreotide acetate kit, SOMATULINE DEPOT SOLIRIS (For Myasthenia Gravis Only) VYVGART, VYVGART HYTRULO SOMAVERT octreotide acetate kit, SOMATULINE DEPOT SPRYCEL dasatinib, imatinib mesylate, nilotinib, BOSULIF, SCEMBLIX STRIBILD efavirenz-emtricitabine-tenofovir disoproxil fumarate, efavirenz-lamivudine- tenofovir disoproxil fumarate, emtricitabine-rilpivirine-tenofovir disoproxil fumarate, BIKTARVY, CABENUVA, DOVATO, GENVOYA, ODEFSEY, SYMTUZA, TRIUMEQ SUPARTZ FX DUROLANE, EUFLEXXA, GELSYN-3, ORTHOVISC SUTENT pazopanib, sunitinib, CABOMETYX, INLYTA, LENVIMA DRUG NAME(S) PREFERRED OPTION(S) SYNAGIS Talk to your doctor SYNVISC, SYNVISC- ONE DUROLANE, EUFLEXXA, GELSYN-3, ORTHOVISC SYPRINE trientine TARGRETIN bexarotene TASIGNA dasatinib, imatinib mesylate, nilotinib, BOSULIF, SCEMBLIX TAVALISSE ALVAIZ, DOPTELET TECFIDERA dimethyl fumarate delayed-rel, fingolimod, glatiramer, teriflunomide, AVONEX, BAFIERTAM, BETASERON, COPAXONE 40 MG/ML, KESIMPTA, MAYZENT, OCREVUS, REBIF, TYSABRI, VUMERITY, ZEPOSIA THIOLA tiopronin THIOLA EC tiopronin delayed-rel TOBI, TOBI PODHALER tobramycin inhalation solution TRACLEER ambrisentan, bosentan, OPSUMIT TRELSTAR MIXJECT ELIGARD TRUVADA abacavir-lamivudine, emtricitabine- tenofovir disoproxil fumarate, lamivudine- zidovudine, APRETUDE, CIMDUO, DESCOVY TRUXIMA RUXIENCE UDENYCA FULPHILA, NYVEPRIA ULTOMIRIS (For Myasthenia Gravis Only) VYVGART, VYVGART HYTRULO VEMLIDY entecavir, lamivudine, tenofovir disoproxil fumarate VIRACEPT atazanavir, darunavir, lopinavir-ritonavir VISCO-3 DUROLANE, EUFLEXXA, GELSYN-3, ORTHOVISC VOTRIENT pazopanib, sunitinib, CABOMETYX, INLYTA, LENVIMA VPRIV CERDELGA, CEREZYME XALKORI CAPSULE ALECENSA, ALUNBRIG, AUGTYRO, IBTROZI, ROZLYTREK, ZYKADIA XENAZINE tetrabenazine, AUSTEDO, INGREZZA XGEVA OSENVELT XYREM LUMRYZ, WAKIX, XYWAV ZARXIO NIVESTYM

10 DRUG NAME(S) PREFERRED OPTION(S) ZELBORAF BRAFTOVI, TAFINLAR ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6) ZIEXTENZO FULPHILA, NYVEPRIA ZOLADEX ELIGARD, ORILISSA DRUG NAME(S) PREFERRED OPTION(S) ZYDELIG BRUKINSA, CALQUENCE ZYTIGA abiraterone, bicalutamide, ERLEADA, NUBEQA, XTANDI, YONSA

11 TABLE 1 - PREFERRED OPTIONS FOR INDICATION BASED SELF-ADMINISTERED AUTOIMMUNE EXCLUDED MEDICATIONS CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S) ANKYLOSING SPONDYLITIS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) SIMPONI TALTZ XELJANZ XELJANZ XR ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) RINVOQ CROHN'S DISEASE AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENTYVIO SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS HIDRADENITIS SUPPURATIVA AMJEVITA BIMZELX HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS BIMZELX TALTZ CIMZIA PREFILLED SYRINGE COSENTYX SUBCUTANEOUS RINVOQ PSORIASIS AMJEVITA COSENTYX SUBCUTANEOUS ENBREL HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) TALTZ ADALIMUMAB-ADAZ ADALIMUMAB-FKJP BIMZELX HYRIMOZ (except NDCs 61314-XXXX-XX) OTEZLA PYZCHIVA SUBCUTANEOUS SKYRIZI SUBCUTANEOUS

12 CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S) SOTYKTU STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS PSORIATIC ARTHRITIS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS SIMPONI TALTZ XELJANZ XELJANZ XR ADALIMUMAB-ADAZ ADALIMUMAB-FKJP COSENTYX SUBCUTANEOUS ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) OTEZLA PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS YESINTEK SUBCUTANEOUS RHEUMATOID ARTHRITIS ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) KINERET OLUMIANT SIMPONI ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX) KEVZARA ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS RINVOQ XELJANZ XELJANZ XR ULCERATIVE COLITIS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) SIMPONI ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENTYVIO SUBCUTANEOUS HYRIMOZ (except NDCs 61314-XXXX-XX) PYZCHIVA SUBCUTANEOUS RINVOQ SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS TREMFYA SUBCUTANEOUS VELSIPITY YESINTEK SUBCUTANEOUS ZEPOSIA

13 CONDITION EXCLUDED DRUG NAME(S) PREFERRED OPTION(S) ALL OTHER CONDITIONS ACTEMRA ACTPEN ACTEMRA SUBCUTANEOUS AMJEVITA HUMIRA HYRIMOZ (NDCs 61314-XXXX-XX only) KINERET ORENCIA CLICKJECT ORENCIA SUBCUTANEOUS ADALIMUMAB-ADAZ ADALIMUMAB-FKJP ENBREL HYRIMOZ (except NDCs 61314-XXXX-XX)

14 FOR YOUR INFORMATION: New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. For VOSEVI listing above: For use in patients previously treated with an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). For HYRIMOZ listing above: Sandoz manufactured NDCs (61314-XXXX-XX) are excluded. Cordavis manufactured NDCs are preferred. An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication. For more information, please sign in or register on Caremark.com and click Plan Summary on the Plan & Benefits menu. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2025 CVS Health and/or one of its affiliates. All rights reserved. 106-31697C 010126