Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Abilify Maintena Aripiprazole UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Abraxane paclitaxel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Abstral fentanyl transmucosal drug Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Actemra IV Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Actemra SC tocilizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Actimmune Interferon Gamma-1b,Recomb. Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Actiq Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Adakveo crizanlizumab-tmca Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Adcetris brentuximab vedotin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Adcirca Tadalafil Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Adderall Amphetamine and Dextroamphetamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Adderall XR Amphetamine and Dextroamphetamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Adempas Riociguat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Adlyxin lixisenatide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Advair Diskus Fluticasone Propionate and Salmeterol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Advair HFA Fluticasone Propionate and Salmeterol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Advate Antihemoph.FVIII, Full Length UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Adynovate Antihemophilic Factor VIII UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Adzenys XR-ODT Amphetamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Afinitor (o) Everolimus Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Afstyla Antihemophilic Factor (Recombinant) UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Aimovig erenumab Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 AirDuo Digihaler Fluticasone Propionate/Salmeterol Xinafoate Inhalation Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 AirDuo Respiclick Fluticasone Propionate and Salmeterol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ajovy fremanezumab-vfrm Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Aklief Trifarotene Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Alecensa (o) Alectinib Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Alimta premetrexed disodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Aliqopa copanlisib Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Alphanate Antihemophilic Factor/vWF UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 AlphaNine SD Factor IX UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Alprolix Factor IX Rec, Fc Fusion Protn UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Altreno topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Alunbrig Brigatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Amikacin Sulfate Solution Amikacin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Amondys-45 casimersen Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Amphetamine Salt Combo amphetamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ampicillin Sodium Powder Ampicillin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ampyra Dalfampridine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Androderm topical testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 AndroGel topical testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Aptensio XR Methylphenidate Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Aralast NP Alpha-1-Proteinase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Aranesp Darbepoetin Alfa In Polysorbat Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Arazlo topcial tazarotene Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Arcalyst rilonacept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Arikayce Amikacin liposome inhalation Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Aristada Aripiprazole Lauroxil UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Aristada Initio Aripiprazole Lauroxil UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Arzerra ofatumumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Asceniv immune globilin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Asparlas calaspargase pegol -mknl Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179

HCR-0717-043021 1 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Atgam Lymphocyte Ig, Antithymocyte Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Atralin topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Aubagio Teriflunomide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Austedo Deutetrabenazine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Avastin bevacizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Aveed injectable testosterone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Avelox IV Moxifloxacin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Avinza class II narcotic Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Avita topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Avonex interferon beta-1a Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Avsola infliximab-axxq Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Axiron topical testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ayvakit avapritinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Azedra Iobenguane I 131 Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Bafiertam Monomethyl Fumarate Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Balversa erdafitinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Banzel rufinamide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Bavencio avelumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Baxdela Delafloxacin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Bebulin Factor IX Cplx(Pcc)#6, 3factor UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Beleodaq belinostat Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Belrapzo bendamustine Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Bendeka bendamustine Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 BeneFIX Factor IX Human Recombinant UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Benlysta IV belimumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Benlysta SC belimumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Beovu brolucizumab-dbll Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Berinert c1 Esterase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Besponsa inotuzumab ozogamicin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Betaseron interferon beta-1b Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Bethkis Tobramycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Bimatoprost 0.03% bimatoprost Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Bivigam immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Blenrep belantamab mafodotin-blmf Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Blincyto blinatumomab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Boniva IV Ibandronate Sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 bortezomib bortezomib Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Bosulif (o) Bosutinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Botox onabotulinumtoxina Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Braftovi encorafenib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Breo Ellipta Fluticasone and Vilanterol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Breyanzi lisocabtagene maraleucel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Brineura cerliponase alfa Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Brukinsa zanubrutinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Buphenyl Sodium Phenylbutyrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Buprenorphine Buprenorphine HCl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Bydureon/Bydureon BCISE exenatide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Byetta exenatide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cabenuva cabotegravir/rilpivirine extended release Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cablivi caplacizumab-yhdp Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cabometyx extended-release injection Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Calquence Acalabrutinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

HCR-0717-043021 2 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Caprelsa Vandetanib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Carbaglu Carglumic Acid Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Carbidopa Carbidopa Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Carimune NF immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cayston Aztreonam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cefazolin Sodium Powder Cefazolin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cefotan Nasal Rinse Cefotetan Disodium Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cefoxitin Powder cefoxitin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ceftriaxone Powder ceftriaxone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cequa Cyclosporine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cerdelga eligulustat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Chemet Succimer Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Chenodal chenodiol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cholbam Cholic Acid Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cimzia certolizumab pegol Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cinqair reslizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cinryze c1 Esterase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cipro IV ciprofloxacin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Claforan Cefotaxime Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cleocin Phosphate Clindamycin Phosphate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Clindamycin/Tretinoin Gel Clindamycin and Tretinoin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Coagadex coagulation Factor X UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Coly-Mycin M Colistimethate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cometriq Cabozantinib S-Malate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Concerta Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Copaxone glatiramer acetate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Copegus, Rebetol, Ribasphere Ribavirin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Copiktra Duvelisib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Corifact Factor XIII UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Corlanor ivabradine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cosela trilaciclib Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cosentyx secukinumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cotellic Cobimetinib Fumarate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cresemba Isavuconazonium Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Crysvita burosumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cubicin Daptomycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cutaquig immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cuvitru immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cyramza ramucirumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Cystagon Cysteamine Bitartrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cystaran Cysteamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Cytogam human cytomegalovirus immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Dacogen decitabine Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Daliresp roflumilast Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Danyelza naxitamab-gqgk Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Daraprim Pyrimethamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Darzalex daratumumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Darzalex Faspro daratumumab-hyaluronidase-fihj Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Daurismo glasdegib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Daytrana Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Delatestryl injectable testosterone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Depo - Testosterone injectable testosterone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179

HCR-0717-043021 3 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Desoxyn Methamphetamine Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dexedrine Dextroamphetamine Sulfate Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dexmethylphenidate HCL Dexmethylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dexmethylphenidate HCL ER Dexmethylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dextramphetamine-Amphetamine Dextroamphetamine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dextramphetamine-Amphetamine ER Dextroamphetamine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dextroamphetamine Sulfate Dextroamphetamine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dextroamphetamine Sulfate ER Dextroamphetamine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dextrostat Dextroamphetamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Diacomit stiripentol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dojolvi Triheptanoin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Doptelet avatrombopag Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Doripenem Powder Doripenem Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Doxy 100 Doxycycline Injection Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dulera Formoterol and Mometasone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dupixent dupilumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Durolane hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Durysta bimatoprost Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Dynavel XR Amphetamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Dysport abobotulinumtoxina Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Egrifta tesamorelin acetate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Eligard leuprolide long acting Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Eliquis Apixaban Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Eloctate Antihemoph.FVIII Rec, Fc Fusion UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Elzonris tagraxofusp-erzs Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Emend Powder Packet Powder Packet Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Emflaza Deflazacort Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Emgality galcanezumab-gnlm Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Empliciti elotuzumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Enbrel etanercept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Endari L-glutamine oral powder Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Enhertu fam-trastuzumab deruxtecan-nxki Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Enspryng satralizumab-mwge Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Entyvio vedolizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Epaned enalapril maleate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Epclusa Sofosubuvir/velpatasvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Epidiolex Cannabidiol oral solution Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Epogen Epoetin Alfa Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Epoprostenol Sodium epoprostenol Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Erbitux cetuximab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Erivedge Vismodegib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Erleada apalutamide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Erwinaze asparaginase Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Erythrocin Lactobionate Lyophilized Powder Erythromycin Lactobionate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Esbriet Pirfenidone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Esperoct turoctocog alfa pegol UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Euflexxa hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Evekeo Amphetamine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Evenity romosozumab-aqqg Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Evkeeza 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HCR-0717-043021 4 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Exjade Deferasirox Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Exondys 51 eteplirsen Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Exservan Riluzole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Extavia interferon beta-1b Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Eylea aflibercept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Eysuvis Loteprednol Etabonate Ophthalmic Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Fabior topical tazarotene products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Farydak Panobinostat Lactate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Fasenra benralizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Faslodex fulvestrant Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Feiba NF Anti-Inhibitor Coagulant Comp. UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Fensolvi leuprolide acetate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fentanyl Transdermal (Duragesic, generics) Fentanyl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Fentora fentanyl transmucosal drug Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Feraheme ferumoxytol Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ferriprox Deferiprone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ferrlecit sodium ferric gluconate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fibryga Fibrinogen UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Fintepla Fenfluramine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Firazyr Icatibant Acetate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Firdapse amifampridine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Firmagon degarelix Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Flebogamma DIF immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Flolan epoprostenol Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fluconazole Intravenous Solution Fluconazole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Focalin/Focalin XR Dexmethylphenidate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Folotyn pralatrexate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fortaz Ceftazidime Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Forteo teriparatide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fortesta topical testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Fulphila Pegfilgrastim-jmdb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fulvestrant fulvestrant Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Fusilev levoleucovorin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Galafold Migalastat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Gamifant emapalumab-lzsg Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gammagard Liquid immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gammagard S/D immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gammaked immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gammaplex immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gamunex-C immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gattex Teduglutide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Gavreto pralsetinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Gazyva obinutuzumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gel-One hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gelsyn-3 hyaluronic acid Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Genotropin somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gentamicin Sulfate Solution Gentamicin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 GenVisc 850 hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gilenya Fingolimod HCl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Gilotrif (o) Afatinib Dimaleate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Givlaari givosiran Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Glassia Alpha-1-Proteinase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179

HCR-0717-043021 5 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Glatopa glatiramer acetate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Gleevec (o) Imatinib Mesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Gocovri XR Amantadine ER Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Granix Tbo-Filgrastim Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Grastek Grass Pollen-Timothy, Standard Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Haegarda c1 Esterase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Halaven eribulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Harvoni Ledipasvir/Sofosbuvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Helixate FS Antihemoph.FVIII, Full Length UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Hemlibra Emicizumab UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Hemofil M Antihemophilic Factor, Human UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Herceptin trastuzumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Herceptin Hylecta trastuzumab hyaluronidase-oysk Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Herzuma trastuzumab-pkrb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Hetlioz tasimelteon Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Hizentra immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 HP Acthar Corticotropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Humate-P Antihemophilic Factor/vWF UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Humatrope somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Humira adalimumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Hyalgan hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Hycamtin Topotecan Hydrochloride Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Hydrocodone ER Hydrocodone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5897 Hydromorphone ER Hydromorphone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5898 Hymovis hyaluronic acid Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 HyQvia immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ibrance Palbociclib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Icatibant icatibant Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Iclusig Ponatinib Hcl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Idelvion factor ix recom,albumin fusion UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Idhifa enasidenib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ilaris canakinumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ilumya tildrakizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Imatinib Mesylate Imatinib Mesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Imbruvica Ibrutinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Imcivree setmelanotide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Imfinzi durvalumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Imlygic talimogene laherparepvec Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Impavido Miltefosine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Inbrija Levodopa Inhalation Powder Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Increlex mecasermin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 INFed iron dextran Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Inflectra infliximab-dyyb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ingrezza valbenazine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Injectafer ferric Carboxymaltose Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Inlyta axitinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Inqovi cedazuridine and decitabine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Inrebic fedratinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Intuniv Guanfacine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Invanz Ertapenem Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Invega Sustenna Paliperidone Palmitate UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Invega Trinza Paliperidone Palmitate UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384

HCR-0717-043021 6 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Iressa gefitinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Istodax romidepsin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Isturisa Osilodrostat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ixinity Factor IX Human Recomb, Thr 148 UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Jadenu Deferasirox Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Jadenu Sprinkles Deferasirox Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Jakafi Ruxolitinib Phosphate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Jatenzo Testosterone Undecanoate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Jelmyto mitomycin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Jevtana cabazitaxel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Jivi Antihemophilic Factor [Recombinant] Pegylated-Aucl UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Juxtapid Lomitapide Mesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Jynarque tolvaptan Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kadcyla ado-trastuzumab emtansine Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kadian class II narcotic Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kalbitor ecallantide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kalydeco Ivacaftor Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kanjinti trastuzumab-anns Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kanuma Sebelipase Alfa Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kapvay CloNIDine Hydrochloride Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kcentra Hum Prothrombin Cplx(Pcc)4fact UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Kesimpta ofatumumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Keveyis dichlorphenamide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kevzara sarilumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Keytruda pembrolizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Khapzory levoleucovorin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kineret anakinra Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kisqali Ribociclib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kitabis Tobramycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Koate-DVI Antihemophilic Factor, Human UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Kogenate FS Antihemoph.FVIII, Full Length UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Korlym Mifepristone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Koselugo Selumetinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kovaltry antihemoph.fviii,full length UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Krystexxa pegloticase Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kuvan Sapropterin Dihydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kymriah tisagenlecleucel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Kynmobi Apomorphine HCL Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Kyprolis carfilzomib Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lacrisert Hydroxypropyl Cellulose Insert Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lartruvo olaratumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lazanda fentanyl transmucosal drug Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ledipasvir/Sofosbuvir Ledipasvir/Sofosbuvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lemtrada alemtuzumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lenvima Lenvatinib Mesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Letairis Ambrisentan Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Leukine Sargramostim Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Levo Dromoran Levorphanol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Levofloxacin Solution Levlofloxacin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Levoleucovorin Calcium levoleucovorin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Libtayo cemiplimab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lidoderm lidocaine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

HCR-0717-043021 7 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Lodosyn Carbidopa Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lonsurf Trifluridine/Tipiracil Hcl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lorbrena Lorlatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lovaza omega- 3 fatty acids Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lucemyra Lofexidine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lucentis ranibizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lumigan ophthalmic prostaglandin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lumoxiti moxetumomab pasudotox Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lupaneta Pack leuprolide/norethindrone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lupkynis Voclosporin Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lupron Depot leuprolide long acting Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lupron Depot-Ped leuprolide long acting Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lutathera lutetium lu 177 dotatate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Luxturna voretigene neparvovec Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Lynparza Olaparib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Lyrica pregabalin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Makena hydroxyprogesterone caproate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Margenza margetuximab-cmkb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Mavenclad cladribine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mavyret Glecaprevir/Pibrentasvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Maxipime Cefepime Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mayzent siponimod Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mekinist Trametinib Dimethyl Sulfoxide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mektovi binimetinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mepsevii Vestronidase Alfa Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Merrem Meropenem Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Metadate CD Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Metadate ER Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methadone class II narcotic Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methamphetamine HCL Methamphetamine Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methylin/Methylin ER Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methylphenidate ER Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methylphenidate HCL Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methylphenidate HCL CD Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Methylphenidate LA/SR Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Metronidazole Solution Metronidazole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mircera Methoxy Peg-Epoetin Beta Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Mirvaso Topical Gel Brimonidine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Moderiba Ribavirin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Monjuvi tafasitamab-cxix Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Monoclate-P Antihemophilic Factor, Human UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Monoferric ferric derisomaltose Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Mononine Factor IX UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Monovisc hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Morphine Sulfate ER Morphine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mulpleta Lusutrombopag Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Mvasi bevacizumab-awwb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Myalept metreleptin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Mylotarg gemtuzumab ozogamicin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Myobloc rimabotulinumtoxinb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nafcillin Sodium Powder Nafcillin Sodium Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Natesto Testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

HCR-0717-043021 8 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Natpara parathyroid Hormone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nayzilam midazolam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nerlynx Neratinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Neulasta Pegfilgrastim Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Neupogen Filgrastim Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nexavar Sorafenib Tosylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nexletol Bempedoic Acid Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nexlizet Bempedoic Acid and Ezetemibe Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nilandron Nilutamide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ninlaro Ixazomib Citrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 nitisinone nitisinone (generic Orfadin) Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nityr nitisinone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nivestym filgrastim-aafi Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nocdurna Desmopressin acetate sublingual tablets Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Norditropin somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Northera droxidopa Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nourianz istradefylline Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Novoeight Antihemoph.FVIII, B-Dom Truncat UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 NovoSeven RT Coagulation Factor Viia,Recomb UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Noxafil posaconazole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Noxafil IV posaconazole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nplate Romiplostim Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nubeqa darolutamide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nucala mepolizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nucynta class II narcotic Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nuedexta dextromethorphan/quinidine sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nulibry fosdenopterin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nulojix belatacept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nuplazid pimavanserin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nurtec ODT Rimegepant Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nutropin somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nutropin AQ somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nutropin AQ Nuspin somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Nuwiq Antihemoph.FVIII, Hek B-Delete UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Nuzyra Omadacycline Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Nyvepria pegfilgrastim-apgf Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Obizur Antihemophilic Factor VIII, Recomb Porcine UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Ocaliva Obeticholic Acid Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ocrevus ocrelizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Octagam immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Odactra House Dust Mite Allergen Extract Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Odomzo Sonidegib Phosphate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ofev Nintedanib Esylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ogivri trastuzumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Olumiant bariticinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Omnitrope somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Oncaspar pegaspargase Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Onfi Clobazam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ongentys Opicapone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Onivyde irinotecan liposomal Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Onpattro patisiran Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ontruzant trastuzumab-dttb Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179

HCR-0717-043021 9 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Onureg Azacitidine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Onzetra Xsail sumatriptan nasal powder Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Opdivo nivolumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Opsumit Macitentan Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oralair Gr Pol-Orc/Sw Ver/Rye/Kent/Tim Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orencia IV abatacept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Orencia SC abatacept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Orenitram Treprostinil Diolamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orfadin nitisinone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orgovyx Relugolix Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oriahnn Elagolix, estradiol and Norethindrone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orilissa Elagolix Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orkambi Lumacaftor/Ivacaftor Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orladeyo Berotralstat Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Orthovisc hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Osmolex ER Amantadine ER Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Otezla Apremilast Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oxacillin Sodium Powder Oxacillin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oxbryta voxelotor Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oxervate cenegermin-bkbj Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oxlumo lumasiran Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Oxycodone ER class II narcotic Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Oxymorphone ER (Generics) Oxymorphone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ozempic semaglutide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Padcev enfortumab vedotin-ejfv Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Palforzia Arachis Hypogaea Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Palynziq pegvaliase Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Panzyga immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Pegasys peginterferon alfa-2a Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 PEG-Intron peginterferon alfa-2b Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Pemazyre Pemigatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Peniciliin G Sodium Powder Penicillin G Sodium Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Penicillin G Benzathine Suspension Penicillin G Benzathine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Penicillin G Potassium Solution Penicillin G Potassium Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Penicillin G Procaine Suspension Penicillin G Procaine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Pennsaid Topical Solution diclofenac sodium topical solution Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Pepaxto melphalan flufenamide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Perjeta pertuzumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Phesgo pertuzumab/trastuzumab/hyaluronidase-zzxf Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Piqray alpelisib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Plegridy peginterferon beta-1a Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Polivy polatuzumab vedotin – piiq Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Pomalyst Pomalidomide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Portrazza necitumumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Poteligeo mogamulizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Pradaxa Dabigatran Etexilate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Praluent Alirocumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Pretomanid Pretomanid Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Privigen immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Procentra Dextroamphetamine Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Procrit Epoetin Alfa Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Profilnine Factor IX Cplx(Pcc)#4, 3factor UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384

HCR-0717-043021 10 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Profilnine SD Factor IX Cplx(Pcc)#4, 3factor UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Prolastin Alpha-1-Proteinase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Prolastin-C Alpha-1-Proteinase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Prolia denosumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Promacta Eltrombopag Olamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Provenge 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https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Radicava edaravone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ragwitek Weed Pollen-Short Ragweed Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rasuvo methotrexate injection Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ravicti Glycerolphenylbutyrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rebetol Ribavirin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rebif interferon beta-1a Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Rebinyn Factor IX UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Reblozyl luspatercept-aamt Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Reclast zoledronic Acid Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 RECOMBINATE Antihemophilic Factor, Hum Rec UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 ReliOn Novolin N isophane insulin human suspension Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Remicade infliximab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Remodulin treprostinil Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Renflexis infliximab-abda Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Repatha Evolocumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Restasis Cyclosporine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Retacrit epoetin alfa-epbx Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Retevmo Selpercatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Retin-A topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Retin-A Micro topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Revatio Sildenafil Citrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Revcovi elapegademase-lvlr Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Revlimid Lenalidomide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Reyvow lasmiditan Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rhofade Cream Oxymetazoline Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Riabni rituximab-arrx Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 RiaSTAP Fibrinogen UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Ribasphere Ribavirin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ribavirin Ribavirin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rilutek riluzole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rinvoq upadacitinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ritalin Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ritalin LA/SR Methylphenidate Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rituxan rituximab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Rituxan Hycela rituximab hyaluronidase Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Rixubis Factor IX Human Recombinant UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Rocklatan Netarsudil/Latanoprost Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Romidespin romidepsin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Rozlytrek entrectinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rubraca Rucaparib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ruconest c1 Esterase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179

HCR-0717-043021 11 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Rukobia ER Fostemsavir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ruxience rituximab-pvvr Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ruzurgi amifampridine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rybelsus semaglutide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Rydapt Midostaurin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sabril vigabatrin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Saizen somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Samsca tolvaptan Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 SandoSTATIN LAR Depot octreotide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Sarclisa isatuximab-irfc Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Savaysa Edoxaban Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Scenesse afamelanotide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Sensipar Cinacalcet Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Serostim somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Sevenfact recombinant factor VIIa UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Signifor LAR pasireotide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Siliq brodalumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Simponi golimumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Simponi Aria golimumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Sirturo bedaquiline Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sitavig acyclovir buccal tablets Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Skyrizi risankizumab-rzaa Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 sodium hyaluronate sodium hyaluronate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Sodium Phenylbutyrate Sodium Phenylbutyrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sofosbuvir/Velpatasvir Sofosbuvir/Velpatasvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Solaraze diclofenac 3% topical gel Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Soliris eculizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Somatuline Depot lanreotide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Somavert Pegvisomant Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sovaldi Sofosbuvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Spinraza Nusinersen Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Spiriva Handihaler tiotropium bromide inhalation powder Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Spiriva Respimat tiotropium bromide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Spravato esketamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sprycel Dasatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Stelara IV ustekinumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Stelara SC ustekinumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Stivarga Regorafenib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Strattera Atomoxetine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Strensiq asfotase alfa Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Streptomycin Sulfate Lyophilized Powder Streptomycin Sulfate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Striant topical testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Striverdi Respimat olodaterol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Subsys fentanyl transmucosal drug Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sucraid Sacrosidase Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sulfamethoxazole-Trimethoprim Solution Sulfamethoxazole-Trimethoprim Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Supartz hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Supartz FX hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Supprelin LA histrelin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Sutent Sunitinib Malate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sylvant siltuximab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Symbicort Budenoside/Formoterol Fumarate Dihydrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

HCR-0717-043021 12 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Symdeko tezacaftor / ivacaftor Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Symlin pramlintide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Sympazan Clobazam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Synagis palivizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Synarel Nafarelin Acetate Nasal Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Synercid Quinupristin and Dalfopristin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Synojoynt sodium yyaluronate 1% Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Synribo omacetaxine mepesuccinate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Synvisc hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Synvisc One hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Syprine Trientine Hydrochloride Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tabrecta Capmatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tafinlar Dabrafenib Mesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tagrisso Osimertinib Mesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Takhzyro lanadelumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Taltz ixekizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Talzenna Talazoparib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tanzeum dulaglutide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tapentadol ER Tapentadol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tarceva Erlotinib Hcl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Targretin Bexarotene Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tasigna Nilotinib Hcl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tasmar Tolcapone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tavalisse fostamatinib disodium hexahydrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Taxotere docetaxel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tazarotene topical tazarotene products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tazicef Ceftazidime Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tazorac topical tazarotene products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tazverik tazemetostat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tecartus brexucabtagene autoleucel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tecentriq atezolizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tecfidera Dimethyl Fumarate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tegsedi inotersen Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Temodar (Capsules) Temozolomide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Temozolomide INJ temozolomide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tepadina thiotepa Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tepezza teprotumumab-trbw Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tepmetko Tepotinib Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Testim topical testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Testopel testosterone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 testosterone cypionate injectable testosterone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 testosterone enanthate injectable testosterone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Thalomid Thalidomide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Thiola Tiopronin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Thiola EC Tiopronin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tibsovo Ivosidenib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tiglutik riluzole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tivorbex indomethacin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 TOBI tobramycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 TOBI Podhaler tobramycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tobramycin Sulfate Solution tobramycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tolcapone Tolcapone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

HCR-0717-043021 13 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Torisel temsirolimus Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tracleer Bosentan Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tramadol ER Tramadol Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Travatan Z ophthalmic prostaglandin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Trazimera trastuzumab-qyyp Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Treanda bendamustine HCl Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Trelstar triptorelin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tremfya guselkumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tretin-X topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tretten Factor XIII A-Subunit, Recomb UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Trikafta elexacaftor/tezacaftor/ivacaftor and ivacftor Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Triluron sodium hyaluronate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Triptodur leuprolide long acting Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Trisenox arsenic trioxide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 TriVisc sodium hyaluronate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Trodelvy sacituzumab govitecan-hziy Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Trogarzo ibalizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Trulicity GLP-1 agonist Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Truxima rituximab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tudorza Pressair aclidinium bromide inhalation powder Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tukysa Tucatinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Turalio pexidartinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tykerb Lapatinib Ditosylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Tymlos abaloparatide Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tysabri natalizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Tyvaso Treprostinil Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ubrelvy ubrogepant Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Udenyca pegfilgrastim-cbqv Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ukoniq Umbralisib Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ultomiris ravulizumab-cwvz Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Unasyn Ampicillin/Sulbactam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Uplizna inebilizumab-cdon Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Upneeq Oxymetazoline Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Uptravi Selexipag Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vabomere Meropenem/Vaborbactam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Valchlor Mechlorethamine HCl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Valstar valrubicin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Valtoco Diazepam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vancomycin Capsules Vancomycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vancomycin HCL Lyophilized Powder Vancomycin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vantas histrelin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Vascepa Cosapent Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vecamyl Mecamylamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vectibix panitumumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Velcade bortezomib Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Veletri epoprostenol Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Velphoro sucroferric oxyhyroxide UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Veltin topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Venclexta Venetoclax Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Venofer Iron Sucrose Complex Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ventavis Iloprost Tromethamine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

HCR-0717-043021 14 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Verzenio abemaciclib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vfend Voriconazole Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Victoza GLP-1 agonist Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Viekira Pak Ombita/Paritap/Riton/Dasabuvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vigabatrin vigabatrin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Viltepso viltolarsen Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Visco-3 hyaluronate sodium Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Vistogard uridine triacetate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vitrakvi larotrectinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vivlodex meloxicam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vizimpro Dacomitinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vogelxo Testosterone Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vonvendi von Willebrand factor UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Vosevi Sofosbuvir/Velpatasvir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Votrient Pazopanib Hcl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vumerity diroximel Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vyepti eptinezumab-jjmr Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Vyndamax tafamidis meglumine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vyndaqel tafamidis meglumine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vyondys-53 golodirsen Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Vyvanse Lisdexamfetamine dimesylate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Vyzulta Latanoprostene Bunod Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Wilate Antihemophilic Factor/Vwf UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Winlevi Clascoterone Topical Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xalatan Latanoprost Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xalkori Crizotinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xarelto Rivaroxaban Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xatmep methotrexate oral solution Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xeljanz Tofacitinib Citrate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xelpros Latanoprost Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xembify immune globulin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Xenazine Tetrabenazine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xeomin incobotulinumtoxina Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Xerava Eravacycline Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xermelo Telotristat Ethyl Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xgeva denosumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Xiaflex Collagenase Clostridium Hist. UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Xiidra Lifitegrast Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xolair omalizumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Xospata Gilteritinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xpovio selinexor Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xtandi Enzalutamide Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xuriden Uridine Triacetate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xyntha Antihemoph.FVIII, B-Domain Del UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Xyntha Solofuse Antihemoph.FVIII, B-Domain Del UHA Internal Clinical Review Submit PAs to UHA Health Care Services at https://uhahealth.com/portals/providerlogin/ phone (808) 532-4006 / fax (866) 572-4384 Xyosted testosterone enanthate Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Xyrem Sodium Oxybate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Xywav calcium, magnesium, potassium and sodium oxybate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Yervoy Ipilimumab Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Yescarta axicabtagene ciloleucel Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Yondelis trabectedin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Yonsa abiraterone acetate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zaltrap ziv-aflibercept Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179

HCR-0717-043021 15 of 16 Drug Prior Authorization List Effective 04/01/2021

Drugs Generic Name PA Program Submit PA or Call Zarxio Filgrastim-Sndz Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zavesca miglustat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zejula Niraparib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zelboraf Vemurafenib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zemaira Alpha-1-Proteinase Inhibitor Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zemdri Plazomicin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zenzedi Dextroamphetamine Sulfate Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zepatier Elbasvir/Grazoprevir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zeposia Ozanimod Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zepzelca lurbinectedin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Ziana topical tretinoin products Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Ziextenzo pegfilgrastim-bmez Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zinacef cefuroxime Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zioptan ophthalmic prostaglandin Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zipsor diclofenac potassium Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zirabev bevacizumab-bvzr Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zokinvy Lonafarnib Oral Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zoladex goserelin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zoledronic Acid zoledronic acid Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zolgensma onasemnogene abeparvovec-xioi Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zolinza vorinostat Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zomacton somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zometa zoledronic acid Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zontivity vorapaxar Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zorbtive somatropin Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zosyn piperacillin/tazobactam Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zovirax acyclovir Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 ZTlido lidocaine Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zulresso brexanolone Medical Management/PA Submit PAs to Medical Benefit Management Express Path at https://provider.express-path.com/ phone (866) 877-7042 / fax (866) 877-7179 Zydelig idelalisib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zykadia ceritinib Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zytiga abiraterone acetate Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896 Zyvox linezolid Pharmacy PA Submit PAs to Pharmacy Benefit Management Express Path at https://provider.express-path.com/ phone (800) 753-2851 / fax (877) 251-5896

KEY: Drugs in RED text are formulary exclusions on our National Preferred Formulary Medical Management/PA: Drug will be subject to prior authorization under the medical benefit Pharmacy PA: Drug is non-injectable and will be subject to prior authorization under the pharmacy benefit Post-Service Claim Edits: Claim will be reviewed by MBM team Drugs in purple are on the Exclude at Launch Drug List

HCR-0717-043021 16 of 16