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Advanced Control Formulary Change Summary ReportEffective 04-01-2020This report highlights all changes (additions, deletions, and removals) to the CVS Caremark AdvancedControl yProductBrand Agents:Vascepa (icosapentethyl)oral tilipemics/ Omega-3Fatty AcidsVascepa is indicated as an adjunct to diet toreduce triglyceride (TG) levels in adultpatients with severe ( 500 mg/dL)hypertriglyceridemia.To provide an additional option for reducing triglyceridelevels in those with high triglycerides.buprenorphinetransdermaltransdermal systemAnalgesics/ OpioidAnalgesicsTo provide an additional generic option for severe painmanagement.fenofibric aciddelayed-reloral delayed-releasecapsuleCardiovascular/Antilipemics/ FibratesBuprenorphine is indicated for themanagement of pain severe enough torequire daily, around-the-clock, long-termopioid treatment and for which alternativetreatment options are inadequate.Fenofibric acid delayed-release capsule isindicated as adjunctive therapy to diet to: Reduce TG in patients with severehypertriglyceridemia Reduce elevated LDL-C, Total-C, TGand Apo B, and to increase HDL-C inpatients with primaryhypercholesterolemia or mixeddyslipidemiaGeneric Agents:To provide an additional generic option for reducing lipidlevels in those with high lipids.This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2020 CVS Caremark. All rights reserved.106-40278A 013120Pg. 1 of 14

Advanced Control Formulary Change Summary ReportEffective ntanyltransmucosalbuccal tabletAnalgesics/ OpioidAnalgesicsfulvestrantintramuscular injectionAntineoplastic Agents/Hormonal AntineoplasticAgents/ AntiestrogensIndicationOptions/CommentsFentanyl transmucosal is indicated for themanagement of breakthrough pain incancer patients 18 years of age and olderwho are already receiving and who aretolerant to around-the-clock opioid therapyfor their underlying persistent cancer pain.Fulvestrant is indicated for the treatment of: Hormone receptor (HR)-positive, humanepidermal growth factor receptor 2(HER2)-negative advanced breastcancer in postmenopausal women notpreviously treated with endocrinetherapy HR-positive advanced breast cancer inpostmenopausal women with diseaseprogression following endocrine therapy HR-positive, HER2-negative advancedor metastatic breast cancer inpostmenopausal women in combinationwith ribociclib, as initial endocrine basedtherapy or following diseaseprogression on endocrine therapy HR-positive, HER2-negative advancedor metastatic breast cancer incombination with palbociclib orabemaciclib in women with diseaseprogression after endocrine therapyTo provide an additional generic option for breakthroughpain management in those with cancer.To provide an additional option for the treatment ofhormone receptor (HR)-positive, human epidermalgrowth factor receptor 2 (HER2)-negative breast cancer.This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2020 CVS Caremark. All rights reserved.106-40278A 013120Pg. 2 of 14

Advanced Control Formulary Change Summary ReportEffective salamine delayedrel capsuleoral y BowelDisease/ Oral Agentspregabalinoral capsule, oralsolutionCentral NervousSystem/ Fibromyalgiaramelteonoral tabletCentral NervousSystem/ cstriamtereneoral capsuleIndicationOptions/CommentsMesalamine delayed-release capsule isindicated for: Treatment of mildly to moderately activeulcerative colitis in patients 5 years ofage and older Maintenance of remission of ulcerativecolitis in adultsPregabalin is indicated for: Neuropathic pain associated withdiabetic peripheral neuropathy (DPN) Postherpetic neuralgia (PHN) Adjunctive therapy for the treatment ofpartial-onset seizures in patients 1month of age and older Fibromyalgia Neuropathic pain associated with spinalcord injuryRamelteon is indicated for the treatment ofinsomnia characterized by difficulty withsleep onset.Triamterene is indicated in the treatment of: Edema associated with congestiveheart failure, cirrhosis of the liver andthe nephrotic syndrome Steroid-induced edema, idiopathicedema and edema due to secondaryhyperaldosteronismTo provide an additional generic option for the treatmentof ulcerative colitis.To provide a generic option for the management ofneuropathic pain associated with diabetic peripheralneuropathy or spinal cord injury, postherpetic neuralgia,partial-onset seizures, and fibromyalgia.To provide an additional generic option for the treatmentof insomnia.To provide an additional generic potassium-sparingdiuretic option.This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2020 CVS Caremark. All rights reserved.106-40278A 013120Pg. 3 of 14

Advanced Control Formulary Change Summary ReportEffective ncomycin capsuleoral omycin is indicated in the treatment of: C. difficile-associated diarrhea Enterocolitis caused by Staphylococcusaureus (including methicillin-resistantstrains)Options/CommentsTo provide a generic oral option for the treatment of C.difficile-associated diarrhea and enterocolitis caused byStaphylococcus oductBrand Agents:Faslodex (fulvestrant)intramuscular injectionAntineoplastic Agents/Hormonal AntineoplasticAgents/ AntiestrogensIndicationOptions/CommentsFaslodex is indicated for the treatment of: Hormone receptor (HR)-positive, humanepidermal growth factor receptor 2(HER2)-negative advanced breastcancer in postmenopausal women notpreviously treated with endocrinetherapy HR-positive advanced breast cancer inpostmenopausal women with diseaseprogression following endocrine therapy HR-positive, HER2-negative advancedor metastatic breast cancer inpostmenopausal women in combinationwith ribociclib, as initial endocrine basedAvailability of a generic option for the treatment ofhormone receptor (HR)-positive, human epidermalgrowth factor receptor 2 (HER2)-negative breast cancer.The preferred option on the Advanced ControlFormulary is fulvestrant.This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2020 CVS Caremark. All rights reserved.106-40278A 013120Pg. 4 of 14

Advanced Control Formulary Change Summary ReportEffective rica (pregabalin)oral capsule, oralsolutionCentral NervousSystem/ FibromyalgiaIndicationOptions/Commentstherapy or following diseaseprogression on endocrine therapy HR-positive, HER2-negative advancedor metastatic breast cancer incombination with palbociclib orabemaciclib in women with diseaseprogression after endocrine therapyLyrica is indicated for: Neuropathic pain associated withdiabetic peripheral neuropathy (DPN) Postherpetic neuralgia (PHN) Adjunctive therapy for the treatment ofpartial-onset seizures in patients 1month of age and older Fibromyalgia Neuropathic pain associated with spinalcord injuryAvailability of additional options for the management ofneuropathic pain associated with diabetic peripheralneuropathy or spinal cord injury, postherpetic neuralgia,partial-onset seizures, and fibromyalgia.Preferred options on the Advanced Control Formularyinclude carbamazepine, carbamazepine ext-rel,divalproex sodium, divalproex sodium ext-rel,gabapentin, lamotrigine, lamotrigine ext-rel,levetiracetam, levetiracetam ext-rel, oxcarbazepine,phenobarbital, phenytoin, phenytoin sodium extended,pregabalin, primidone, tiagabine, topiramate,valproic acid, zonisamide, Fycompa (perampanel),Gralise (gabapentin ext-rel), Oxtellar XR (oxcarbazepineext-rel), Trokendi XR (topiramate ext-rel), and Vimpat(lacosamide).This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2020 CVS Caremark. All rights reserved.106-40278A 013120Pg. 5 of 14

Advanced Control Formulary Change Summary ReportEffective ProductBrand Agents:Atopaderm(mechanical allergenparticle barrier)topical creamCicatrace (silicone gelmatrix)topical sheetTopical/ Dermatology/Wound Care ProductsTopical/ Dermatology/Scar TreatmentEnteraGam (serumderived bovineimmunoglobulin/proteinisolate, SBI)oral packetGastrointestinal/MiscellaneousNicadan plements/Vitamins and Minerals/Folic Acid/ CombinationsIndicationOptions/CommentsAtopaderm is indicated to: Manage and relieve the burning, itchingand pain experienced with various typesof dermatoses, including atopicdermatitis, allergic contact dermatitisand radiation dermatitis Relieve dry, waxy skin by maintaining amoist wound and skin environment,which is beneficial to the healingprocessCicatrace is indicated for non-invasivemanagement of old and new hypertrophic orkeloid scars resulting from burns, generalsurgical procedures, injuries or traumawounds.EnteraGam is a medical food productintended for the dietary management ofchronic diarrhea and loose stools.Availability of generic options to manage and relieve theburning, itching and pain experienced with various typesof dermatoses.Nicadan is a dietary supplement that isbeneficial in maintaining overall skin health,Preferred options on the Advanced Control Formularyinclude desonide and hydrocortisone.Availability of additional options for the management ofhypertrophic or keloid scars.Consult doctor for preferred options on the AdvancedControl Formulary.Availability of additional options for the management ofchronic diarrhea and loose stools.Preferred options on the Advanced Control Formularyinclude alosetron, Viberzi (eluxadoline), and Xifaxan 550mg (rifaximin).Availability of additional supplementation options.This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceuticalmanufacturers not affiliated with CVS Caremark. The information contained in this document is proprietary. The information may not be copied inwhole or in part without written permission. 2020 CVS Caremark. All rights reserved.106-40278A 013120Pg. 6 of 14