DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.167 T0 Effective Date: November 1, 2017

UnitedHealthcare® Oxford Clinical Policy

Table of Contents Page Related Policies INSTRUCTIONS FOR USE ...... 1 Refer to Payment Guidelines below CONDITIONS OF COVERAGE ...... 1 DESCRIPTION OF SERVICES ...... 1 DEFINITIONS ...... 2 PAYMENT GUIDELINES ...... 3 POLICY HISTORY/REVISION INFORMATION ...... 151

INSTRUCTIONS FOR USE

This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

CONDITIONS OF COVERAGE

This policy applies to Oxford plan membership.

Notes:  Not all Oxford groups have selected the same pharmacy benefits. Refer to the group's pharmacy plan number for specific exclusions, exceptions, and dispensing limitations.  New Jersey (NJ) Small Members should refer to their Certificate of Coverage for precertification and quantity limit guidelines.

DESCRIPTION OF SERVICES

 The Drug Coverage Guidelines table of medications contains medications that:

o Have a quantity limit in place; and/or o Require precertification through Oxford's Pharmacy Benefit Manager (PBM); and/or o Require precertification through Oxford's Medical Management; and/or o Are standard exclusions (such as weight loss medications, fluorides, vitamins)  Medications are listed alphabetically with an explanation of how precertification is obtained and under which benefit it is covered.  While a medication by itself may not require precertification, Home Care for the administration of a medication does require precertification. Exception: The first seven days of therapy with low molecular weight heparin are an exception to the Home Care precertification requirement.

Notes:  Opioid Overutilization: The Center for Disease Control (CDC) recommends that clinicians should prescribe the lowest effective dosage when opioids are started. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine equivalent doses (MED) or more per day, and should avoid increasing dosage to 90 MED or more per day or carefully justify a decision to titrate dosage to 90 MED or more per day. o This includes all salt forms, single and combination ingredient products, all long- and short-acting formulations, and all brand and generic formulations: codeine, dihydrocodeine, fentanyl, methadone, meperidine, morphine, hydrocodone, hydromorphone, levorphanol, oxycodone, oxymorphone, pentazocine, tapentadol, tramadol. o For additional coverage criteria for the above drugs, please refer to: Utilization Review Guideline: Opioid Overutilization Cumulative Drug Utilization Review Criteria  Quantity duration (QD) and quantity level limitations (QLL) may be in place for certain medications. To request coverage for a greater quantity of a medication with a QLL, providers must call Oxford's Pharmacy Benefit Manager (PBM). For information regarding QD or QLL supply limits, refer to the following documents on UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > Clinical Programs > Supply Limits: o QD Supply Limits (defines the maximum quantity of medication that can be covered in a specified time period) o QLL Supply Limits (defines the maximum quantity of medication that is covered for one prescription or copayment)  Oxford's PBM provides a nationwide network of participating pharmacies that administers prescription drugs on a retail level. Groups that purchase the Pharmacy Rider and Medicare Members with a Pharmacy benefit will have their retail pharmacy benefit administered by the PBM.  For information regarding medication coverage related to the Member's pharmacy benefit, providers may contact Oxford's PBM.  For issues of medication coverage unrelated to the Member's pharmacy benefit (Intravenous infusions, intramuscular injections, etc), Oxford may be contacted directly.  Over-the-Counter (OTC) Medications: o NJ Plans: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are not excluded from coverage. Refer to specific drug policies where applicable. o Connecticut (CT) and New York (NY) Plans: A prescription drug product that is therapeutically equivalent to an over-the-counter (OTC) drug may be covered if it is determined to be medically necessary. In order for a prescription drug to be deemed "medically necessary" when there is an equivalent OTC drug available, the physician must show that there is something about the prescription drug that is superior to the OTC drug, and likely to be more beneficial to the Member than the OTC drug. Documentation supporting medical necessity must be submitted by the provider.  New FDA-approved drug products may require precertification immediately upon launch of the medication.  For information on coverage of recent FDA-approved drug products for which drug-specific criteria are unavailable, please refer to Interim New Product Coverage Criteria.  New Jersey Formulary Regulations: Members who are enrolled in a New Jersey group Product with a 3-Tier Prescription Drug Benefit and for whom the NJ Formulary Regulations apply should refer to Prior Authorization/Notification Non-Formulary (i.e., Tier 3 or higher) Copay Adjustment – New Jersey.

DEFINITIONS

For all of the definitions below, copayment/cost share will vary based on the Member’s plan design. Refer to the Member's specific Certificate of Coverage, contract and/or Prescription Drug Rider as applicable.

Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply of certain prescription medications (new or refill) by mail.

Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription medications (new or refill). Note: For Members enrolled in NY LOBs new and renewing on or after 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates and terms and conditions as the mail order or specialty pharmacy, covered prescriptions will be available at the same co-payment or other reimbursement level that would apply to the mail-order or non-retail specialty pharmacies (should any of these pharmacies be available in the service area).

Specialty Pharmacy: A network pharmacy contracted to provide coverage for specialty medications at an in-network benefit level for members enrolled on NY and NJ LOBs.

PAYMENT GUIDELINES

The following list of procedure codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes J0400 and IM injection N/A N/A Medical N/A J1942 Abilify  Therapeutic Equivalent (aripiprazole) Tablet, oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A suspension Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Absorica (isotretinoin) Absorica Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (isotretinoin)  Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Tablet or Abstral (fentanyl) Abstral (fentanyl) Sublingual J8499 PBM  Therapeutic Equivalent Pharmacy N/A Tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Acanya  Therapeutic Equivalent (clindamycin Guidelines: Drug Coverage phosphate 1.2% Topical J3490 PBM Criteria - New and Therapeutic Pharmacy N/A and benzoyl Equivalent Medications peroxide 2.5%)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Acetaminophen/  Therapeutic Equivalent Caffeine/ Guidelines: Drug Coverage Dihydrocodeine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Bitartrate Equivalent Medications 325/30/16 mg  Therapeutic Equivalent Aciphex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (rabeprazole) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Aciphex Sprinkle Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (rabeprazole) Criteria - New and Therapeutic Equivalent Medications J0883 and Acova (argatroban) IV Injection N/A N/A Medical N/A J0884  Prior Authorization/ Notification Guidelines: Actemra (tocilizumab) Injection SQ J3490 PBM for Intravenous Infusion Pharmacy N/A Injection  Step Therapy Guidelines: Actemra (tocilizumab) Injection for Intravenous Infusion Hospital Outpatient Facility: Actemra Administration of Actemra in a (tocilizumab)  Precertification Guidelines: hospital outpatient facility o Actemra (tocilizumab) (including any ambulatory Oxford’s Injection for Intravenous infusion suite associated with the Injection J3262 Medical Infusion Medical hospital) requires precertification Management o Specialty Medication with review by a Medical Director Administration – Site of Care or their designee. Refer to: Review Guidelines Specialty Medication Administration – Site of Care Review Guidelines.  Therapeutic Equivalent Acticlate Guidelines: Drug Coverage (doxycycline Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hyclate) Equivalent Medications  Prior Authorization/ Actimmune SQ Notification Guidelines: (interferon J9216 PBM Pharmacy N/A Injection Actimmune (interferon gamma- gamma-1b) 1b)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Notification Guidelines: Actiq (fentanyl citrate) Actiq (fentanyl Lozenge J8499 PBM Therapeutic Equivalent Pharmacy N/A citrate)  Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Actos (brand only) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (pioglitazone) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Acuvail (ketorlac/ Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A tromethamine) Solution Criteria - New and Therapeutic Equivalent Medications Aczone 7.5% Topical Gel J3490 N/A N/A Pharmacy N/A (dapsone) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Adapalene 0.1% Cream, Gel, J3490 N/A N/A N/A equivalent are excluded from (generic Differin) Lotion coverage. Refer to the member specific benefit plan document as applicable. Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Adapalene 0.3% Gel J3490 N/A N/A N/A equivalent are excluded from (generic Differin) coverage. Refer to the member specific benefit plan document as applicable.  Prior Authorization/Medical Adcirca (tadalafill) Tablet J3490 PBM Necessity Guidelines: Adcirca Pharmacy N/A (tadalafill)  Prior Authorization/ Notification Guidelines: Adderall Adderall and Adderall XR (amphetamine/ Tablet S0160 PBM  Therapeutic Equivalent Pharmacy N/A dextroamphetamin) Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Adderall XR  Prior Authorization/ amphetamine/ Tablet S0160 PBM Notification Guidelines: Pharmacy N/A dextroamphetamin Adderall and Adderall XR [extended release])  Prior Authorization/Medical Addyi (flibanserin) Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Addyi  Prior Authorization/Medical Pharmacy N/A Adempas Tablet J8499 PBM Necessity Guidelines: (riociguat) Adempas Adlyxin Injection J3490 N/A N/A Pharmacy N/A (lixisenatide)  Therapeutic Equivalent Adoxa (doxycycline Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A monohydrate) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Adrenaclick Pen Guidelines: Drug Coverage J0171 PBM Pharmacy N/A (epinephrine) Injection Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Adynovate Guidelines: Drug Coverage (antihemophillic Injection J3490 PBM Pharmacy N/A Criteria - New and Therapeutic factor) Equivalent Medications  Prior Authorization/ Notification Guidelines: Orally Adzenys XR Adzenys XR Disinter- (amphetamine J8499 PBM  Therapeutic Equivalent Pharmacy N/A grating extended-release Guidelines: Drug Coverage Tablet Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Afinitor years or older. All other oral Oral J7527 PBM* Notification Guidelines: Pharmacy** (everolimus) chemotherapy drugs do not Afinitor require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Afrezza (Insulin, Inhalation  Prior Authorization/Medical J3490 PBM Pharmacy N/A human) Powder Necessity Guidelines: Afrezza Afstyla (Antihemophilic  Prior Authorization/Medical Factor Injection J7192 PBM Pharmacy N/A Necessity Guidelines: Afstyla [Recombinant] Single Chain) Airduo RespiClick  Therapeutic Equivalent (fluticasone Guidelines: Drug Coverage Inhaler J3490 PBM Pharmacy N/A propionate/ Criteria - New and Therapeutic salmeterol) Equivalent Medications  Therapeutic Equivalent Aktipak gel Guidelines: Drug Coverage (erythromycin and Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic benzoyl peroxide) Equivalent Medications Akynzeo (netupitant/ Capsule J8499 N/A N/A Pharmacy N/A palonosetron) Albenza  Authorization/Medical Tablet J8499 PBM Pharmacy N/A (albendazole) Necessity Guidelines: Albenza Aldurazyme® Intravenous J1931 N/A N/A Medical N/A (laronidase)  Prior Authorization/ Alecensa Capsule J8999 PBM Notification Guideline: Pharmacy N/A (alectinib) Alencensa

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Alesse (ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives levonorgestrel) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Allegra D (fexofenadine & pseudoephedrine), Tablet J8499 N/A N/A Pharmacy N/A Allegra suspension/ Allegra ODT  Therapeutic Equivalent Allzital (allzital Guidelines: Drug Coverage butalbital/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic acetaminophen) Equivalent Medications  Therapeutic Equivalent Alogliptin (Nesina Guidelines: Drug Coverage Authorized Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Generic) Equivalent Medications Alogliptin/  Therapeutic Equivalent Metformin (Kazano Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Authorized Criteria - New and Therapeutic Generic) Equivalent Medications Alogliptin/  Therapeutic Equivalent Pioglitazone (Oseni Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Authorized Criteria - New and Therapeutic Generic) Equivalent Medications Injection Alpha Baclofen J0475 and and N/A N/A Medical N/A (baclofen) J0476 Intrathecal  Therapeutic Equivalent Altoprev Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (lovastatin) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Alunbrig Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (brigatinib) Alunbrig  Therapeutic Equivalent Ambien (zolpidem Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A tartrate) Criteria - New and Therapeutic Equivalent Medications Ambien CR  Therapeutic Equivalent (zolpidem tartrate Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A extended- Criteria - New and Therapeutic release[ER]) Equivalent Medications *Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Amerge  Supply Limit Guidelines: Tablet J8499 PBM* Pharmacy** precertification. (naratriptan) Triptans Supply Limits **Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Amevive Injection, SQ J0215 N/A N/A Medical N/A (alefacept) Injection Aminolevulinic acid Topical J7308 N/A N/A Medical N/A HCL  Prior Authorization/Medical Amitiza Capsule J8499 PBM Necessity Guidelines: Amitiza Pharmacy N/A (lubiprostone) (lubiprostone) Amlodipine/ Atorvastatin Tablet J8499 N/A N/A Pharmacy N/A (generic)  Prior Authorization/ Amnesteem Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (isotretinoin) Amnesteem

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Amphetamine/ Notification Guidelines: dextro- Adderall and Adderall XR amphetamine Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A extended-release Guidelines: Drug Coverage (generic Adderall Criteria - New and Therapeutic XR) Equivalent Medications **Precertification Note: Precertification through the PBM is required for Members age 19  Prior Authorization/ and older. Ampyra Tablet J8499 PBM** Notification Guidelines: Pharmacy* *Benefit Note: NJ Small (dalfampridine) Ampyra (dalfampridine) Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Amrix/ Guidelines: Drug Coverage cyclobenzaprine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic extended release Equivalent Medications Amturnide  Therapeutic Equivalent (aliskiren, Guidelines: Drug Coverage amlodipine, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloro- Equivalent Medications thiazide) Anabolin (nandrolone Injection J2320 N/A N/A Medical N/A deconoate) Anadrol-50 Tablet J8499 N/A N/A Pharmacy N/A (oxymetholone)  Therapeutic Equivalent Anafranil Guidelines: Drug Coverage (clomipramine) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Analpram Advanced Guidelines: Drug Coverage Kit (hydrocortisone Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetate/pramoxine) Equivalent Medications  Prior Authorization/Medical Androderm Gel J3490 PBM Necessity Guidelines: Pharmacy N/A (testosterone) Androderm

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Necessity Guidelines: Androgel Androgel Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (testosterone)  Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Android, Oreton, Methyl, Virilon and Tablet J8499 N/A N/A Pharmacy N/A Methitest (methyl- testosterone) *Precertification Notes: HCPCS code S0132 (ganirelix) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Notes: Coverage is S0132* and through Optum Pharmacy/ Antagon (ganirelix) Injection Infertility Diagnosis and limited to Members with J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Antara  Therapeutic Equivalent (fenofibrate) - Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A 30mg and 90mg Criteria - New and Therapeutic strengths only Equivalent Medications  Therapeutic Equivalent Antara 43mg, Guidelines: Drug Coverage 130mg Capsule J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (fenofibrate) Equivalent Medications Anusol HC  Therapeutic Equivalent Suppository Guidelines: Drug Coverage Suppository J8499 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic (hydrocortisone) Equivalent Medications Anzemet Injection J1260 N/A N/A Medical N/A (dolasetron) Tablet Q0180 N/A N/A Pharmacy N/A

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Aplenzin Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A (bupropion) Brand Medications Apligraf Patch Q4101 N/A N/A Medical N/A Apop 10% gel Topical Gel J3490 N/A N/A Pharmacy N/A (sulfacetamide) Apriso Capsule J8499 N/A N/A Pharmacy N/A (mesalamine)  Prior Authorization/ Notification Guidelines: Aptensio XR Aptensio XR Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Aptiom  Prior Authorization/Medical (eslicarbazepine Tablet J8499 PBM Necessity Guidelines: Aptiom Pharmacy N/A acetate) (eslicarbazepine acetate)  Therapeutic Equivalent Aqua Glycolic HC Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (hydrocortisone) Criteria - New and Therapeutic Equivalent Medications J0882- Oxford’s  Precertification Guidelines: Injection, *Precertification is required if Aranesp ESRD OR Medical Anemia Drugs: Darbepoetin Alfa, SQ Medical provided in a hospital or MD's (darbepoetin) J0881-Non- Management Epoetin Alfa and Methoxy Injection office. ESRD Department* Polyethylene Glycol-Epoetin Beta Injection,  Prior Authorization/ Arcalyst SQ J2793 PBM Notification Guidelines: Pharmacy N/A (rilonacept) Injection Rilonacept (Arcalyst)  Therapeutic Equivalent Aricept 23mg Guidelines: Drug Coverage (donepezil Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Therapeutic Equivalent Arimidex (brand Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A only) (anastrozole) Criteria - New and Therapeutic Equivalent Medications Injection, *No precertification is required if Arixtra SQ J1652 N/A* N/A Pharmacy dispensed by a retail pharmacy (fondaparinux) Injection or mail order through PBM.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Armodafinil Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (generic Nuvigil) Nuvigil (armodafinil) ArmonAir  Therapeutic Equivalent RespiClick Inhalation Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (fluticasone powder Criteria - New and Therapeutic propionate) Equivalent Medications Arnuity Ellipta Inhalation (fluticasone J3490 N/A N/A Pharmacy N/A Powder furoate)  Prior Authorization/Medical Necessity Guidelines: Arymo ER Arymo ER Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A (morphine sulfate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Asacol HD Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (mesalamine) Criteria - New and Therapeutic Equivalent Medications AsmalPred and AsmalPred Plus Tablet J8499 N/A N/A Pharmacy N/A (Prednisolone) Asmanex HFA Inhaler J3490 N/A N/A Pharmacy N/A (mometasone)  Therapeutic Equivalent Astagraf XL Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (tacrolimus) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Astelin (brand) Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (azelastine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Astepro Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A (azelastine) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Atelvia Guidelines: Drug Coverage (risedronate Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Ativan (brand only) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (lorazepam) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Atorvastatin Notification Guidelines: - *Applies to New York Lines of (generic Lipitor) Tablet J8499 PBM* Pharmacy Cardiovascular Disease Business only. 10mg, 20mg Prevention Zero Cost Share* **Precertification Notes:  Prior Authorization/ Precertification for NJ Small LOBs Notification Guidelines: is based on the Member's Atralin (tretinoin) benefit. Atralin (tretinoin) Varies S0117 PBM**  Therapeutic Equivalent Pharmacy* *Benefit Note: Not all groups Guidelines: Drug Coverage have selected the standard Criteria - New and Therapeutic pharmacy benefit. Refer to Equivalent Medications Member's pharmacy plan if applicable.  Prior Authorization/ Aubagio Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (teriflunomide) Aubagio Augmentin  Therapeutic Equivalent (amoxicillin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A clavulanate) Criteria - New and Therapeutic (brand) Equivalent Medications Augmentin ED-600  Therapeutic Equivalent (amoxicillin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A clavulanate) Criteria - New and Therapeutic (brand) Equivalent Medications Augmentin XR/ Amoxicillin-  Therapeutic Equivalent Clavulanate ER Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (amoxicillin and Criteria - New and Therapeutic clavulanate Equivalent Medications potassium) Auralgan 5.5%/1.4% Drops, J3490 N/A N/A Pharmacy N/A (antipyrine, Solution benzocaine)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Auryxia (ferric Tablet J8499 N/A N/A Pharmacy N/A citrate)  Therapeutic Equivalent Austedo Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (deutetrabenazine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Auvi-Q Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A (epinephrine) Criteria - New and Therapeutic Equivalent Medications Avar Foam (9.5%-  Therapeutic Equivalent 5%), Avar, Avar LS Guidelines: Drug Coverage (sodium Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfacetamide/ Equivalent Medications sulfur)  Medical Management Avastin IV Infusion, *Non-Oncology Indications: J9035 N/A* Guidelines: Maximum Dosage Medical (bevacizumab) Injection No precertification required. Policy  Therapeutic Equivalent Avelox tablet Guidelines: Drug Coverage (Brand Only) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (moxifloxacin hcl) Equivalent Medications  Prior Authorization/Medical Avinza (morphine Necessity Guidelines: Avinza sulfate extended  Therapeutic Equivalent Capsule J8499 PBM Pharmacy N/A release) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Avita (tretinoin) Avita (tretinoin) Varies S0117 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Avodart Guidelines: Drug Coverage (dutasteride) Capsule J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes J1826,  Prior Authorization/ Avonex (Interferon IM Injection Q3025 and PBM Notification Guidelines: Pharmacy N/A Beta 1a) or Injection Q3026 Avonex **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan  Supply Limit Guidelines: Ceiling Limit. Triptans Supply Limits NJ Plans do not require Axert (almotriptan)  Therapeutic Equivalent Tablet J8499 PBM** Pharmacy* precertification. (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic *Benefit Note: New York Plans Equivalent Medications and Products, Members should refer to their Certificate of Coverage as certain triptan drugs are included in the select designated pharmacy program.  Prior Authorization/Medical Necessity Guidelines: Axiron Axiron  Therapeutic Equivalent Gel J3490 PBM Pharmacy N/A (testosterone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications *Step Therapy coverage criteria is for groups on the Essential PDL  Step Therapy Guidelines: only. More information about if Azilect (rasagiline) Tablet J8499 PBM Pharmacy Azilect* this program applies can be found on myuhc.com or by calling customer service. Azor (amlodipine  Therapeutic Equivalent besylate and Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A olmesartan Criteria - New and Therapeutic medoxomil) Equivalent Medications  Prior Authorization/ Banzel Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Rufinamide) Banzel (Rufinamide) Beconase AQ  Therapeutic Equivalent (beclomethasone Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A dipropionate, Criteria - New and Therapeutic monohydrate) Equivalent Medications Belbuca  Prior Authorization/Medical Buccal film J3490 PBM Pharmacy N/A (buprenorphine) Necessity Guidelines: Belbuca

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Belsomra  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (suvorexant) Belsomra Benicar  Therapeutic Equivalent (olmesartan) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Benicar HCT (olmesartan  Therapeutic Equivalent medoxomil- Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloro- Criteria - New and Therapeutic thiazide)(brand Equivalent Medications only) Benlysta Injection J0490 N/A N/A Medical N/A (belimumab) Benzaclin Jar  Therapeutic Equivalent (brand only) Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (benzoyl peroxide Criteria - New and Therapeutic and clindamycin) Equivalent Medications  Therapeutic Equivalent Benzaclin Pump Guidelines: Drug Coverage (benzoyl peroxide Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic and clindamycin) Equivalent Medications Benzaclin Kit (1%-  Therapeutic Equivalent 5%) (Clindamycin Guidelines: Drug Coverage Gel J3490 PBM Pharmacy N/A Phosphate-Benzoyl Criteria - New and Therapeutic Peroxide) Equivalent Medications  Therapeutic Equivalent Benzefoam Aerosol/ Guidelines: Drug Coverage J3490 PBM Pharmacy N/A BenzeFoam Ultra Foam Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Bepreve Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (bepotastine) Drops Criteria - New and Therapeutic Equivalent Medications Berinert (C1  Prior Authorization/ esterase inhibitor Injection J0597 PBM Notification Guidelines: Pharmacy N/A human) Berinert  Therapeutic Equivalent Betamethasone Guidelines: Drug Coverage valerate foam Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (generic Luxiq) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Betapace (sotalol) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic Equivalent Medications Betaseron  Prior Authorization/ J1830 or (Interferon Beta Injection PBM Notification Guidelines: Pharmacy N/A J3490 1b) Betaseron  Prior Authorization/ Bethkis Inhalation J3490 PBM Notification Guidelines: Pharmacy N/A (tobramycin) Solution Bethkis Bevespi Aerosphere Inhalation (glycopyrrolate/ J3490 N/A N/A Pharmacy N/A Aerosol formoterol fumarate)  Therapeutic Equivalent Bexarotene caps Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (generic Targretin) Criteria - New and Therapeutic Equivalent Medications Bexxar Injection J3490 N/A N/A Medical N/A (tositumomab) Beyaz  Therapeutic Equivalent (drospirenone/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A ethinyl estradiol/ Criteria - New and Therapeutic levomefolate) Equivalent Medications  Therapeutic Equivalent bimatoprost 0.03% Guidelines: Drug Coverage Eye Drops J3490 PBM Pharmacy N/A (generic Lumigan) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Binosto Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (alendronate) Criteria - New and Therapeutic Equivalent Medications Boniva (ibandronate Injection J1740 Medical sodium) N/A N/A N/A Boniva Tablet (ibandronate Tablet J8499 Pharmacy sodium)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Notification Guidelines: Bosulif (bosutinib) Tablet J8999 PBM Bosutinib (bosulif) Pharmacy N/A  Step Therapy Guidelines: Bosutinib (bosulif) Botox, Botulinum Oxford’s Toxin Type Medical  Precertification Guidelines: Injection J0585 Medical N/A (onabotulinumtoxin Management Botulinum Toxins A and B A) Department *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members without a Pharmacy Benefit. Precertification  Precertification Guidelines: Bravelle IM or SQ *NY Plans: Pharmacy Benefit.* J3355 through Follicle Stimulating Hormone See Notes* (urofollitropin) Injection Optum* (FSH) Gonadotropins *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Brilinta (Ticagrelor) Tablet J8499 N/A N/A Pharmacy N/A Oxford’s Brineura  Precertification Guidelines: Injection J3590 Medical Medical N/A (cerliponase alfa) Brineura (cerliponase alfa) Management Brintellix  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (vortioxetine) Brintellix  Therapeutic Equivalent Brisdelle Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (paroxetine) Criteria - New and Therapeutic Equivalent Medications Briviact  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (brivaracetam) Necessity Guidelines: Briviact Bromday Ophthalmic J3490 N/A N/A Pharmacy N/A (bromfenac) Drops  Therapeutic Equivalent Topical Bromsite Guidelines: Drug Coverage Ophthalmic J3490 PBM Pharmacy N/A (bromfenac) Criteria - New and Therapeutic Solution Equivalent Medications  Therapeutic Equivalent Budesonide nasal Guidelines: Drug Coverage spray (generic Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Rhinocort Aqua) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Bunavail Film Necessity Guidelines: (buprenorphine Buccal Film J3490 PBM Pharmacy N/A Buprenorphine/Naloxone and naloxone) Products Sublingual Buprenorphine HCl J3490 N/A N/A Pharmacy N/A Tablet Buprenorphine Tablet J3490 N/A N/A Pharmacy N/A (generic Subutex)  Prior Authorization/Medical Buprenorphine/ Necessity Guidelines: naloxone (generic Tablet J8499 PBM Pharmacy N/A Buprenorphine/Naloxone Suboxone) Products Benefits for Smoking Cessation  Prior Authorization/Medical Bupropion (generic for Health Care Reform apply to Tablet J8499 PBM Necessity Guidelines: Tobacco Pharmacy Zyban) all plans subject to health care Cessation for Health Care Reform reform. Butalbital/ acetaminophen/  Therapeutic Equivalent caffeine/codeine Guidelines: Drug Coverage 50mg/300mg/ Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic 40mg/30mg Equivalent Medications (generic Fioricet with Codeine)  Prior Authorization/Medical Necessity Guidelines: Butrans Butrans  Therapeutic Equivalent Coverage Criteria does not apply Patch J3490 PBM Pharmacy (buprenorphine) Guidelines: Drug Coverage to CT of business. Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Byvalson (nebivolol Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A and valsartan) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Cabometyx Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (cabozantinib) Cabometyx Caduet and generic  Therapeutic Equivalent Caduet Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (amlodipine and Criteria - New and Therapeutic atorvastatin) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Injectable prescription vitamins administered under the direction Calcijex (Calcitriol) Injection J0636 N/A N/A Medical* of a physician as medically necessary are reimbursed under the Medical Benefit. Calderol Capsule J8499 N/A N/A Pharmacy N/A (calcifediol)  Therapeutic Equivalent Powder, Cambia (diclofenac Guidelines: Drug Coverage Tablet, J8499 PBM Pharmacy N/A potassium) Criteria - New and Therapeutic Capsule Equivalent Medications  Therapeutic Equivalent Capecitabine Guidelines: Drug Coverage Tablet J8999 PBM Pharmacy N/A (generic Xeloda) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Caprelsa Pharmacy* years or older. All other oral Oral J8999 PBM* Notification Guidelines: (vandetanib) * chemotherapy drugs do not Caprelsa require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Carbaglu Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (carglumic acid) Carbaglu Cardizem Tablet J8499 PBM Pharmacy N/A (diltiazem) (brand)  Therapeutic Equivalent Cardizem CD Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (diltiazem) (brand) Criteria - New and Therapeutic Cardizem LA Equivalent Medications Tablet J8499 PBM Pharmacy N/A (diltiazem) (brand) Coverage is limited to Members Carnitor Tablet or with coverage for vitamins/ (levocarnitine/ J8499 N/A N/A Pharmacy* Solution supplements through their L-Carnitine) prescription drug plan. If the

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Member does not have vitamin/ supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Medical Management *Benefit is State Specific. Medical Injection J1955 N/A Guidelines: Formula & Medical* Benefit/Pharmacy Benefit. Specialized Food  Prior Authorization/ Caverject Vial J0270 PBM Notification Guidelines: Pharmacy N/A (alprostadil) Erectile Dysfunction Agents Cayston  Prior Authorization/ *NJ Small Members should refer (Aztreonam for Inhalation J3490 PBM* Notification Guidelines: Pharmacy* to their Certificate of Coverage Inhalation Solution Cayston for precertification guidelines. Solution)  Therapeutic Equivalent Celebrex (brand Guidelines: Drug Coverage Capsule J3490 PBM Pharmacy N/A only) (celecoxib) Criteria - New and Therapeutic Equivalent Medications Celexa  Prior Authorization/Medical (citalopram) Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A (brand only) Brand Medications Oxford Cellcept  Therapeutic Equivalent (mycophenolate Tablet/ Guidelines: Drug Coverage J8499 PBM Pharmacy N/A mofetil) (brand Capsule Criteria - New and Therapeutic only) Equivalent Medications Cenestin  Therapeutic Equivalent (conjugated Guidelines: Drug Coverage tablet J8499 PBM Pharmacy N/A estrogens) (brand Criteria - New and Therapeutic only) Equivalent Medications  Therapeutic Equivalent Centany AT Kit Guidelines: Drug Coverage Ointment J3490 PBM Pharmacy N/A (mupirocin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Cerdelga Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (eliglustat) Cerdelga

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Ceredase® IV Infusion, J0205 N/A N/A Medical N/A (algucerase) Injection Oxford’s  Precertification Guidelines: Cerezyme® IV Infusion, J1786 Medical Enzyme Replacement Therapy Medical N/A (imiglucerase) Injection Management (ERT) for Gaucher Disease Cesamet (nabilone) Capsule J8650 N/A N/A Pharmacy N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Cetirizine Solution Oral J8499 N/A N/A N/A equivalent are excluded from (generic Zyrtec) Solution coverage. Refer to the member specific benefit plan document as applicable. Benefit Note: *Coverage is limited to Members with coverage for fertility drugs Precertification through their prescription drug  Precertification Guidelines: Cetrotide through Optum Pharmacy/ plan. If the Member does not Injection J3490 Infertility Diagnosis and (cetrorelix acetate) may be Medical* have fertility drug coverage Treatment required through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Cetylev Tablet J8499 N/A N/A Pharmacy N/A (acetylcysteine) Benefits for Smoking Cessation Chantix  Prior Authorization/Medical for Health Care Reform apply to (varenicline Tablet J3490 PBM Necessity Guidelines: Tobacco Pharmacy* all plans subject to health care tartrate) Cessation for Health Care Reform reform. J3490 Oxford’s  Precertification Guidelines: Chelation Therapy IV Infusion M0300 and Medical Medical N/A Chelation Therapy S9355 Management* J0640- J0641 J9000-  eviCore Guidelines: Injectable Chemotherapy J9999 Chemotherapy Drugs: *Precertification is required Injection eviCore* Medical (Injectable) Drugs Q2017 Application of NCCN Clinical through eviCore. Q2043 Practice Guidelines Q2049 and Q2050

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Cholbam (cholic Capsule J8499 PBM Notification Guidelines: Pharmacy N/A acid) Cholbam  Therapeutic Equivalent Choline Fenofibrate Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Trilipix) Criteria - New and Therapeutic Equivalent Medications *Precertification Note: HCPCS code J0725 (chorionic gonadatropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with Gonadatropin J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines.  Prior Authorization/ Cialis (tadalafil) Tablet J3490 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents Ciclodan  Therapeutic Equivalent Combination Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Package Criteria - New and Therapeutic (ciclopirox) Equivalent Medications  Therapeutic Equivalent Ciclodan Kit Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (ciclopirox) Criteria - New and Therapeutic Equivalent Medications Cimzia  Prior Authorization/ (certolizumab SQ Injection J0717 PBM Notification Guidelines: Cimzia Pharmacy N/A pegol) (certolizumab pegol) J3490, Oxford’s  Precertification Guidelines: Cinqair Intravenous J3590, and Medical Respiratory Interleukins (Cinqair Medical N/A (reslizumab) infusion J2786 Management and Nucala)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Cinryze (C1  Prior Authorization/Medical esterase inhibitor Injection J0598 PBM Pharmacy N/A Necessity Guidelines: Cinryze (human)) Cipro Tablet J8499 Pharmacy N/A N/A N/A (ciprofloxacin) Injection J0744 Medical Cipro suspension Oral (Brand Only) J8499 N/A N/A Pharmacy N/A Suspension (ciprofloxacin) Cipro XR (ciprofloxacin Tablet J8499 N/A N/A Pharmacy N/A extended-release) *Step Therapy coverage criteria Ciprodex is for groups on the Essential PDL (ciprofloxacin  Step Therapy Guidelines: only. More information about if Tablet J8499 PBM Pharmacy HCL/dexamethaso Ciprodex this program applies can be ne) found on myuhc.com or by calling customer service. *Precertification is only required Claforan Oxford’s only when used in the treatment  Precertification Guidelines: (cefotaxime IV Infusion J0698 Medical Medical of Lyme disease. Exception: Lyme Disease sodium) Management* Precert is not required for Connecticut Members.  Prior Authorization/ Claravis Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (isotretinoin) Claravis  Therapeutic Equivalent Clarifoam EF Topical Guidelines: Drug Coverage (sulfacetamide/ J3490 PBM Pharmacy N/A Foam Criteria - New and Therapeutic sulfur) (brand) Equivalent Medications  Therapeutic Equivalent Clarinex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (desloratadine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Clarinex D Guidelines: Drug Coverage (desloratadine and Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic pseudoephedrine) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Clarinex Reditab (desloratadine orally Tablet J8499 N/A N/A Pharmacy N/A disintegrating tablet)  Therapeutic Equivalent Clindacin Pack Guidelines: Drug Coverage (clindamycin Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic phosphate) Equivalent Medications  Therapeutic Equivalent Clindagel Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (clindamycin) Criteria - New and Therapeutic Equivalent Medications Clindamycin  Therapeutic Equivalent 1%/benzoyl Guidelines: Drug Coverage peroxide 5% Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (generic Equivalent Medications BenzaClin) gel Clindamycin1.2%/ benzoyl peroxide Topical J3490 N/A N/A Pharmacy N/A 5% gel (Generic Duac)  Therapeutic Equivalent Clobeta J3490 and Guidelines: Drug Coverage Ointment PBM Pharmacy N/A (Clobetasol) J8499 Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Clobetasol Guidelines: Drug Coverage shampoo (generic Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Clobex shampoo) Equivalent Medications  Therapeutic Equivalent Clobex Lotion Guidelines: Drug Coverage (clobetasol Lotion J3490 PBM Pharmacy N/A Criteria - New and Therapeutic propionate) Equivalent Medications  Therapeutic Equivalent Clobex Shampoo Guidelines: Drug Coverage (clobetasol Shampoo J3490 PBM Pharmacy N/A Criteria - New and Therapeutic propionate) Equivalent Medications  Therapeutic Equivalent Clodan 0.05% Guidelines: Drug Coverage (clobetasol Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic proprionate) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Clodan 0.05% kit Guidelines: Drug Coverage (clobetasol Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic proprionate) Equivalent Medications Cloderm 0.1%  Step Therapy Guidelines: cream Cream J3490 PBM Pharmacy N/A Cloderm (clocortolone) Cloderm cream (Brand Only Cream J3490 N/A N/A Pharmacy N/A (clocortolone) Cocet Plus  Therapeutic Equivalent (acetaminophen J3490 and Guidelines: Drug Coverage Tablet PBM Pharmacy N/A and codeine J8499 Criteria - New and Therapeutic phosphate) Equivalent Medications  Therapeutic Equivalent Colazal Guidelines: Drug Coverage (balsalazide) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Colchicine Capsule Guidelines: Drug Coverage (manufacturer: Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic West-Ward) Equivalent Medications  Prior Authorization/ Notification Guidelines: Colchicine Tablet Colchicine Tablet (manufacturer: Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A Prasco Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Colcrys Colcrys (colchicine) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Cometriq Pharmacy* years or older. All other oral Oral J8999 PBM* Notification Guidelines: (cabozantinib) * chemotherapy drugs do not Cometriq require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Comfort Pac w/ Guidelines: Drug Coverage Tizanidine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (tizanidine) Equivalent Medications Compounds and  Prior Authorization/ *NJ Small Members should refer Bulk Powders: Various J7999 PBM Notification Guidelines: Pharmacy to their Certificate of Coverage various drugs Compounds and Bulk Powders for precertification guidelines.  Prior Authorization/ Concerta Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (methylphenidate) Concerta  Therapeutic Equivalent Guidelines: Drug Coverage Conzip (tramadol) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications Copaxone  Prior Authorization/ Injection, (glatiramer J1595 PBM Notification Guidelines: Pharmacy N/A SQ Injection acetate) Copaxone Copaxone  Prior Authorization/ (glatiramer Injection J3490 PBM Notification Guidelines: Pharmacy N/A acetate) 40mg Copaxone J3490 and Copegus (ribarivin) Tablet N/A N/A Pharmacy N/A J3590 Cordran 0.05 %  Step Therapy Guidelines: cream Cream J3490 PBM Pharmacy N/A Cordran (clurandrenolide)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Cordran 0.05%  Step Therapy Guidelines: lotion Lotion J3490 PBM Pharmacy N/A Cordran (flurandrenolide) Cordran Ointment Topical  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (flurandrenolide) Ointment Cordran Ointment  Therapeutic Equivalent Coreg CR J3490 and Guidelines: Drug Coverage (carvedilol Capsule PBM Pharmacy N/A J8499 Criteria - New and Therapeutic phosphate) Equivalent Medications Corgard (nadolol) Tablet J3490 N/A N/A Pharmacy N/A  Prior Authorization/ Corlanor Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (ivabradine) Corlanor  Prior Authorization/ Notification Guidelines: Cosentyx Injection J3490 PBM Cosentyx Pharmacy N/A (secukinumab)  Step Therapy Guidelines: Cosentyx  Therapeutic Equivalent Cosopt PF Ophthalmic Guidelines: Drug Coverage (dorzolamide hcl/ J3490 PBM Pharmacy N/A solution Criteria - New and Therapeutic timolol maleate Equivalent Medications  Prior Authorization/ Cotellic Tablet J8999 PBM Notification Guidelines: Pharmacy N/A (cobimetinib) Cotellic  Therapeutic Equivalent Oral Cotempla XR-ODT Guidelines: Drug Coverage disintegratin J8499 PBM Pharmacy N/A (methylphenidate) Criteria - New and Therapeutic g tablet Equivalent Medications Cresemba (isavuconazonium Capsule J8499 N/A N/A Pharmacy N/A sulfate)  Therapeutic Equivalent Crestor Guidelines: Drug Coverage (rosuvastatin Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic calcium) Equivalent Medications *Benefit Note for Infertility  Precertification Guidelines: Use: Coverage is limited to Crinone Gel J3490 N/A Infertility Diagnosis and Pharmacy* Members with coverage for (progesterone gel) Treatment fertility drugs through their prescription drug plan. If the

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Benefit Note: Coverage is limited to Members with coverage for fertility drugs Precertification through their prescription drug  Precertification Guidelines: Crinone 8% through Optum Pharmacy/ plan. If the Member does not Injection J3490 Infertility Diagnosis and (progesterone) may be Medical* have fertility drug coverage Treatment required through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Crofab (crotalidae polyvalent immune Injection J0840 N/A N/A Medical N/A fab (ovine) Cultivate  Step Therapy Guidelines: (fluticasone Lotion J3490 PBM Pharmacy N/A Cultivate propionate 0.05%)  Therapeutic Equivalent Cuprimine Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (penicillamine) Criteria - New and Therapeutic Equivalent Medications  Precertification Guidelines: o Immune Globulin (IVIG & Cuvitru [immune Oxford’s SCIG) globulin Injection 90284 Medical Medical N/A subcutaneous o Immune Globulin Site of Management (human)] Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Cyclophosphamide Oral J8530 N/A N/A Pharmacy N/A (Cytoxan) Cyclophosph Capsule Capsule J8999 N/A N/A Pharmacy N/A (cyclophosphamide)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Cymbalta Guidelines: Drug Coverage (duloxetine) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Prior Authorization/ Cystaran Ophthalmic J3490 PBM Notification Guidelines: Pharmacy N/A (cysteamine) Solution Cystaran (cysteamine) Cytogam (cytomegalovirus 90291 or immune globulin Injection N/A N/A Medical N/A J0850 intravenous (human) Daklinza  Prior Authorization/Medical Tablet J3490 PBM Pharmacy N/A (daclatasvir) Necessity Guidelines: Daklinza  Prior Authorization/ *NJ Small Members should refer Daliresp Tablet J3490 PBM* Notification Guidelines: Pharmacy* to their Certificate of Coverage (Roflumilast) Daliresp for precertification guidelines.  Prior Authorization/Medical Daraprim Tablet J3490 PBM Necessity Guidelines: Pharmacy N/A (pyrimethamine) Daraprim *No precertification is required if J0882-  Benefit Guidelines: Anemia dispensed by a retail pharmacy Oxford’s Darbepoetin Alfa Injgection, ESRD OR Drugs: Darbepoetin Alfa, Epoetin through the PBM. Medical Pharmacy (Aranesp) SQ Injection J0881-Non- Alfa and Methoxy Polyethylene *Precertification is required if Management* ESRD Glycol-Epoetin Beta provided in a hospital or MD's office.  Therapeutic Equivalent Daxbia Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (cephalexin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Daytrana Daytrana Patch J3490 PBM  Therapeutic Equivalent Pharmacy N/A (methylphenidate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Deca-Durabolin Injection J2320 N/A N/A Medical N/A (nandrolone)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Delatestryl (testosterone Injection J3490 N/A N/A Medical N/A enanthate)  Therapeutic Equivalent Delos Guidelines: Drug Coverage lotion/cleanser Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (benzoyl peroxide) Equivalent Medications Delzicol  Therapeutic Equivalent (mesalamine Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A delayed release Criteria - New and Therapeutic Capsule) Equivalent Medications  Therapeutic Equivalent Denavir Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (penciclovir) Criteria - New and Therapeutic Equivalent Medications Depakote  Prior Authorization/Medical (divalproex Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A sodium) Depakote Depakote ER  Prior Authorization/Medical (divalproex sodium Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A extended release) Depakote ER *Coverage is limited to Members with coverage for contraceptives through their prescription drug Depo Provera plan. If the Member does not 150mg, Depo- have contraceptive coverage  Benefit Guidelines: subQ provera 104 Injection J3490 N/A Pharmacy* through their prescription drug Contraceptives (medroxy- plan, then this is not covered. progesterone) Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Depo Provera 400mg (medroxy- Injection J3490* N/A N/A Medical Only administered in MD's office. progesterone) Depo Testosterone (testosterone Injection J3490 N/A N/A Medical N/A cypionate)  Therapeutic Equivalent Dermasorb AF 3- Guidelines: Drug Coverage 0.5% kit Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (hydrocortisone) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Dermasorb XM Guidelines: Drug Coverage 39% kit Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (hydrocortisone) Equivalent Medications Descovy (emtricitabine/ Tablet J8499 N/A N/A Pharmacy N/A tenofovir alafenamide)  Therapeutic Equivalent Desloratadine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Clarinex) Criteria - New and Therapeutic Equivalent Medications Desonate 0.05%  Step Therapy Guidelines: Gel J3490 PBM Pharmacy N/A gel (desonide) Desonate  Therapeutic Equivalent Desonil Guidelines: Drug Coverage cream/ointment Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (Kit) (desonide) Equivalent Medications  Prior Authorization/ Desoxyn (meth- Tablet J3490 N/A Notification Guidelines: Pharmacy N/A amphetamine) Desoxyn  Therapeutic Equivalent Desvenlafaxine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (desvenlafaxine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Desvenlafaxine ER Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (desvenlafaxine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Detrol (tolterodine) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Detrol LA J3490 and Guidelines: Drug Coverage (tolterodine Capsule PBM Pharmacy N/A J8499 Criteria - New and Therapeutic tartrate) Equivalent Medications  Prior Authorization/ Dexedrine (dextro- Tablet or S0160 PBM Notification Guidelines: Pharmacy N/A amphetamine) Capsule Dexedrine

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Dexilant (brand) Capsule J8499 N/A N/A Pharmacy N/A (dexlansoprazole)  Therapeutic Equivalent Dexmethylphen- Guidelines: Drug Coverage idate extended- Criteria - New and Therapeutic release capsule Capsule J8499 PBM Equivalent Medications Pharmacy N/A (generic Focalin  Prior Authorization/ XR) Notification Guidelines: Focalin  Prior Authorization/ Dextrostat (dextro- Tablet S0160 PBM Notification Guidelines: Pharmacy N/A amphetamine) Dextrostat D.H.E. 45  Therapeutic Equivalent (dihydro- Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A ergotamine) Criteria - New and Therapeutic (brand) Equivalent Medications A4206, A4210, A4233- A4236, A4244- A4245, A4250, A4253, A4256, A4258- A4259,  Precertification Guidelines: A9275, Diabetes Supply Coverage for Diabetic Supplies Varies E0607, N/A N/A N/A Commercial Plans (Including New E2100- Jersey Small Group Plans) E2101, E0784, K0601- K0605, A4230- A4232, A6257, J1610, J1815, J1817 and J3490

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Dibenzyline Guidelines: Drug Coverage (phenoxyl- Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic benzamine) (brand) Equivalent Medications Diclegis (doxylamine  Prior Authorization/Medical succinate and Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Diclegis pyridoxine hydrochloride)  Therapeutic Equivalent Diclofenac 1% Guidelines: Drug Coverage topical gel (generic Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Voltaren) Equivalent Medications Dicloxacillin Sodium (Dycil, Capsule J8499 N/A N/A Pharmacy N/A Dynapen) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Differin 0.1% Varies J3490 N/A N/A N/A equivalent are excluded from (adapalene) coverage. Refer to the member specific benefit plan document as applicable. Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Differin 0.3% Gel Topical Gel J3490 N/A N/A N/A equivalent are excluded from (adapalene) coverage. Refer to the member specific benefit plan document as applicable. Diflucan Tablet J8499 N/A N/A Pharmacy N/A (fluconazole)  Therapeutic Equivalent Diovan (valsartan) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Diovan HCT Guidelines: Drug Coverage (valsartan) (brand Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic only) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Tablet and Guidelines: Drug Coverage Disalcid (salsalate) J8499 PBM Pharmacy N/A Capsule Criteria - New and Therapeutic Equivalent Medications Donepezil 5 or Oral Dis- 10mg (generic intergrating J8499 N/A N/A N/A N/A Aricept) Tablet  Therapeutic Equivalent Donepezil 23mg Guidelines: Drug Coverage (generic Aricept Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic 23mg) Equivalent Medications Doribax IV Infusion J1267 N/A N/A Medical N/A (doripenem)  Therapeutic Equivalent Doryx (doxycycline Guidelines: Drug Coverage hyclate) delayed Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic release tablet Equivalent Medications  Prior Authorization/ Topical Doxepin Cream J3490 PBM Notification Guidelines: Pharmacy N/A Cream Doxepin Cream Doxorubicin Q2049 and Hydrochloride Injection N/A N/A Medical N/A Q2050 Liposomal  Therapeutic Equivalent Doxycycline 75mg Guidelines: Drug Coverage capsule (generic Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Monodox) Equivalent Medications  Therapeutic Equivalent Doxycycline Guidelines: Drug Coverage 150mg capsule Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (generic Monodox) Equivalent Medications  Therapeutic Equivalent Doxycycline Guidelines: Drug Coverage Delayed-Release Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Capsule 40mg Equivalent Medications *Oral chelation agents do not D-Pennicillamine Oral Agent J3490 N/A* N/A Pharmacy require precertification. Drisdol Capsule, J3490, and N/A N/A Pharmacy N/A (ergocalciferol) Liquid J8499

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Duac (Clindamycin and Benzoyl Topical J3490  Therapeutic Equivalent Peroxide) Guidelines: Drug Coverage PBM Pharmacy N/A Duac CS Criteria - New and Therapeutic (Clindamycin and Topical J3490 Equivalent Medications Benzoyl Peroxide) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Duexis (famotidine Tablet J8499 N/A N/A Pharmacy equivalent are excluded from and ibuprofen) coverage. Refer to the member specific benefit plan document as applicable. Dulera (mometasone  Step Therapy Guidelines: furoate/formoterol Inhaler J3490 PBM Pharmacy N/A Dulera fumarate dihydrate) Duopa (carbidopa/ Enteral  Prior Authorization/Medical J3490 PBM Pharmacy N/A levodopa) Suspension Necessity Guidelines: Duopa  Prior Authorization/Medical Dupixent Injection J3590 PBM Necessity Guidelines: Pharmacy N/A (dupilumab) Dupixent  Therapeutic Equivalent Duragesic (Brand Transdermal Guidelines: Drug Coverage J3490 PBM Pharmacy N/A Only) (fentanyl) Patch Criteria - New and Therapeutic Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Durlaza (aspirin) Capsule J8499 N/A N/A N/A equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Dutoprol Tablet J8499 N/A N/A Pharmacy  Therapeutic Equivalent Dyanavel XR Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (amphetamine) Suspension Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Dymista Guidelines: Drug Coverage (fluticasone Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (Flonase) Equivalent Medications Dynavel XR  Prior Authorization/ Oral (amphetamine J8499 PBM Notification Guidelines: Pharmacy N/A Suspension extended release) Dynavel XR Dysport Oxford’s  Precertification Guidelines: (abobotulinumtoxi Injection J0586 Medical Medical N/A Botulinum Toxins A and B n A) Management  Therapeutic Equivalent Ecoza (econazole Guidelines: Drug Coverage nitrate topical Topical J3490 PBM Pharmacy* N/A Criteria - New and Therapeutic foam 1%) Equivalent Medications  Prior Authorization/ Edex (alprostadil) Vial J0270 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents  Therapeutic Equivalent Guidelines: Drug Coverage Edluar (zolpidem) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications E.E.S. 400  Therapeutic Equivalent (erythromycin Guidelines: Drug Coverage Oral Liquid J8499 PBM Pharmacy N/A ethylsuccinate) Criteria - New and Therapeutic (brand) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Select Effexor XR Brand Medications Oxford (venlafaxine) Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Egrifta Injection J8999 PBM Notification Guidelines: Egrifta Pharmacy N/A (tesamorelin) (tesamorelin) Elaprase IV Infusion, J1743 N/A N/A Medical N/A (idursulfase) Injection Oxford’s  Precertification Guidelines: Elelyso Injection J3060 Medical Enzyme Replacement Therapy Medical N/A (taliglucerase alfa) Management (ERT) for Gaucher Disease

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Elestat (epinastine Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A HCL) Solution Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Elidel Topical J3490 PBM Notification Guidelines: Elidel Pharmacy N/A (pimecrolimus) (pimecrolimus) J1950,  Prior Authorization/ Eligard (leuprolide J9217, SQ Injection PBM Notification Guidelines: Pharmacy N/A acetate) J9218 and Eligard (leuprolide acetate) J9219  Therapeutic Equivalent Emadine Ophthalmic Guidelines: Drug Coverage (emedastine J3490 PBM Pharmacy N/A Solution Criteria - New and Therapeutic difumarate) Equivalent Medications Embeda (morphine  Prior Authorization/Medical sulphate and Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Embeda naltrexone hcl) Emend Capsule or J8501 Pharmacy (aprepitant) Trifold Pack N/A N/A N/A Emend IV Infusion J1453 Medical (fosaprepitant)  Prior Authorization/Medical Necessity Guidelines: Emflaza Emflaza Oral  Therapeutic Equivalent J8499 PBM Pharmacy N/A (deflazacort) suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Empagliflozin/ Tablet J3490 N/A N/A Pharmacy N/A Metformin Emverm Chewable  Prior Authorization/Medical J8499 PBM Pharmacy N/A (mebendazole) Tablet Necessity Guidelines: Emverm  Therapeutic Equivalent Enablex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (darifenacin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Enbrel Notification Guidelines: Enbrel Injection J1438 PBM Pharmacy N/A (etanercept) (etanercept)  Step Therapy: Enbrel

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility Endometrin Vaginal J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progesterone) Insert Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Enstilar foam Topical (calcipotriene/ J3490 N/A N/A Pharmacy N/A Foam betamethasone)  Therapeutic Equivalent Entocort EC Guidelines: Drug Coverage (budesonide) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Entresto  Prior Authorization/Medical (valsartan – Tablet J8499 PBM Necessity Guidelines: Entestro Pharmacy N/A sacubitril) (valsartan-sacubitril) Hospital Outpatient Facility:  Medical Management Administration of Entyvio in a Guidelines: Maximum Dosage hospital outpatient facility Policy (including any ambulatory Oxford’s infusion suite associated with the Entyvio J3380 and  Precertification Guidelines: Injection Medical Medical hospital) requires precertification (vedolizumab) J3490 o Entyvio (vedolizumab) Management with review by a Medical Director o Specialty Medication or their designee. Refer to: Administration – Site of Care Specialty Medication Review Guidelines Administration – Site of Care Review Guidelines.  Therapeutic Equivalent Envarsus XR Guidelines: Drug Coverage Tablet J7508 PBM Pharmacy N/A (tacrolimus) Criteria - New and Therapeutic Equivalent Medications Powder for  Prior Authorization/Medical Epaned (enalapril) Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Solution Solid Oral Dosage Forms

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Epanova (omega- Capsule J8499 PBM Notification Guidelines: Pharmacy N/A 3-carboxylic acids) Epanova Epclusa  Prior Authorization/Medical (sofosbuvir/ Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Epclusa velpatasfir) *Benefit Notes: Not covered for cosmetic conditions. Not all Epi Quinn Micro groups have selected the Varies J3490 N/A N/A Pharmacy* (hydroquinone) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Therapeutic Equivalent Epiduo (adapalene Guidelines: Drug Coverage and benzoyl Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic peroxide) Equivalent Medications  Therapeutic Equivalent Epiduo Forte Guidelines: Drug Coverage (adapalene and Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic benzoyl peroxide) Equivalent Medications Epinephrine Pen  Therapeutic Equivalent Injection, 0.15mg Pen Guidelines: Drug Coverage and 0.3mg J0171 PBM Pharmacy N/A Injection Criteria - New and Therapeutic (generic Equivalent Medications Adrenaclick)  Therapeutic Equivalent EpiPen/EpiPen Jr. J0171, Guidelines: Drug Coverage (epinephrine) Injection PBM Pharmacy N/A J3490 Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Epzicom (abacavir/ Guidelines: Drug Coverage lamivudine) (brand Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic only) Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Ergomar Criteria - New and Therapeutic (ergotamine Tablet J8499 PBM Pharmacy N/A Equivalent Medications tartrate)  Prior Authorization/Medical Necessity Guidelines: Ergomar

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Erivedge years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (vismodegib) chemotherapy drugs do not Erivedge require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Ertaczo Guidelines: Drug Coverage (sertaconazole Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic nitrate) Equivalent Medications *No precertification is required if dispensed by a retail pharmacy Oxford’s through the PBM. Q4081- Medical  Precertification Guidelines: Erythropoetin *Precertification is required if Injection, ESRD OR Management* Anemia Drugs: Darbepoetin Alfa, Medical/ (EPO, Epoetin Alfa, provided in a hospital or MD's SQ Injection J0885-non- Epoetin Alfa and Methoxy Pharmacy Epogen, Procrit) office. ESRD Polyethylene Glycol-Epoetin Beta *No precertification is required if N/A* dispensed by a retail pharmacy through the PBM.  Prior Authorization/Medical Esbriet Capsule J8499 PBM Necessity Guidelines: Esbriet Pharmacy N/A (pirfenidone) (pirfenidone) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Esomeprazole Capsule J8499 N/A* N/A N/A* equivalent are excluded from Strontium coverage. Refer to the member specific benefit plan document as applicable. Estradiol TD twice  Therapeutic Equivalent weekly patch Transdermal Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (generic Vivelle- Patch Criteria - New and Therapeutic Dot) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Estradiol vaginal tablet [Yuvafem Vaginal J3490 N/A N/A Pharmacy N/A (generic for Tablet Vagifem)] *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Estrostep FE have contraceptive coverage  Benefit Guidelines: (ethinyl estradiol Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives and norethindrone) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Eucrisa Topical  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (crisaborole) Ointment Eucrisa *Precertification is not required in Intra- Oxford’s Euflexxa (sodium  Precertification Guidelines: the office for Oxford's preferred Articular J7323 Medical Medical hyaluronate) Sodium Hyaluronate products of Euflexxa, Synvisc or Injection Management* Synvisc-One (J7323 and J7325).  Prior Authorization/ Notification Guidelines: Evekeo Evekeo (amphetamine Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A sulfate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Regulatory Guidelines: Evista Evista (raloxifene)  Therapeutic Equivalent Oral J8999 PBM Pharmacy N/A (Brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Evotaz (atazanavir/ Tablet J8499 N/A N/A Pharmacy N/A cobicistat) Evzio (nalozone Auto-  Prior Authorization/Medical J3490 PBM Pharmacy N/A HCL injection) Injector Necessity Guidelines: Evzio Exalgo  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (hydromorphone) Necessity Guidelines: Exalgo

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Excelon Patch Transdermal Guidelines: Drug Coverage (rivastigmine) J3490 PBM Pharmacy N/A patch Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Exforge J3490 and Guidelines: Drug Coverage (amlodipine Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic valsartan) Equivalent Medications Exforge HCT  Therapeutic Equivalent (amlodipine, J3490 and Guidelines: Drug Coverage Tablet PBM Pharmacy N/A hydrochlorothiazide J8499 Criteria - New and Therapeutic and valsartan) Equivalent Medications  Prior Authorization/ Exjade Tablet J3490 PBM Notification Guidelines: Pharmacy N/A (Deferasirox) Exjade  Precertification Guidelines: Hospital Outpatient Facility: o Exondys 51 Administration of Exondys 51 in a o Specialty Medication hospital outpatient facility Administration – Site of Care (including any ambulatory Oxford’s Review Guidelines infusion suite associated with the Exondys 51 Intravenous J3590 Medical Medical hospital) requires precertification (eteplirsen) Management with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines.  Prior Authorization/ Notification Guidelines: Extavia (interferon J1830 or Injection PBM Extavia Pharmacy N/A B-1b) J3490  Step Therapy Guidelines: Extavia (interferon B-1b) Eylea (afibercept) Injection J0178 N/A N/A Medical N/A  Prior Authorization/ Notification Guidelines: Fabior (tazarotene) Fabior (tazarotene) Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fabrazyme® IV Infusion, J0180 N/A N/A Medical N/A (agalsidase beta) Injection

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Falessa Kit (birth  Therapeutic Equivalent control plus Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A vitamin Criteria - New and Therapeutic supplement) Equivalent Medications Famvir Tablet J8499 N/A N/A Pharmacy N/A (famciclovir) Fanapt Oral J8499 N/A N/A Pharmacy N/A (iloperidone) The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications SGLT2 Farxiga to New York and Connecticut Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy (depagliflozin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.  Prior Authorization/ Farydak Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (panobinostat) Farydak Tablet and Felbatol  Prior Authorization/Medical Oral J8499 PBM Pharmacy N/A (felbamate) Necessity Guidelines: Felbatol Suspension  Therapeutic Equivalent Femara (letrozole) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Fenofibrate 43mg, Guidelines: Drug Coverage 130mg (generic Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Antara) capsule Equivalent Medications  Therapeutic Equivalent Fenofibrate 48mg, Guidelines: Drug Coverage 145mg (generic Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Tricor) Equivalent Medications  Therapeutic Equivalent Fenofibrate 50mg, Guidelines: Drug Coverage 150mg (generic Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Lipofen) capsule Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Fenoglide Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (fenofibrate) Criteria - New and Therapeutic Equivalent Medications Fentanyl  Therapeutic Equivalent transdermal patch Topical Guidelines: Drug Coverage (37.5, 62.5 and J3490 PBM Pharmacy N/A Patch Criteria - New and Therapeutic 87.5 mcg/hr Equivalent Medications strengths only)  Prior Authorization/ Notification Guidelines: Fentora (fentanyl) Fentora (fentanyl Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A buccal) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Ferriprox Tablet J3490 PBM Notification Guidelines: Pharmacy N/A (Deferiprone) Ferriprox *Precertification Note: HCPCS code J3355 (urofollitropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification **Benefit Note: Coverage is  Precertification Guidelines: Fertinex J3355* and through Optum Pharmacy/ limited to Members with Injection Infertility Diagnosis and (urofollitropin) J3490 may be Medical** coverage for fertility drugs Treatment required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Fetzima  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (Levomilnacipran) Fetzima  Therapeutic Equivalent Fibricor 35mg, Guidelines: Drug Coverage 105mg (fenofibric Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic acid) Equivalent Medications Finacea 15% Foam Foam J3490 N/A N/A Pharmacy N/A (azelaic acid)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Fioricet with  Therapeutic Equivalent Codeine capsule Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A 50mg/300mg/ Criteria - New and Therapeutic 40mg/30mg Equivalent Medications Fioricet with  Therapeutic Equivalent Codeine Guidelines: Drug Coverage 50mg/325mg/ Capsule J8499 PBM Criteria - New and Therapeutic Pharmacy N/A 40mg/30mg Equivalent Medications (Brand Only)  Prior Authorization/ Firazyr (icatibant) Injection J1744 PBM Notification Guidelines: Pharmacy N/A Firazyr *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Precertification Guidelines: Firmagon Injection J9155 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility First Progesterone Varies J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progestin) Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Precertification Guidelines: o Immune Globulin (IVIG) and Flebogamma Oxford’s SCIG (immune globulin Injection J1572 Medical o Immune Globulin Site of Care Medical N/A Non-Lyophilized) Management Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent J3490, Guidelines: Drug Coverage Flector (diclofenac) Patch PBM Pharmacy N/A J8499 Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Flomax Guidelines: Drug Coverage (tamsulosin) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Flo-Pred J3490 and Guidelines: Drug Coverage Suspension PBM Pharmacy N/A (prednisolone) J8499 Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Floxin 0.3% Otic Otic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (ofloxacin) Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent FlowTuss Oral Guidelines: Drug Coverage (hydrocodone/ J8499 PBM Pharmacy N/A Solution Criteria - New and Therapeutic guaifenesin) Equivalent Medications Flublok (Influenza  Medical Management Vaccine, Intra- Guidelines: Recombinant muscular Q2033 N/A Medical N/A o Preventive Care Services Hemagglutinin Injection o Vaccines Antigens) FluMist (influenza virus vaccine Nasal Spray 90660 N/A N/A Medical N/A (nasal))  Therapeutic Equivalent Fluocinonide 0.1% Guidelines: Drug Coverage cream (generic Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Vanos) Equivalent Medications  Therapeutic Equivalent Fluorouracil 0.5% Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Cream Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Fluticasone/ Guidelines: Drug Coverage Inhaler J3490 PBM Pharmacy N/A Salmeterol Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Fluticasone Topical J3490 PBM Notification Guidelines: Pharmacy N/A (topical) Compounds and Bulk Powders

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Focalin  Prior Authorization/ (dexmethylphenida Capsule J8499 PBM Notification Guidelines: Pharmacy N/A te HCl) Focalin  Prior Authorization/ Notification Guidelines: Focalin XR Focalin XR (dexmethylphenida Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A te HCl [extended Guidelines: Drug Coverage release]) Criteria - New and Therapeutic Equivalent Medications *Coverage is limited to Members with coverage for vitamins/ supplements through their prescription drug plan. If the Member does not have vitamin/ supplement coverage through Folic Acid Tablet J8499 N/A N/A Pharmacy* their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members Precertification  Precertification Guidelines: without a Pharmacy Benefit. Follistim AQ Injection S0128 through Follicle Stimulating Hormone See Notes* *NY Plans: Pharmacy Benefit. (follitropin beta) Optum* (FSH) Gonadotropins *Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.  Prior Authorization/Medical Forfivo XL Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A (bupropion HCL) Brand Medications Oxford  Prior Authorization/Medical Fortamet Necessity Guidelines: (metformin Tablet J8499 PBM Pharmacy N/A Fortamet (metformin extended- extended-release) release)  Prior Authorization/ Forteo Injection, J3110 PBM Notification Guidelines: Pharmacy N/A (teriparatide) SQ Injection Teriparatide (Forteo)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Necessity Guidelines: Fortesta  Therapeutic Equivalent Gel J3490 PBM Pharmacy N/A Fortesta Guidelines: Drug Coverage (testosterone) Criteria - New and Therapeutic Equivalent Medications Injection J1950 N/A N/A Medical N/A *No precertification is required if Fragmin Injection, J1645 N/A* N/A Pharmacy dispensed by a retail pharmacy (dalteparin) SQ Injection or Mail Order through PBM. **Precertification Note: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not Frova  Supply Limit Guidelines: require precertification. Tablet J8499 PBM** Pharmacy* (frovatriptan) Triptans Supply Limits *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Fuzeon Injection J3490 N/A N/A Medical N/A (enfuvirtide)  Prior Authorization/Medical Fycompa Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A (perampanel) Fycompa Gammagard® Liquid J1569 (immunoglobulin,  Precertification Guidelines: Non-Lyophilized) o Immune Globulin (IVIG) and Gammaplex Oxford’s SCIG (immunoglobulin, Injection J1557 Medical o Immune Globulin Site of Medical N/A Non-Lyophilized) Management Care Review Guidelines for Gamunex-C, Medical Necessity of Hospital Gammaked Outpatient Facility Infusion J1561 (immune globulin, Non-Lyophilized) Gattex  Prior Authorization/ Injection, (teduglutide [rDNA J3490 PBM Notification Guidelines: Pharmacy N/A SQ Injection origin]) Gattex

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Gelnique Guidelines: Drug Coverage Topical gel J3490 PBM Pharmacy N/A (oxybutynin) Criteria - New and Therapeutic Equivalent Medications *Precertification with review by a Intra- Oxford’s Medical Director or their Gel-One  Precertification Guidelines: Articular J7324 Medical Medical Designee is required in all sites of (Hyaluronan) Sodium Hyaluronate Injection Management* service for J7321, J7324 and J7326. Intra- Oxford’s Gel-Syn (sodium  Precertification Guidelines: Articular J7328 Medical Medical N/A hyaluronate) Sodium Hyaluronate Injection Management  Therapeutic Equivalent Guidelines: Drug Coverage Genadur Kit Nail Laquer J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Generess FE Guidelines: Drug Coverage (norethindrone/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic ethinyl estradiol) Equivalent Medications Generic Tablet J8499 N/A N/A Pharmacy N/A Levetiracetam XR  Prior Authorization/Medical Necessity Guidelines: Genotropin (somatropin) Genotropin Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Genotropin Guidelines: Drug Coverage MiniQuick Injection J2941 PBM Pharmacy N/A Criteria - New and Therapeutic (somatropin) Equivalent Medications Genvisc 850 Intra- Oxford’s  Precertification Guidelines: (sodium Articular J7320 Medical Medical N/A Sodium Hyaluronate hyaluronate) Injection Management Genvoya (elvitegravir/ cobicistat/  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A emtricitabine/ Genvoya tenofovir alafenamide)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Geodon Guidelines: Drug Coverage (ziprasisdone) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Gialax Kit Orol Guidelines: Drug Coverage (polyethylene J8499 PBM Pharmacy N/A solution Criteria - New and Therapeutic glycol) Equivalent Medications  Therapeutic Equivalent Giazo (balsalazide Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A disodium) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Gilenya Injection J3490 PBM Notification Guidelines: Pharmacy N/A (fingolimod) Gilenya Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Gilotrif (afatinib) Tablet J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Gilotrif (Afatinib) require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Notification Guidelines: Glatopa Glatopa (Glatiramer 20mg Injection J3490 PBM  Therapeutic Equivalent Pharmacy N/A [generic Guidelines: Drug Coverage Copaxone]) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed  Prior Authorization/ in a Coverage Criteria/Guideline Notification Guidelines: when the Member is age 19 Gleevec Gleevec (imatinib years or older. All other oral Oral, Varies S0088 PBM*  Therapeutic Equivalent Pharmacy** mesylate) chemotherapy drugs do not Guidelines: Drug Coverage require precertification. Criteria - New and Therapeutic Benefit Note: **NJ Small Equivalent Medications Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Glucophage XR  Prior Authorization/Medical (metformin Necessity Guidelines: Tablet J8499 PBM Pharmacy N/A extended-release Glucophage XR (metformin [brand only]) extended-release [brand only])  Prior Authorization/Medical Glumetza Necessity Guidelines: (metformin Tablet J8499 PBM Pharmacy N/A Glumetza (metformin extended- extended-release) release) The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Glyxambi Diabetes Medications SGLT2 to New York and Connecticut (empagliflozin/ Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy plans and products. linagliptin)  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members Gonal-F /Gonal-f Precertification  Precertification Guidelines: without a Pharmacy Benefit. IM or SQ RFF (follitropin S0126 through Follicle Stimulating Hormone See Notes* *NY Plans: Pharmacy Benefit.* Injection alfa) Optum* (FSH) Gonadotropins *Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Gonitro Sublingual Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (nitroglycerin) Powder Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Gralise J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A (gabapentin) J8499 Criteria - New and Therapeutic Equivalent Medications *Pharmacy Benefit: If dispensed by a retail pharmacy  eviCore Guidelines: White or mail order through PBM. Blood Cell Colony Stimulating Precertification through the PBM Factors** Granix PBM*/ is required. Injection J1447  Therapeutic Equivalent See Notes (tbo-filgrastiim) eviCore** **Medical Benefit: If provided Guidelines: Drug Coverage in a hospital, MD's office, or in Criteria - New and Therapeutic conjunction with home health Equivalent Medications* care. Precertification through eviCore is required.  Prior Authorization/Medical Grastek (Timothy Sublingual Necessity Guidelines: Grastek Grass Pollen J8499 PBM Pharmacy N/A Tablet (Timothy Grass Pollen Allergen Allergen Extract) Extract)  Prior Authorization/ Notification Guidelines: Haegarda [C1 Haegarda Esterase Inhibitor Injection J3490 PBM  Therapeutic Equivalent Pharmacy N/A Subcutaneous Guidelines: Drug Coverage (Human)] Criteria - New and Therapeutic Equivalent Medications Halog 0.1% cream  Step Therapy Guidelines: Cream J3490 PBM Pharmacy N/A (halcinonide) Halog Halog 0.1%  Step Therapy Guidelines: ointment Ointment J3490 PBM Pharmacy N/A Halog (halcinonide) Halotestin Tablet J3490 N/A N/A Pharmacy N/A (fluoxymesterone) Harvoni™  Prior Authorization/Medical (ledipasvir/ Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Harvoni sofosbuvir)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) J0725 requires precertification through Optum in all sites of service when associated with an infertility Precertification diagnosis code.  Precertification Guidelines: HCG (chorionic J0725* and through Optum Pharmacy/ **Benefit Note: Coverage is Injection Infertility Diagnosis and gonadotropin) J3490 may be Medical** limited to Members with Treatment required* coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines. Hectorol Capsule J8499 N/A N/A Pharmacy N/A (doxercalciferol) Injection J1270 N/A N/A Medical N/A  Therapeutic Equivalent Helidac (bismuth Capsule/ Guidelines: Drug Coverage J8499 PBM Pharmacy N/A subsalicylate) Tablet Criteria - New and Therapeutic Equivalent Medications Hemangeol Oral  Therapeutic Equivalent solution Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (propranolol Solution Criteria - New and Therapeutic hydrochloride) Equivalent Medications HEMOPHILIA J7175 See Notes*  Precertification Guidelines: See Notes* Effective 12/01/2013 for NY DRUGS J7178 o Assisted Administration of LOBS (excluding Healthy NY Brand Names J7179 Clotting Factors and and NY Individual Plans) and Coagulant Blood Products Adynovate, J7180 New Jersey Large and Small o Clotting Factors and Groups: Advate, J7181 Coagulant Blood Products *Precertification: Afstyla, J7182 o Eloctate™ (Antihemophilic Alphanate, J7183 Factor (Recombinant), FC Is required through Oxford for self-administered clotting factor Alphanine SD J7185 Fusion Protein) for drugs (including Eloctate) Alprolix Connecticut Lines of Business J7186 provided by a Hemophilia Bebulin, J7187 (Medical Benefit) o Home Health Care Treatment Center including Benefix, J7188 (Medical benefit applies):  Prior Authorization/Medical Coagadex, J7189 Necessity Guidelines: - NY Presbyterian Hospital- Corifact J7190 o Advate Weill Cornell Center Eloctate J7192 o Adynovate - Mount Sinai Medical Center Feiba NF J7193 o Eloctate Medical Necessity - Long Island Jewish Medical

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Feiba VH J7194 o Helixate FS Center Helixate FS**, J7195 o Ixinity Is required for self- Hemofil-M, J7198 o Recombinate administered Eloctate when o Humate-P, J7199 Xyntha covered under the pharmacy  Therapeutic Equivalent Idelvion, J7200 benefit, with precertification Guidelines: Drug Coverage through the PBM. Ixinity** J7201 Criteria - New and Therapeutic Is NOT required for all other Koate-DVI, J7202 Equivalent Medications** self-administered clotting factor Kogenate FS, J7205 drugs (except Eloctate) obtained Kovaltry J7207 through any specialty designated Monoclate-P J7209 pharmacy (Pharmacy benefit Mononine applies). Novoeight Is required if assisted Novoseven RT administration (provider’s office, Nuwig clinic, home, etc). Obizur Eloctate is covered under the medical benefit, precertification Profilnine SD obtained through Oxford. Recombinate, For Connecticut LOB RiaSTAP Member’s regardless of date Rixubis of service: Tretten *Self-administered clotting Vonvendi factor drugs (except Eloctate) Wilate do not require pre-certification Xyntha and are covered under the Xyntha Solofuse medical benefit. Self-administered Eloctate requires precertification through Oxford and is covered under the medical benefit. *If the member requires assisted administration of their clotting factor drugs, precertification is required in all sites of service and is covered under the medical benefit. For assisted administration in the home, please refer to Home Health Care. *HMO Members: If drugs are requested or supplied through a non-par vendor and authorization is not approved, these services

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes will not be reimbursed by Oxford. HepaGam B (hepatitis B J1571 and Injection N/A N/A Medical N/A immune globulin J1573 [human]) *Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM. J1642 or Heparin Injection N/A N/A See Notes* *Medical Benefit: If provided in J1644 a hospital, MD's office, or in conjunction with home health care.  eviCore Guidelines: Injectable Chemotherapy Drugs: Oxford’s *For Oncology and Non- Herceptin Application of NCCN Clinical Injection J9355 Medical Medical Oncology Use: Precertification (trastuzumab) Practice Guidelines Management* is required  Precertification Guidelines: Maximum Dosage Policy Hetlioz  Prior Authorization/Medical Capsule J8499 PBM Pharmacy N/A (tasimelteon) Necessity Guidelines: Hetlioz  Precertification Guidelines: o Immune Globulin (IVIG) and Oxford’s SCIG Hizentra (immune Injection J1559 Medical o Immune Globulin Site of Medical N/A globulin) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion  Therapeutic Equivalent Horizant Guidelines: Drug Coverage (gabapentin, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic enacarbil) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Humatrope (somatropin) Humatrope Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: *HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: Benefit Note: **Coverage is Humegon S0122* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with (menotropins) J3490 may be Medical** Treatment coverage for fertility drugs required through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines.  Prior Authorization/ Humira Injection, J0135 PBM Notification Guidelines: Pharmacy N/A (adalimumab) SQ Injection Humira (adalimumab) Intra- Oxford’s Hyalgan (sodium  Precertification Guidelines: Articular J7321 Medical Medical N/A hyaluronate) Sodium Hyaluronate Injection Management Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 Hycamtin  Prior Authorization/ years or older. All other oral (topotecan Oral J8705 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not hydrochloride) Hycamtin require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Hycofenix  Therapeutic Equivalent (hydrocodone/ Oral Guidelines: Drug Coverage J3490 PBM Pharmacy N/A pseudoephedrine/ solution Criteria - New and Therapeutic guaifenesin) Equivalent Medications hydrocortisone 1% ointment in Ointment J3490 N/A N/A Pharmacy N/A absorbase

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Hydromorphone ER Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A Hydromorphone ER Hysingla ER  Prior Authorization/Medical (hydrocodone Tablet J8499 PBM Necessity Guidelines: Hysingla Pharmacy N/A bitartrate) ER Hytakerol Capsule J8499 N/A N/A Pharmacy N/A (dihydrotachysterol)  Prior Authorization/ Ibrance Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (palbociclib) Ibrance Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Iclusig (ponatinib) Oral J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Iclusig require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Ilaris Injection J0638 N/A N/A Medical N/A (canakinumab)  Therapeutic Equivalent Ophthalmic Guidelines: Drug Coverage Ilevro (nepafenac) J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 Imatinib (generic S0088 and years or older. All other oral Oral N/A N/A Pharmacy Gleevec) J8999 chemotherapy drugs do not require precertification. Benefit Note: NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Imbruvica Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (ibrutinib) Imbruvica **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. J3490, *NJ Plans do not require Imitrex  Supply Limit Guidelines: Nasal Spray J8499 and PBM** Pharmacy* precertification. (sumatriptan) Triptans Supply Limits J3030 *Benefit Note: *New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Therapeutic Equivalent Imitrex Guidelines: Drug Coverage (sumatriptan) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Supply Limit Guidelines: Triptans Supply Limits Imitrex  Therapeutic Equivalent (sumatriptan) Injection J3030 PBM Pharmacy N/A Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Immune Globulin (IVIG and SCIG)

IVIg: Bivigam Carimune NF ® Gammaplex J1459 ® Flebogamma J1556 Flebogamma® DIF J1557 Gammagard®  Precertification Guidelines: J1559 Liquid o Immune Globulin (IVIG and Gammagard® S/D J1561 Oxford’s SCIG) Gammaked™ IV Infusion J1566 Medical o Immune Globulin Site of Medical N/A ®- Management Care Review Guidelines for Gamunex C J1568 Medical Necessity of Hospital Octogam® J1569 Outpatient Facility Infusion Privigen® J1572 J1575 SCIG: J1599 Gammagard® Liquid Gammaked™ Gamunex®-C Hizentra® HyQvia  Prior Authorization/ Impavido Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (miltefosine) Impavido  Therapeutic Equivalent Imuran J7500, Guidelines: Drug Coverage (azathioprine) Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic (brand only) Equivalent Medications  Prior Authorization/Medical Increlex SQ Injection J2170 PBM Necessity Guidelines: Increlex Pharmacy N/A (mecasermin) (mecasermin) Incruse Ellipta Inhalation J3490 N/A N/A Pharmacy N/A (umeclidinium) Powder

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification is required in all sites of service. Hospital Outpatient Facility:  Precertification Guidelines: Administration of Inflectra in a o Infliximab (Remicade®, hospital outpatient facility Oxford’s Inflectra™, Renflexis™) (including any ambulatory Inflectra Intravenous Q5102-ZB Medical o Maximum Dosage Policy Medical infusion suite associated with the (infliximab) Management* o Specialty Medication hospital) requires precertification Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Inlyta (axitinib) Oral J8999 PBM* Pharmacy** Notification Guidelines: Inlyta chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. *No precertification is required if Innohep Injection, J1655 N/A* N/A Pharmacy dispensed by a retail pharmacy (tinzaparin) SQ Injection or mail order through PBM Insulins (Novolin *The Prior Authorization/ 70/30, Novolog  Prior Authorization/ Notification Guidelines: Insulin pens and vials, Notification Guidelines: policy applies to New York and Novolog Mix 70/30 Injection J1815 PBM Insulin* Pharmacy Connecticut plans and products. pens and vials,  Step Therapy Guidelines: The Step Therapy: Insulin policy Apidra, Apidra Insulin applies to New Jersey plans and Solostar, Novolin products. N, Novolin R)  Therapeutic Equivalent Intermezzo Sublingual Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (zolpidem tartrate) Tablet Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Intrarosa Vaginal Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (prasterone) Inserts Criteria - New and Therapeutic Equivalent Medications  eviCore Guidelines: Injectable Chemotherapy Drugs: Intron-A Application of NCCN Clinical *For Oncology and Non- (interferon Alfa- Injection J9212 PBM* Practice Guidelines Pharmacy Oncology use: Precertification 2b)  Prior Authorization/ is required. Notification Guidelines: Intron-A (interferon alpha-2b)  Therapeutic Equivalent Intuniv Guidelines: Drug Coverage (guanfacine) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Invega Injection J3490 N/A N/A Medical N/A (paliperidone)  Therapeutic Equivalent Invega Guidelines: Drug Coverage (paliperidone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications SGLT2 Invokana to New York and Connecticut Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy (canagliflozin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.  Therapeutic Equivalent Guidelines: Drug Coverage Irenka (duloxetine) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Iressa (gefitinib) Tablet J8999 PBM Pharmacy NA Notification Guidelines: Iressa  Prior Authorization/ Jadenu Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (defirasirox) Jadenu

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Jakafi (ruxolitinib) Oral J8999 PBM* Pharmacy** Notification Guidelines: Jakafi chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Jalyn (dutasteride J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A and tamsulosin) J8499 Criteria - New and Therapeutic Equivalent Medications The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications DPP4 Notification Guidelines: Janumet Inhibitors (CT/NY) policy applies Diabetes Medications DPP4 (sitagliptin and to New York and Connecticut Tablet J3490 PBM Inhibitors (CT/NY) Pharmacy metformin plans and products.  Step Therapy Guidelines: hydrochloride) The Step Therapy Guidelines: Diabetes Medications DPP4 Diabetes Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications DPP4 Janumet XR Notification Guidelines: Inhibitors (CT/NY) policy applies (sitagliptin and Diabetes Medications DPP4 to New York and Connecticut metformin Tablet J3490 PBM Inhibitors (CT/NY) Pharmacy plans and products. hydrochloride,  Step Therapy Guidelines: The Step Therapy Guidelines: extended release) Diabetes Medications DPP4 Diabetes Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications DPP4 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications DPP4 Januvia to New York and Connecticut Tablet J3490 PBM Inhibitors (CT/NY) Pharmacy (sitagliptin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications DPP4 Diabetes Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications SGLT2 Jardiance to New York and Connecticut Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy (empagliflozin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Jentadueto XR Extended (linagliptin/ release J8499 N/A N/A Pharmacy N/A metformin) tablet Jublia  Prior Authorization/Medical Topical J3490 PBM Pharmacy N/A (efinaconazole) Necessity Guidelines: Jublia Juxtapid  Prior Authorization/Medical Capsule J8499 PBM Pharmacy N/A (lomitapide) Necessity Guidelines: Juxtapid Kadian (morphine  Prior Authorization/Medical sulfate extended Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Kadian release) Kalbitor IV Infusion J1290 N/A N/A Medical N/A (ecallantide)  Prior Authorization/Medical Kalydeco Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A (ivacaftor) Kalydeco  Therapeutic Equivalent Kapvay (clonidine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Karbinal ER Oral Guidelines: Drug Coverage (carbinoxamine J8499 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic maleate) Equivalent Medications  Therapeutic Equivalent Kenalog Spray Topical Guidelines: Drug Coverage (triamcinolone) J3490 PBM Pharmacy N/A Spray Criteria - New and Therapeutic (brand) Equivalent Medications Keppra Injection J1953 N/A N/A Medical N/A (levatiricetam) Keppra  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (levetiracetam) Necessity Guidelines: Keppra Keppra XR  Prior Authorization/Medical (levetiracetam Tablet J8499 PBM Necessity Guidelines: Keppra Pharmacy N/A extended XR release[XR])  Therapeutic Equivalent Keralac 47% Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A cream (urea) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Keralyt Scalp Kit Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (salicylic acid) Criteria - New and Therapeutic Equivalent Medications Kerydin  Prior Authorization/Medical Topical J3490 PBM Pharmacy N/A (tavaborole) Necessity Guidelines: Kerydin  Therapeutic Equivalent Ketocon J3490 and Guidelines: Drug Coverage Ointment PBM Pharmacy N/A (ketoconazole) J8499 Criteria - New and Therapeutic Equivalent Medications Ketodan  Therapeutic Equivalent Combination Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Package Criteria - New and Therapeutic (ketoconazole) Equivalent Medications Keveyis  Prior Authorization/ (dichlorphena- Tablet J8499 N/A Notification Guidelines: Pharmacy N/A mide) Keveyis

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Notification Guidelines: Kevzara Kevzara Injection J3490 PBM  Therapeutic Equivalent Pharmacy N/A (sarilumab) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Khedezla Guidelines: Drug Coverage (desvenlafaxine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic extended release) Equivalent Medications  Prior Authorization/ Injection, Kineret (anakinra) J3490 PBM Notification Guidelines: Pharmacy N/A SQ Injection Kineret (anakinra)  Prior Authorization/ Kisqali (ribociclib) Tablet J8499 PBM Pharmacy N/A Notification Guidelines: Kisqali Kisqali Femara 200 Pak (ribociclib/ Tablet J8499 N/A N/A Pharmacy N/A letrozole)  Prior Authorization/ Notification Guidelines: Kitabis Pak Kitabis Pak Inhalation J3490 PBM  Therapeutic Equivalent Pharmacy N/A (tobramycin) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications *NJ Small Members should refer  Prior Authorization/ Korlym J3490 and to their Certificate of Coverage Oral PBM Notification Guidelines: Pharmacy* (mifepristone) J8499 for precertification and quantity Korlym limit guidelines. Krystexxa Injection J2507 N/A N/A Medical N/A (pegloticase)  Prior Authorization/ Kuvan (sapropterin Tablet J8499 PBM Notification Guidelines: Kuvan Pharmacy N/A dihydrochloride) (sapropterin dihydrochloride)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Chimeric Antigen Receptor (CAR)-T Cell Therapy may be eligible for coverage as an autologous stem cell therapy  eviCore Guidelines: Injectable under a member’s Kymriah Chemotherapy Drugs: Transplantation Services benefit. (tisagenlecleucel) Precertification Application of NCCN Clinical Transplant- Coverage determinations are – [CAR-T (Chimeric Injection S2107 through Practice Guidelines ation based on the Optum Transplant Antigen Receptor) Optum*  Optum Transplant Review Services Review Guidelines: Cell Therapy] Guidelines: Hematopoietic Hematopoietic Stem Cell Stem Cell Transplantation Transplantation criteria for covered transplants.

Precertification through Optum is required in all sites of service. Kynamro  Prior Authorization/Medical (Mipomersen SQ Injection J3490 PBM Necessity Guidelines: Pharmacy N/A Sodium) Kynamro™ IV Injection J1626 N/A N/A Medical N/A Kytril (granisetron Tablet, Oral Q0166 and hydrochloride) N/A N/A Pharmacy N/A Solution J8499 Lamictal  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (lamotrigine) Necessity Guidelines: Lamictal Lamictal ODT  Prior Authorization/Medical (lamotrigine orally Tablet J8499 PBM Necessity Guidelines: Lamictal Pharmacy N/A disintegrating ODT Tablet) Lamictal XR  Prior Authorization/Medical (lamotrigine Tablet J8499 PBM Necessity Guidelines: Lamictal Pharmacy N/A extended release) XR Lamisil (terbinafine Tablet J8499 N/A N/A N/A N/A hydrochloride)  Prior Authorization/Medical Lamotrigine XR Tablet J3490 PBM Necessity Guidelines: Pharmacy N/A Lamotrigine XR  Therapeutic Equivalent Lantus (insulin Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A glargine) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Lantus Solostar Guidelines: Drug Coverage Pen J3490 PBM Pharmacy N/A (insulin glargine) Criteria - New and Therapeutic Equivalent Medications Lazanda (fentanyl  Prior Authorization/Medical Nasal Spray J3490 PBM Pharmacy N/A nasal spray) Necessity Guidelines: Lazanda *Step Therapy coverage criteria is for groups on the Essential PDL Latuda  Step Therapy Guidelines: only. More information about if Tablet J8499 PBM Pharmacy (lurasidone) Latuda* this program applies can be found on myuhc.com or by calling customer service.  eviCore Guidelines: Injectable Chemotherapy Drugs: Oxford’s Application of NCCN Clinical *For Oncology and Non- Lemtrada J9010 and Infusion Medical Practice Guidelines Medical Oncology Use: Precertification is (alemtuzumab) J9999 Management*  Precertification Guidelines: required. Lemtrada (Alemtuzumab) (for non-oncology indications)  Prior Authorization/ Lenvima Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (lenvatinib) Lenvima  Step Therapy Guidelines: Lescol XL Lescol (fluvastatin)  Therapeutic Equivalent Capsule J8499 PBM Pharmacy N/A (brand and Guidelines: Drug Coverage generic) Criteria - New and Therapeutic Equivalent Medications Letairis  Prior Authorization/Medical Tablet J3490 PBM Pharmacy N/A (ambrisentan) Necessity Guidelines: Letairis Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM.  eviCore Guidelines: White Precertification is not required. Leukine Injection, J2820 eviCore* Blood Cell Colony Stimulating See Notes *Medical Benefit: If provided in (sargramostim) SQ Injection Factors* a hospital, MD's office, or in conjunction with home health care. Precertification through eviCore is required.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes

Leuprolide Acetate  Prior Authorization/ *For Oncology and Non- (subcutaneous) Injection J9218 PBM* Notification Guidelines: Pharmacy Oncology Use: Precertification (Eligard), Leuprolide Acetate is required. 1mg/0.2mL

 Therapeutic Equivalent Levalbuterol nebs Guidelines: Drug Coverage (generic Xopenex Inhalation J8499 PBM Pharmacy N/A Criteria - New and Therapeutic nebs) Equivalent Medications  Prior Authorization/ Levitra (vardenafil Tablet J3490 PBM Notification Guidelines: Pharmacy N/A HCI) Erectile Dysfunction Agents  Therapeutic Equivalent Lexapro Guidelines: Drug Coverage (escitalopram) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Lexiscan IV Infusion J2785 N/A N/A Medical N/A (regadenoson)  Therapeutic Equivalent Librax Guidelines: Drug Coverage (chlordiazepoxide / Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic clidinium) (brand) Equivalent Medications  Prior Authorization/ Topical Lidocaine Patch J3490 PBM Notification Guidelines: Pharmacy N/A Patch Lidocaine Patch  Therapeutic Equivalent Lidoderm Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (lidocaine) Criteria - New and Therapeutic Equivalent Medications Lidorx (lidocaine Topical Gel J3490 N/A N/A Pharmacy N/A hydrochloride) Lidovin 3.95% Topical J3490 N/A N/A Pharmacy N/A (lidocaine) Cream  Prior Authorization/ Linzess Capsule J3490 PBM Notification Guidelines: Pharmacy N/A (linaclotide) Linzess (Linaclotide)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes

 Therapeutic Equivalent Lipitor (brand only) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (atorvastatin) Criteria - New and Therapeutic Equivalent Medications

 Therapeutic Equivalent Lipofen Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (fenofibrate) Criteria - New and Therapeutic Equivalent Medications Liptruzet (ezetimibe and Tablet J8499 N/A N/A Pharmacy N/A atorvastatin) Livalo  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (pitavastatin) Livalo  Therapeutic Equivalent Lo Minastrin FE Guidelines: Drug Coverage (ethinyl estradiol / Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic norethindrone) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives Lo/Ovral (ethinyl through their prescription drug estradiol and plan. If the Member does not norgestrel) have contraceptive coverage  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives plan, then these are not covered. Loestrin/FE Members should refer to their Certificate of Coverage or (ethinyl estradiol and norethindrone) Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Lodosyn Guidelines: Drug Coverage (carbidopa) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications Locoid Lipocream &  Therapeutic Equivalent Locoid Lotion Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (hydrocortisone Criteria - New and Therapeutic butyrate) Equivalent Medications  Therapeutic Equivalent Lofibra 54mg, Guidelines: Drug Coverage 160mg (Brand Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic only) (fenofibrate) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Lofibra 67, 134, Guidelines: Drug Coverage 200mg Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (fenofibrate) Equivalent Medications Lonsurf  Prior Authorization/ (trifluridine/ Tablet J8999 PBM Notification Guidelines: Pharmacy N/A tipiracil) Lonsurf  Therapeutic Equivalent Loprox Shampoo Guidelines: Drug Coverage Shampoo J3490 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Loprox Suspension Topical Guidelines: Drug Coverage 95251 PBM Pharmacy N/A (ciclopirox) Suspension Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Loprox 0.77% Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A cream (ciclopirox) Cream Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Lorzone Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (chlorzoxazone) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Lotemax Gel Ophthalmic Guidelines: Drug Coverage (loteprednol J3490 PBM Pharmacy N/A Gel Criteria - New and Therapeutic etabonate) Equivalent Medications  Prior Authorization/ Notification Guidelines: Lotronex (Alosteron) Lotronex FDA approved only for use in Tablet J8499 N/A  Therapeutic Equivalent Pharmacy (alosetron) (brand) women. Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Lovaza (Brand Lovaza Only) (omega-3- Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A acid ethyl esters) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lovaza (Generic)  Prior Authorization/ (omega-3-acid Capsule J8499 PBM Notification Guidelines: Pharmacy N/A ethyl esters) Lovaza

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Lovenox Injection, J1650 N/A N/A Pharmacy N/A (enoxaparin) SQ Injection Lucentis Injection J2778 N/A N/A Medical N/A (ranibizumab) *Pharmacy Benefit if dispensed by a retail pharmacy. *Medical Benefit if provided in an MD's office. *Coverage is limited to Members Lunelle with coverage for contraceptives (medroxyprogester  Benefit Guidelines: through their prescription drug one acetate and Injection J3490 N/A See Notes* Contraceptives plan. If the Member does not estradiol have contraceptive coverage cypionate) through their prescription drug plan then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Lunesta Guidelines: Drug Coverage (eszopicione) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Lupron, *Precertification Note: Lupron-3, For Oncology Use Lupron-4, precertification is required. Lupron Depot, For Non-Oncology Use Lupron Depot precertification through Oxford Pediatric Medical Management is required Lupron Implant  eviCore Guidelines: Injectable for all indications for: (Leuprolide Chemotherapy Drugs: - Lupron Depot Pediatric (all Acetate): J1950, Oxford’s Application of NCCN Clinical dosages) and Injection J9217, and Medical Practice Guidelines Medical** - Lupron Depot 3.75mg, Lupron Depot J9219 Management*  Precertification Guidelines: 11.25mg 3.75mg, Gonadotropin Releasing Hormone Analogs 11.25 (3 month Precertification is required for all supply of 3.75 dosages of Lupron Depot for the dose) diagnosis of gender dysphoria; refer to Precertification Lupron Depot Guidelines: Gonadotropin 7.5mg Releasing Hormone Analogs for applicable Gender Dysphoria 22.5 (3 month

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes supply of 7.5mg ICD-10 diagnosis codes. dose) 30mg (4 month Precertification is not required dose of 7.5mg) for Lupron Depot 7.5mg, 22.5mg, and 30mg for the diagnosis of Prostate Cancer. Lupron Depot- Pediatric: New Jersey Small Members 7.5mg, should refer to their Certificate of 11.25mg, Coverage for precertification guidelines. 15mg **Benefit Note: For Connecticut Large and Small Plans: Infertility drugs will be covered under the Pharmacy Benefit if the Member has pharmacy coverage. If the Member does not have pharmacy coverage, infertility drugs will be covered under the Medical Benefit.  Therapeutic Equivalent Luxiq foam Guidelines: Drug Coverage (betamethasone Foam J3490 PBM Pharmacy N/A Criteria - New and Therapeutic valerate) Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Luzu (luliconazole) Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Lynparza Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (olaparib) Lynparza  Step Therapy Guidelines: Lyrica (pregabalin) Tablet J8499 PBM Pharmacy N/A Lyrica Macugen (pegaptanib Injection J2503 N/A N/A Medical N/A sodium) Makena (17-alpha- Oxford’s  Precertification Guidelines: hydroxy- J1725 and Injection Medical 17-Alpha-Hydroxyprogesterone Medical N/A progesterone J2675 Management Caproate (Makena and 17P) caproate or 17P)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members with coverage for prenatal vitamins through their Materna, prescription drug plan. If the Natalcare, Natalins Member does not have prenatal Rx, Niferex-PN, vitamin coverage through their Prenate 90, Tablet S0197 N/A N/A Pharmacy* prescription drug plan then these Prenatal Plus, are not covered. Members should Prenatal Rx, and refer to their Certificate of Stuartnatal Plus Coverage or Prescription Drug Rider language for coverage guidelines.  Prior Authorization/Medical Necessity Guidelines: Mavyret Mavyret  Therapeutic Equivalent (glecaprevir and Tablet J8499 PBM Pharmacy N/A Guidelines: Drug Coverage pibrentasvir) Criteria - New and Therapeutic Equivalent Medications  Supply Limit Guidelines: Triptans Supply Limits Maxalt and Maxalt-  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A MLT (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Mekinist Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Trametinib) Mekinist (Trametinib) *Precertification Note: HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is Precertification  Precertification Guidelines: Menopur S0122* and Pharmacy/ limited to Members with Injection through Human Menopausal (Menotropins) J3490 Medical** coverage for fertility drugs Optum* Gonadotropins (hMG) through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Mepron  Therapeutic Equivalent suspension (Brand Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A Only) Suspension Criteria - New and Therapeutic (atovaquone) Equivalent Medications  Prior Authorization/ Metadate CD Notification Guidelines: (methylphenidate Metadate CD hydrochloride) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A ([controlled Guidelines: Drug Coverage release brand only) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Metadate ER Tablet J8499 PBM Notification Guidelines: Pharmacy N/A Metadate ER Methitest (methyl- Tablet J8499 N/A N/A Pharmacy N/A testosterone) Methylin and  Prior Authorization/ Methylin ER Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (methylphenidate) Methylin and Methylin ER Methylphenidate  Prior Authorization/ extended-release Capsule J8499 PBM Notification Guidelines: Pharmacy N/A capsule (generic Metadate CD Metadate CD)  Prior Authorization/ Notification Guidelines: Methylphenidate Concerta extended-release Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A tablet (generic Guidelines: Drug Coverage Concerta) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Metoprolol Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A 37.5mg, 75mg Criteria - New and Therapeutic Equivalent Medications metoprolol succinate/  Therapeutic Equivalent hydrochloro- Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A thiazide (Dutoprol Criteria - New and Therapeutic Authorized Equivalent Medications Generic)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Metozolv ODT Guidelines: Drug Coverage (metoclopramide Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications *Precertification Note: HCPCS code J3355 (urofollitropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification **Benefit Note: Coverage is  Precertification Guidelines: Metrodin J3355* and through Optum Pharmacy/ limited to Members with Injection Infertility Diagnosis and (urofollitropin) J3490 may be Medical** coverage for fertility drugs Treatment required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Metrogel 0.75%  Therapeutic Equivalent Vaginal Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Metrogel 1% Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Metronidazole 1% Guidelines: Drug Coverage gel (generic Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Metrogel 1%) Equivalent Medications Metvixia (Methyl Topical J7309 N/A N/A Medical N/A aminolevulinate)  Therapeutic Equivalent Micardis (Brand Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Only) (telmisartan) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Micardis HCT (Brand Guidelines: Drug Coverage Only) (telmisartan/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochlorothiazide) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Micort-HC 2.5%  Therapeutic Equivalent cream Topical Guidelines: Drug Coverage PBM Pharmacy N/A (hydrocortisone Cream Criteria - New and Therapeutic acetate) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage Micronor  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug (norethidrone) Contraceptives plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Certain groups may exclude these services from coverage if such coverage would be contrary Oxford’s  Precertification Guidelines: to the Group's bona fide religious Mifeprex Oral S0190 Medical Mifeprex® (Mifepristone, RU- Medical* tenets. Please refer to the (mifepristone) Management 486) Member's Certificate of Coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit.  Prior Authorization/Medical Necessity Guidelines: Migranal Migranal (dihydro-  Therapeutic Equivalent ergotamine) Nasal Spray J3490 PBM Pharmacy N/A Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Migranal (dihydro-  Prior Authorization/Medical ergotamine) Nasal Spray J3490 PBM Pharmacy N/A Necessity Guidelines: Migranal (generic) Minastrin 24 FE  Therapeutic Equivalent (norethindrone Guidelines: Drug Coverage acetate and ethinyl Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic estradiol/ferrous Equivalent Medications fumarate) Minocin Injection J2265 N/A N/A Medical N/A (minocycline)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Minocin 50mg, Guidelines: Drug Coverage 75mg and 100mg Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (minocycline hcl) Equivalent Medications  Therapeutic Equivalent Minocycline Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Dynacin) Criteria - New and Therapeutic Equivalent Medications Minocycline  Prior Authorization/Medical extended-release Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Solodyn (generic Solodyn)  Therapeutic Equivalent Mirapex ER Guidelines: Drug Coverage (pramipexole Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic dihydrochloride) Equivalent Medications Mircera (methoxy  Precertification Guidelines: Oxford’s polyethylene Anemia Drugs: Darbepoetin Alfa, Injection J3490 Medical Medical N/A glycol-epoetin Epoetin Alfa and Methoxy Management* beta) Polyethylene Glycol-Epoetin Beta Certain groups may exclude these services from coverage if such coverage would be contrary Oxford’s  Precertification Guidelines: to the Group's bona fide religious Misoprostol Tablet S0191 Medical Abortions (Therapeutic and Medical* tenets. Please refer to the Management Elective) Member's Certificate of Coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit. Mitigare Capsule J8499 N/A N/A Pharmacy N/A (colchicine)  Therapeutic Equivalent Moderiba Tablet Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (ribavirin) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Moderiba Pak Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (ribavirin) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Modicon (ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives norethindrone) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Molindone Tablet J8499 N/A N/A Pharmacy N/A Momexin Combo Package Cream J3490 N/A N/A Pharmacy N/A (mometasone furoate)  Therapeutic Equivalent Monodox Guidelines: Drug Coverage (doxycycline) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Morgidox Capsule J8499 N/A N/A Pharmacy N/A (doxycycline) Morgidox Kit/  Therapeutic Equivalent Combo Pkg Capsule/ Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (doxycycline plus Topical Criteria - New and Therapeutic cleanser) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Extended- MorphaBond ER MorphaBond ER release J8499 PBM  Therapeutic Equivalent Pharmacy N/A (morphine sulfate) tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Morphine sulfate Extended Release Tablet J8499 N/A N/A Pharmacy N/A Pellets (generic Kadian)  Therapeutic Equivalent Motofen Guidelines: Drug Coverage (difenoxin/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic atropine) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Movantik Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (naloxegol) Movantik Mozobil (plerixafor) Injection J2562 N/A N/A Medical N/A  Prior Authorization/Medical MS Contin Tablet J8499 PBM Necessity Guidelines: MS Pharmacy N/A Contin  Prior Authorization/ Multaq Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (dronedarone) Multaq  Prior Authorization/ Muse (alprostadil) Pellet J0275 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents  Prior Authorization/Medical Myalept Injection J3490 PBM Necessity Guidelines: Myalept Pharmacy N/A (metreleptin) (metreleptin) Mydayis (mixed  Therapeutic Equivalent salts of a single Guidelines: Drug Coverage entity Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic amphetamine Equivalent Medications product)  Therapeutic Equivalent Myfortic J7518, Guidelines: Drug Coverage (mycophenolic Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic acid) (brand only) Equivalent Medications Myobloc Oxford’s  Precertification Guidelines: (rimabotulinum- Injection J0587 Medical Medical N/A Botulinum Toxins A and B toxin B) Management  Prior Authorization/ Myorisan Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (isotretinoin) Myorisan Myozyme IV Infusion, J0220 N/A N/A Medical N/A (alglucosidase alfa) Injection  Therapeutic Equivalent Myrbetriq Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (mirabegron) Criteria - New and Therapeutic Equivalent Medications Mysoline  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (primidone) Necessity Guidelines: Mysoline Mytesi  Prior Authorization/ Oral J8999 PBM Pharmacy N/A (crofelemer) Notification Guidelines: Mytesi

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Naftin 1% Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (naftifine hcl) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Naftin 2% gel Guidelines: Drug Coverage (naftifine Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Therapeutic Equivalent Namenda XR Guidelines: Drug Coverage (Memantine Capsule J8499 PBM N/A N/A Criteria - New and Therapeutic Hydrochloride) Equivalent Medications  Therapeutic Equivalent Namzaric Guidelines: Drug Coverage (memantine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Therapeutic Equivalent Naprelan J3490 and Guidelines: Drug Coverage (Naproxen Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic Sodium) Equivalent Medications Naprelan CR (Dose J3490 and Card) (Naproxen Tablet N/A N/A Pharmacy N/A J8499 Sodium)  Therapeutic Equivalent Narcan Nasal Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A Spray (naloxone) Criteria - New and Therapeutic Equivalent Medications Nasonex  Therapeutic Equivalent (mometasone Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A furoate Criteria - New and Therapeutic monohydrate) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Natesto Natesto  Therapeutic Equivalent (testosterone nasal Nasal Gel J3490 PBM Pharmacy N/A Guidelines: Drug Coverage gel) Criteria - New and Therapeutic Equivalent Medications Natpara  Prior Authorization/Medical (parathyroid Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Natpara hormone) Natrecor Injection J2325 N/A N/A Medical N/A (nesiritide)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Natroba (spinosad) Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (brand only) Suspension Criteria - New and Therapeutic Equivalent Medications *Benefit Notes: Not covered for cosmetic conditions. Not all Nava-SC groups have selected the Varies J3490 PBM N/A Pharmacy* (hydroquinone) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. NeoBenz Micro Liquid J3490 PBM N/A Pharmacy N/A (benzoyl peroxide)  Therapeutic Equivalent Neoral J7515, Guidelines: Drug Coverage (cyclosporine) Capsule J7502, PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) J8499 Equivalent Medications  Therapeutic Equivalent Neo-Synalar Guidelines: Drug Coverage (neomycin sulfate Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic and fluocinolone) Equivalent Medications  Therapeutic Equivalent Neo-Synalar kit Guidelines: Drug Coverage (neomycin sulfate Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic and fluocinolone) Equivalent Medications Neuac 1.2%-5% (clindamycin Topical J3490 N/A N/A Pharmacy N/A phosphate and benzoyl peroxide) Neuac 1.2%-5% kit (clindamycin Topical J3490 N/A N/A Pharmacy N/A phosphate and benzoyl peroxide) Pharmacy Benefit: If dispensed by a retail pharmacy or mail  Benefit Guidelines: Maximum order through PBM. Dosage Policy* Precertification is not required. Neulasta Injection, J2505 eviCore*  eviCore Guidelines: White See Notes *Medical Benefit: If provided in (pegfilgrastim) SQ Injection Blood Cell Colony Stimulating a hospital, MD's office, or in Factors* conjunction with home health care. Precertification through eviCore is required.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Pharmacy Benefit: If  eviCore Guidelines: White dispensed by a retail pharmacy Blood Cell Colony Stimulating or mail order through PBM. Factors** Precertification is required. Neupogen Injection, PBM*/ J1442  Therapeutic Equivalent See Notes **Medical Benefit: If provided (filgrastim) SQ Injection eviCore** Guidelines: Drug Coverage in a hospital, MD's office, or in Criteria - New and Therapeutic conjunction with home health Equivalent Medications* care. Precertification through eviCore is required. Capsule,  Prior Authorization/Medical Neurontin Tablet or J8499 PBM Necessity Guidelines: Pharmacy N/A (gabapentin) Oral Neurontin Solution Nevirapine  Therapeutic Equivalent extended release Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (nevirapine) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Nexavar (sorafenib years or older. All other oral Tablet J8999 PBM* Notification Guidelines: Pharmacy** tosylate) chemotherapy drugs do not Nexavar require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Nexavir Injection J3490 N/A N/A Medical N/A (kutapressin) Nexiclon XR Tablet, (clonidine J8499 N/A N/A Pharmacy N/A Suspension extended release) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Nexium Capsule J8499 N/A N/A N/A equivalent are excluded from (esomeprazole) coverage. Refer to the member specific benefit plan document as applicable.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Nexium  Prior Authorization/Medical Suspension Suspension J8499 PBM Necessity Guidelines: Non- Pharmacy N/A (esomeprazole) Solid Oral Dosage Forms  Therapeutic Equivalent Nicazeldoxy 30 kit Guidelines: Drug Coverage (Doxycycline plus Oral J8499 PBM Pharmacy N/A Criteria - New and Therapeutic MVI) Equivalent Medications Nicotine OTC Benefits for Tobacco Cessation products: for Health Care Reform apply to nicotine gum (e.g., all plans subject to health care Nicorette, Thrive), reform nicotine lozenge (e.g., Commit,  Prior Authorization/Medical Transdermal Nicorette), nicotine Necessity Guidelines: Tobacco Patch/Gum/ A9150 PBM Pharmacy patch (e.g., Cessation for Health Care Lozenge Nicoderm CQ), Reform Nicotrol Inhaler (nicotine inhalation system), Nicotrol NS (nicotine nasal spray)  Prior Authorization/Medical Benefits for Tobacco Cessation Nicotrol Inhaler Inhalation Necessity Guidelines: Tobacco for Health Care Reform apply to J3490 PBM Pharmacy* (nicotine) System Cessation for Health Care all plans subject to health care Reform reform  Prior Authorization/Medical Benefits for Tobacco Cessation Nicotrol NS Necessity Guidelines: Tobacco for Health Care Reform apply to Varies J3490 PBM Pharmacy* (nicotine) Cessation for Health Care all plans subject to health care Reform reform *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have Niferex (iron A9152 and vitamin/supplement coverage polysaccharide) or Capsule N/A N/A Pharmacy* A9153 through their prescription drug Niferex 150 Forte plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Ninlaro (ixazomib) Capsule J8999 PBM Notification Guidelines: Pharmacy N/A Ninlaro  Therapeutic Equivalent Nitroglycerin spray Guidelines: Drug Coverage (generic Spray J8499 PBM Pharmacy N/A Criteria - New and Therapeutic nitrolingual) Equivalent Medications  Therapeutic Equivalent Nitrolingual Pump Guidelines: Drug Coverage Spray Spray J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (nitroglycerin) Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Nityr (nitisinone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Norditropin AQ Injection J2941 PBM Necessity Guidelines: Pharmacy N/A (Somatropin) Norditropin (somatropin)  Prior Authorization/Medical Necessity Guidelines: Norditropin (somatropin) Norditropin Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (Somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Norditropin FlexPro Pen Guidelines: Drug Coverage J2941 PBM Pharmacy N/A (somatropin) Injection Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Norditropin NordiFlex (somatropin) Pen NordiFlex J2941 PBM  Therapeutic Equivalent Pharmacy N/A Injection (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Noritate Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (metronidazolel) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Northera Capsule J8499 PBM Necessity Guidelines: Pharmacy N/A (droxidopa) Northera

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Novarel (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with gonadotropin) J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Noxafil Tablet J8499 N/A N/A Pharmacy N/A (posaconazole) Sub- J3490, Oxford’s  Precertification Guidelines: Nucala cutaneous J3590, and Medical Respiratory Interleukins (Cinqair Medical N/A (mepolizumab) Injection J2182 Management and Nucala) Nucynta ER  Prior Authorization/Medical (tapentadol Tablet J8499 PBM Necessity Guidelines: Nucynta Pharmacy N/A extended release) ER Nuplazid  Prior Authorization/ (pimavanserin Tablet J8499 N/A Notification Guidelines: Pharmacy N/A tartrate) Nuplazid Nutritonal Therapy, Formula and IV Infusion, Oxford’s  Precertification Guidelines: *Benefit is State Specific. Specialized Foods, Oral Tube Varies Medical See Notes* Formula & Specialized Food Medical Benefit/Pharmacy Benefit Parenteral Feed Management Nutrition Therapy  Prior Authorization/Medical NuSpin Injection J2941 PBM Necessity Guidelines: NuSpin Pharmacy N/A (somatropin) (somatropin) Nutropin and  Prior Authorization/Medical Nutropin AQ Injection J2941 PBM Necessity Guidelines: Nutropin Pharmacy N/A (somatropin) and Nutropin AQ (somatropin)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Nuvaring have contraceptive coverage  Benefit Guidelines: (etonogestrel/ Vaginal Ring J7303 N/A Pharmacy* through their prescription drug Contraceptives ethinyl estradiol) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Nuvessa Guidelines: Drug Coverage Vaginal Gel J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Nuvigil Nuvigil (armodafinil) (armodafinil) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nymalize Oral J3490 N/A N/A Pharmacy N/A (nimodipine) Solution  Therapeutic Equivalent Nystatin/triamcinol Guidelines: Drug Coverage one (generic Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Mycolog II) cream Equivalent Medications Nystatin/triamcinol  Therapeutic Equivalent one (generic Guidelines: Drug Coverage Ointment J3490 PBM Pharmacy N/A Mycolog II) Criteria - New and Therapeutic ointment Equivalent Medications Obredon solution Oral  Step Therapy Guidelines: (hydrocodone/ J8499 PBM Pharmacy N/A Solution Obredon guaifenesin) Ocaliva (obeticholic  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A acid) Necessity Guidelines: Ocaliva Oxford’s  Precertification Guidelines: Ocrevus Injection J3590 Medical Ocrevus (Ocrelizumab) Medical N/A (Ocrelizumab) Management

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Precertification Guidelines: o Immune Globulin (IVIG) and Octagam (immune Oxford’s SCIG globulin, Non- IV Infusion J1568 Medical o Immune Globulin Site of Medical N/A lyophilized) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Odactra (house Sublingual  Prior Authorization/Medical dust mite allergen J8499 PBM Pharmacy N/A Tablet Necessity Guidelines: Odactra extract) Odefsey (emtricitabine/ Tablet J8499 N/A N/A Pharmacy N/A rilpivirine/ tenofovir)  Prior Authorization/ Odomzo Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (sonidegib) Odomzo  Prior Authorization/Medical Ofev (nintedanib) Capsule J8499 PBM Necessity Guidelines: Ofev Pharmacy N/A (nintedanib) Oforta (fludarabine Oral J8562 N/A N/A Pharmacy N/A phosphate)  Therapeutic Equivalent Oleptro (trazodone Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride) Criteria - New and Therapeutic Equivalent Medications Oleptro ER (trazodone Tablet J8499 N/A N/A Pharmacy N/A hydrochloride ER) Olmesartan Tablet J8499 N/A N/A Pharmacy N/A (generic Benicar) Omesartan/ hydrochloro- Tablet J8499 N/A N/A Pharmacy N/A thiazide (generic Benicar HCT)  Therapeutic Equivalent Olux (clobetasol Guidelines: Drug Coverage Foam J3490 PBM Pharmacy N/A propionate) Criteria - New and Therapeutic Equivalent Medications Olux-CP (clobetasol Foam J3490 N/A N/A Pharmacy N/A propionate)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Olux-E (clobetasol Guidelines: Drug Coverage Foam J3490 PBM Pharmacy N/A propionate) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Olysio (simeprevir) Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Olysio Omeclamox-Pak  Therapeutic Equivalent (omeprazole, Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A clarithromycin, Criteria - New and Therapeutic amoxicillin) Equivalent Medications Omeprazole Capsule J8499 N/A N/A Pharmacy N/A (generic) Note: Prescription drugs for which there is a therapeutic Omeprazole/ over-the-counter (OTC) sodium Capsule J8499 N/A N/A N/A equivalent are excluded from bicarbonate coverage. Refer to the member (generic) specific benefit plan document as applicable.  Therapeutic Equivalent Omnaris Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A (ciclesonide) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Omnitrope (somatropin) Omnitrope Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Omtryg (omega-3- Notification Guidelines: Capsule J8499 PBM Pharmacy N/A acid ethyl esters A) Omtryg

Onexton 1.2-  Therapeutic Equivalent 3.75% Guidelines: Drug Coverage (clindamycin Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic phosphate and Equivalent Medications benzoyl peroxide)  Prior Authorization/ Onfi (clobazam) Oral J8999 PBM Pharmacy N/A Notification Guidelines: Onfi

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Onmel Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (itraconazole) Criteria - New and Therapeutic Equivalent Medications Onsolis (fentanyl Film J8499 N/A N/A Pharmacy N/A buccal soluble film)  Supply Limit Guidelines: Triptans Supply Limits Onzetra Xsail Nasal  Therapeutic Equivalent J3490 PBM Pharmacy N/A (sumatriptan) Powder Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Opana ER  Prior Authorization/Medical (oxymorphone Tablet J8499 PBM Necessity Guidelines: Opana Pharmacy N/A extended release) ER Opsumit  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (macitentan) Necessity Guidelines: Opsumit  Therapeutic Equivalent Optivar (brand Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A only) (azelastine) Drops Criteria - New and Therapeutic Equivalent Medications Oralair (Sweet Vernal, Orchard,  Prior Authorization/Medical Perennial Rye, Necessity Guidelines: Oralair Timothy and Sublingual (Sweet Vernal, Orchard, J8499 PBM Pharmacy N/A Kentucky Blue Tablet Perennial Rye, Timothy and Grass, Mixed Kentucky Blue Grass Mixed Pollens Allergen Pollens Allergen Extract) Extract) Oramorph Oral J8499 N/A N/A Pharmacy N/A (morphine) Solution Orbivan (butalbital, acetaminophen, Oral J8499 N/A N/A Pharmacy N/A and caffeine) Hospital Outpatient Facility:  Precertification Guidelines: Administration of Orencia in a o Orencia® (Abatacept) hospital outpatient facility Oxford’s Injection for Intravenous (including any ambulatory Orencia Intravenous J0129 Medical Infusion Medical infusion suite associated with the (abatacept) Management o Specialty Medication hospital) requires precertification Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Administration – Site of Care Review Guidelines  Prior Authorization/ Orencia Notification Guidelines: SQ Injection J3590 PBM Pharmacy N/A (abatacept) Orencia  Step Therapy: Orencia  Prior Authorization/Medical Orenitram N/A Tablet J8499 PBM Necessity Guidelines: Pharmacy (treprostinil) Orenitram  Prior Authorization/ Orfadin (nitisinone) Capsule J8499 PBM Pharmacy N/A Notification Guideline: Orfadin Orkambi™  Prior Authorization/Medical (lumacaftor/ Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Orkambi ivacaftor) Orkambi 100-125  Therapeutic Equivalent mg tablet only Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (lumacaftor/ivacaft Criteria - New and Therapeutic or) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Ortho Cept (ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives desogestrel) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Ortho Cyclen have contraceptive coverage  Benefit Guidelines: (ethinyl estradiol Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives and norgestimate) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Ortho Novum have contraceptive coverage  Benefit Guidelines: (ethinyl estradiol Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives and norethindrone) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug Ortho-Evra plan. If the Member does not (Generic) (Ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Patch J7304 N/A Pharmacy* through their prescription drug Contraceptives norelgestromin plan, then these are not covered. transdermal) Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug  Benefit Guidelines: Ortho-Evra (Brand plan. If the Member does not Contraceptives Only) (Ethinyl have contraceptive coverage  Therapeutic Equivalent estradiol and Patch J7304 PBM Pharmacy* through their prescription drug Guidelines: Drug Coverage norelgestromin plan, then these are not covered. Criteria - New and Therapeutic transdermal) Members should refer to their Equivalent Medications Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug  Benefit Guidelines: plan. If the Member does not Ortho Tri- Contraceptives have contraceptive coverage Cyclen/Lo (ethinyl  Therapeutic Equivalent Pill S4993 N/A Pharmacy* through their prescription drug estradiol and Guidelines: Drug Coverage plan, then these are not covered. norgestimate) Criteria - New and Therapeutic Members should refer to their Equivalent Medications Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification with review by a Intra- Oxford’s Medical Director or their Orthovisc (sodium  Precertification Guidelines: Articular J7324 Medical Medical Designee is required in all sites of hyaluronate) Sodium Hyaluronate Injection Management* service for J7321, J7324 and J7326.  Prior Authorization/Medical Otezla (apremilast) Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Otezla Otic Care Ophthalmic (neomycin/ J3490 N/A N/A Pharmacy N/A Drops polymyxin-B HC) Otovel  Therapeutic Equivalent (ciprofloxacin and Otic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A fluocinolone Solution Criteria - New and Therapeutic acetonide) Equivalent Medications  Step Therapy Guidelines: Otrexup Otrexup  Therapeutic Equivalent (methotrexate Injection J3490 PBM Pharmacy N/A Guidelines: Drug Coverage injection) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Ovace Plus 9.8% Guidelines: Drug Coverage lotion (sodium Lotion J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfacetamide) Equivalent Medications  Therapeutic Equivalent Ovace Plus foam Topical Guidelines: Drug Coverage (sodium J3490 PBM Pharmacy N/A Foam Criteria - New and Therapeutic sulfacetamide) Equivalent Medications *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility Precertification  Precertification Guidelines: diagnosis code. Ovidrel (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and gonadotropin) J3490 may be Medical** **Benefit Note: Coverage is Treatment required* limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Coverage for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage Ovrette  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug (Norgestrel) Contraceptives plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Oxandrin Tablet J8499 N/A N/A Pharmacy N/A (oxandrolone)  Therapeutic Equivalent Oxaydo Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (oxycodone hcl) Criteria - New and Therapeutic Equivalent Medications Oxistat  Prior Authorization/Medical (oxiconazole Cream J3490 PBM Pharmacy N/A Necessity Guidelines: Oxistat nitrate)  Therapeutic Equivalent Oxistat Guidelines: Drug Coverage (oxiconazole Lotion J3490 PBM Pharmacy N/A Criteria - New and Therapeutic nitrate) Equivalent Medications Oxtellar XR  Prior Authorization/Medical (oxcarbazepine Tablet J8499 PBM Necessity Guidelines: Oxteller Pharmacy N/A extended release) XR Oxycontin  Prior Authorization/Medical (oxycodone Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A extended release) Oxycontin  Prior Authorization/Medical Oxycodone ER Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A 12HR Tablet Oxycodone ER  Prior Authorization/Medical Oxymorphone Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A extended release Oxymorphone

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Oxytrol Tablet J8499 N/A N/A N/A equivalent are excluded from (oxybutynin) coverage. Refer to the member specific benefit plan document as applicable. Ozurdex Intravitreal J7312 N/A N/A Medical N/A (dexamethasone) Implant Pacnex HP and Pacnex LP (benzoyl Topical J3490 N/A N/A Pharmacy N/A peroxide) Pancreaze  Step Therapy Guidelines: Capsule J3490, PBM Pharmacy N/A (pancrelipase) Pancreaze Pantoprazole Tablet J8499 N/A N/A Pharmacy N/A (generic)  Therapeutic Equivalent Parlodel Guidelines: Drug Coverage (bromocriptine Tablet J3490 PBM Pharmacy N/A Criteria - New and Therapeutic mesylate) Equivalent Medications  Therapeutic Equivalent Pataday Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (olopatadine) Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Patanol Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (olopatadine HCL) Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Pazeo (olopatadine Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A hydrochloride) Solution Criteria - New and Therapeutic Equivalent Medications Pcp 100 Kit (magesium citrate,  Therapeutic Equivalent bisacodyl, Guidelines: Drug Coverage petrolatum, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic polyethylene glycol Equivalent Medications 3350, metoclopramide)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Pediaderm AF  Therapeutic Equivalent (nystatin) and Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A Pediaderm TA Criteria - New and Therapeutic (triamcinolone) Equivalent Medications  Therapeutic Equivalent Pediprox-4 Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (benzalkonium) Criteria - New and Therapeutic Equivalent Medications Pegasys  Prior Authorization/ (peginterferon Injection J3490 PBM Notification Guidelines: Pharmacy N/A Alfa-2a) Pegasys (peginterferon alfa-2a) Peg-Intron  Prior Authorization/ (peginterferon Injection J3490 PBM Notification Guidelines: PEG- Pharmacy N/A Alfa-2b) Intron (peginterferon alfa-2b) Penicillin g *Precertification Note: J2540 potassium Precertification is only required Oxford’s  Precertification Guidelines: only when used in the treatment IV Infusion Medical Medical Penicillin g Lyme Disease of Lyme disease. J2510 Management* procaine, Aqueous Exception: Precertification is not required for CT Members.  Therapeutic Equivalent Penlac Nail Lacquer Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (ciclopirox) (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Pennsaid 1.5% Guidelines: Drug Coverage Drops (diclofenac Drops J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Pennsaid 2% Topical Guidelines: Drug Coverage (diclofenac J3490 PBM Pharmacy N/A Solution Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Pentasa Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (mesalamine) Criteria - New and Therapeutic Equivalent Medications Percocet  Therapeutic Equivalent (acetaminophen Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A and oxycodone) Criteria - New and Therapeutic (brand only) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification Note: HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification **Benefit Note: Coverage is  Precertification Guidelines: Pergonal S0122* and through Optum Pharmacy/ limited to Members with Injection Infertility Diagnosis and (menotropins) J3490 may be Medical** coverage for fertility drugs Treatment required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Pertzye  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (pancrelipase) Pertzye  Prior Authorization/Medical Pexeva (paroxetine Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A mesylate) Brand Medications Oxford *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have Phoslo (calcium vitamin/supplement coverage Capsule J8499 N/A N/A Pharmacy* acetate) through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Planzapine, long Injection J2358 N/A N/A Medical N/A acting  Therapeutic Equivalent Plavix (clopidogrel) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Plegridy Pen &  Prior Authorization/ Prefilled Syringe Injection J3490 PBM Notification Guidelines: Pharmacy N/A (peginterferon Plegridy beta-1a)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Plexion 9.8-4.8%  Therapeutic Equivalent cream, liquid, Guidelines: Drug Coverage lotion Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (sulfacetamide/ Equivalent Medications sulfur) Plexion Cloth  Therapeutic Equivalent 9.8%-4.8% pads Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (sulfacetamide/ Criteria - New and Therapeutic sulfur) Equivalent Medications *Coverage is limited to Members with coverage for fluoride vitamins through their Poly-Vi-Flor/Iron, prescription drug plan. If the Polyvitamin Member does not have fluoride w/Fluoride, Tri-Vi- Tablet, Oral vitamin coverage through their Flor/Iron, J3490 N/A N/A Pharmacy* Solution prescription drug plan, then Trivitamin these are not covered. Members w/Fluoride, and Vi- should refer to their Certificate of Daylin Coverage or Prescription Drug Rider language for coverage guidelines. Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Pomalyst years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (pomalidomide) chemotherapy drugs do not Pomalyst require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Potiga (Ezogabine) Tablet J8499 PBM Notification Guidelines: Potiga Pharmacy N/A (Ezogabine)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have Potaba Capsule, vitamin/supplement coverage (aminobenzoate Tablet or J8499 N/A N/A Pharmacy* through their prescription drug potassium) Powder plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Prior Authorization/Medical Praluent Injection J3490 PBM Necessity Guidelines: Praluent Pharmacy N/A (alirocumab) (alirocumab)  Therapeutic Equivalent Pramosone E Guidelines: Drug Coverage (hydrocortisone Topical J3490 PBM* Pharmacy N/A Criteria - New and Therapeutic and pramoxine) Equivalent Medications *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Pregnyl (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with gonadotropin) J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines.  Therapeutic Equivalent Prescription Guidelines: Drug Coverage Emollients/ Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Mosturizers Equivalent Medications  Therapeutic Equivalent Prestalia Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (perindopril) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Prevacid (lansoprazole)  Prior Authorization/Medical Solutab Tablet J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Lansoprazole Solid Oral Dosage Forms generic Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Prevacid Capsule J3490 N/A N/A N/A equivalent are excluded from (lansoprazole) coverage. Refer to the member specific benefit plan document as applicable. Prevpac ((lansoprazole 30-  Therapeutic Equivalent mg) (amoxicillin Capsule/ Guidelines: Drug Coverage J8499 PBM* Pharmacy N/A 500-mg) , Tablet Criteria - New and Therapeutic (clarithromycin Equivalent Medications 500-mg) Prezcobix (darunavir/ Tablet J8499 N/A N/A Pharmacy N/A cobicistat) Prilosec Capsule J8499 PBM N/A Pharmacy N/A (omeprazole)  Therapeutic Equivalent Prilosec Guidelines: Drug Coverage Suspension Suspension J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (omeprazole) Equivalent Medications *Step Therapy coverage criteria is for groups on the Essential PDL Pristiq  Step Therapy Guidelines: only. More information about if (desvenlafaxine Tablet J8499 PBM Pharmacy Pristiq* this program applies can be succinate) found on myuhc.com or by calling customer service.  Precertification Guidelines: o Immune Globulin (IVIG) and Oxford’s SCIG Privigen (immune IV Infusion J1459 Medical o Immune Globulin Site of Medical N/A globulin) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes

ProAir Respimat Inhaler J3490 N/A N/A Pharmacy N/A (albuterol)

J3490, Oxford’s Probuphine Subdermal  Precertification Guidelines: J0570, and Medical Medical N/A (buprenorphine) Implant Probuphine® (Buprenorphine) 11981 Management  Prior Authorization/ Procentra (dextro- Oral J8499 PBM Notification Guidelines: Pharmacy N/A amphetamine) Solution Procentra Benefit Note for Infertility Use *Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility Prochieve Gel J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progesterone gel) Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Procort  Therapeutic Equivalent (hydrocortisone Guidelines: Drug Coverage Topical J3490 PBM* Pharmacy N/A acetate and Criteria - New and Therapeutic pramoxine HCl) Equivalent Medications  Therapeutic Equivalent Proctocort Rectal Guidelines: Drug Coverage (hydrocortisone) J3490 PBM Pharmacy N/A Cream Criteria - New and Therapeutic (brand) Equivalent Medications Capsule,  Prior Authorization/ Procysbi Delayed Notification Guidelines: (cysteamine J8499 PBM Pharmacy N/A Release Procysbi (cysteamine bitartrate) bitartrate) Pellet  Step Therapy: Procysbi Prodrin  Therapeutic Equivalent (acetaminophen/ Guidelines: Drug Coverage Caplet J8499 PBM* Pharmacy N/A caffeine/ Criteria - New and Therapeutic isometheptene) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Profasi (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with gonadotropin) J3490 may be Medical** Treatment coverage for fertility drugs required** through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Progesterone Injection J3490 N/A N/A Medical N/A  Therapeutic Equivalent Prograf J7503, Guidelines: Drug Coverage (tacrolimus) Capsule J7507, PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) J8499 Equivalent Medications  Therapeutic Equivalent Prolensa Opthalmic Guidelines: Drug Coverage (Bromfenac J3490 PBM* Pharmacy N/A Solution Criteria - New and Therapeutic Ophthalmic) Equivalent Medications Prolia, Xgeva Injection J0897 N/A N/A Medical N/A (denosumab)  Prior Authorization/ Promacta Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Eltrombopag) Promacta  Therapeutic Equivalent Promiseb Complete Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Kit (Promiseb) Criteria - New and Therapeutic Equivalent Medications *Benefit Notes: Not covered for cosmetic conditions. Not all Propecia, groups have selected the Varies J3490 PBM N/A Pharmacy* finasteride) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Proscar J8499 and Tablet N/A N/A Pharmacy N/A (finasteride) S0138

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Protein C [human] IV Infusion J2724 N/A N/A Medical N/A concentrate  Therapeutic Equivalent Protonix Guidelines: Drug Coverage (Pantoprazole) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Protonix Granules Guidelines: Drug Coverage for Suspension Oral J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (pantoprazole) Equivalent Medications  Prior Authorization/ Notification Guidelines: Protopic (tacrolimus) Protopic Topical J8499 PBM  Therapeutic Equivalent Pharmacy N/A (tacrolimus) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Provigil (modafanil) Provigil (modafinil) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Provigil (modafinil) Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (generic) Provigil (modafanil)  Therapeutic Equivalent Prozac (fluoxetine) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Prozena 4% patch Topical J3490 N/A N/A Pharmacy N/A (lidocaine) Patch  Prior Authorization/ Topical Prudoxin (doxepin) J3490 PBM Notification Guidelines: Pharmacy N/A Cream Prudoxin Pulmicort Flexhaler Inhalation  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (budesonide) Powder Pulmicort  Prior Authorization/ Pulmozyme® Inhalation 7639 PBM Notification Guidelines: Pharmacy N/A (Dornase Alfa) Solution Pulmozyme (dornase alfa)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit Medical Benefit for Members Oxford’s  Precertification Guidelines: without a Pharmacy Benefit. Puregon (follitropin IM or SQ S0128 Medical Infertility Diagnosis and See Notes* *NY Plans: Pharmacy Benefit.* beta) Injection Management Treatment *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.  Prior Authorization/Medical Purixan 20mg/ml Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A (mercaptopurine) Suspension Solid Oral Dosage Forms  Prior Authorization/Medical Oral Qbrelis (lisinopril) J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Solution Solid Oral Dosage Forms  Therapeutic Equivalent Qnasl Guidelines: Drug Coverage (beclomethasone Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic dipropionate) Equivalent Medications  Therapeutic Equivalent Quartette (ethinyl Guidelines: Drug Coverage estradiol/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic levonorgestrel) Equivalent Medications  Prior Authorization/Medical Qudexy XR Capsule J8499 PBM Necessity Guidelines: Qudexy Pharmacy N/A (topiramate) XR  Prior Authorization/ Notification Guidelines: Quillichew ER Quillichew ER (methylphenidate Chewable J8499 PBM  Therapeutic Equivalent Pharmacy N/A hcl) extended Tablet Guidelines: Drug Coverage release Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Quillivant XR Quillivant XR (methylphenidate Liquid J8499 PBM  Therapeutic Equivalent Pharmacy N/A HCL) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Qutenza (capsaicin Patch J3490 N/A N/A Pharmacy N/A 8% patch)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Rabeprazole Tablet J8499 N/A N/A Pharmacy N/A (generic)  Precertification Guidelines: Oxford’s o RadicavaTM (Edaravone) Radicava Intravenous J3490 Medical o Specialty Medication Medical N/A (edaravone) injection Management Administration - Site of Care Review Guidelines  Prior Authorization/Medical Ragwitek (Short Sublingual Necessity Guidelines: Ragweed Pollen J8499 PBM Pharmacy N/A Tablet Ragwitek (Short Ragweed Pollen Allergen Extract) Allergen Extract)  Prior Authorization/ Raloxifene Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (generic) Raloxifene Tablet  Therapeutic Equivalent Rapamune J7520, Guidelines: Drug Coverage (sirolimus) (brand PBM Pharmacy N/A J8499 Criteria - New and Therapeutic only) Equivalent Medications Rasuvo Auto-  Step Therapy Guidelines: (methotrexate J3490 PBM Pharmacy N/A Injector Rasuvo injection) Ravicti (Glycerol  Prior Authorization/Medical Phenylbutyrate Oral Liquid J3490 PBM Pharmacy N/A. Necessity Guidelines: Ravicti Oral Liquid)  Therapeutic Equivalent Rayaldee Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (calcifediol) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Rayos (delayed- Guidelines: Drug Coverage release Tablet J3490 PBM Pharmacy N/A Criteria - New and Therapeutic prednisone) Equivalent Medications J3490 and Rebetol (ribavirin) Tablet N/A N/A Pharmacy N/A J3590 J1826,  Prior Authorization/ Rebif (interferon Injection, Q3025 and PBM Notification Guidelines: Rebif Pharmacy N/A beta-1a) SQ Injection Q3026  Step therapy: Rebif  Medical Management Reclast (zoledronic IV Infusion J3489 N/A Guidelines: Maximum Dosage Medical N/A acid) Policy Rectiv (nitroglycerin Ointment J3490 N/A N/A Pharmacy N/A ointment)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM.  Precertification Guidelines: PBM* Precertification through the PBM Platelet Derived Growth Factors Oxford’s is required. Regranex for Treatment of Wounds** Pharmacy* Gel S0157 Medical **Medical Benefit: If provided (becaplermin gel)  Prior Authorization/ Medical** Manage- in a hospital, MD's office, or in Notification Guidelines: ment** conjunction with Home Health Regranex (becaplermin) Care. Precertification through Oxford’s Medical Management is required. Relenza Oral Inhaler J3490 N/A N/A Pharmacy N/A (zanamivir) Relistor  Prior Authorization/Medical (methylnatrexone Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Relistor bromide) Relistor  Prior Authorization/Medical (methylnaltrexone Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Relistor bromide) **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require  Supply Limit Guidelines: Relpax (eletriptan) Tablet J3490 PBM** Pharmacy* precertification. Triptans Supply Limits *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification Note: No precertification required in office. Precertification is required for outpatient and home setting.  Precertification Guidelines: Hospital Outpatient Facility: o Infliximab (Remicade®, Administration of Remicade in a Oxford’s Inflectra™, Renflexis™) hospital outpatient facility Remicade Intravenous J1745 Medical o Maximum Dosage Policy Medical (including any ambulatory (infliximab) Management* o Specialty Medication infusion suite associated with the Administration – Site of Care hospital) requires precertification Review Guidelines with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines *Precertification Note: Precertification is required in all sites of service.  Medical Management Hospital Outpatient Facility: Guidelines: Maximum Dosage Administration of Renflexis in a Policy hospital outpatient facility Oxford’s  Precertification Guidelines: Renflexis (including any ambulatory Injection Q5102-ZC Medical o Infliximab (Remicade®, Medical (infliximab) infusion suite associated with the Management* Inflectra™, Renflexis™) hospital) requires precertification o Specialty Medication with review by a Medical Director Administration – Site of Care or their designee. Refer to: Review Guidelines Specialty Medication Administration – Site of Care Review Guidelines **Precertification Note: Precertification is not required for Members under 30 years of age.  Prior Authorization/ *Benefit Notes: Not covered for Renova (tretinoin) Varies S0117 PBM** Notification Guidelines: Retin- Pharmacy* cosmetic conditions. Not all A and Retin-A Micro (tretinoin) groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Repatha  Prior Authorization/Medical Injection J3490 PBM Pharmacy N/A (evolocumab) Necessity Guidelines: Repatha Repository Injection J3490 and  Prior Authorization/Medical Corticotropin self- PBM Pharmacy N/A J0800 Necessity Guidelines: Acthar Injection administered

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes (H.P.Acthar Gel) Injection by Oxford’s  Precertification Guidelines: a medical Medical Repository Corticotropin Medical N/A professional Management Injection (H.P. Acthar Gel)  Therapeutic Equivalent Requip XL J8499 and Guidelines: Drug Coverage (ropinirole Tablet PBM Pharmacy N/A J3490 Criteria - New and Therapeutic extended release) Equivalent Medications Rescula Ophthalmic  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (unoprostone) Solution Rescula Restasis  Prior Authorization/Medical (cyclosporine Ophthalmic Necessity Guidelines: Restasis ophthalmic J3490 PBM Pharmacy N/A Solution (cyclosporine ophthalmic emulsion) single- emulsion) use vials Restasis  Prior Authorization/Medical (cyclosporine Necessity Guidelines: Restasis ophthalmic (cyclosporine ophthalmic emulsion) (multi- Ophthalmic emulsion)\ J3490 PBM Pharmacy N/A use) Solution  Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Retin- A and Retin-A Micro (tretinoin) Retin-A (tretinoin) Topical S0117, PBM  Therapeutic Equivalent Pharmacy N/A (brand only) Cream J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Retin- Retin-A (tretinoin) A and Retin-A Micro (tretinoin) S0117, (brand and Topical Gel PBM  Therapeutic Equivalent Pharmacy N/A J3490 generic) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Retin- A and Retin-A Micro (tretinoin) Retin-A Micro Topical S0117 PBM  Therapeutic Equivalent Pharmacy N/A (tretinoin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Notification Guidelines: Retin- Retin-A Micro A and Retin-A Micro (tretinoin) Pump (tretinoin) Topical S0117 PBM  Therapeutic Equivalent Pharmacy N/A (brand and Guidelines: Drug Coverage generic) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Revatio (sildenafil Tablet J3490 PBM Necessity Guidelines: Revatio Pharmacy N/A citrate) (sildenafil citrate)  Prior Authorization/Medical Necessity Guidelines: Revatio (sildenafil citrate) Revatio (sildenafil Oral J3490 PBM  Therapeutic Equivalent Pharmacy N/A citrate) 10mg/ml Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Revlimid years or older. All other oral Oral J8999 PBM Notification Guidelines: Pharmacy** (lenalidomide) chemotherapy drugs do not Revlimid require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Rexaphenac 1% Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A cream (diclofenac) Criteria - New and Therapeutic Equivalent Medications Rexulti  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (brexpiprazole) Necessity Guidelines: Rexulti  Therapeutic Equivalent Rhinocort Aqua Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A (budesonide) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Rho(D) (immune globulin) BayRHo- J2788, D, Gamulin Rh, J2790, HypRho-D Mini-  Medical Management IV Infusion, J2791, Dose, MICRhoGAM, N/A Guidelines: Intravenous Medical N/A IM Injection J2792, and Mini-Gamulin Rh, Immunoglobulin (IVIg) and SCIG 90384- RhoGAM, 90386 Rhophylac, WinRho SDF  Therapeutic Equivalent Rhofade Topical Guidelines: Drug Coverage (oxymetazoline J3490 PBM Pharmacy N/A Cream Criteria - New and Therapeutic hydrochloride) Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Riax (benzoyl Topical J3490 N/A N/A Pharmacy equivalent are excluded from peroxide) Foam coverage. Refer to the member specific benefit plan document as applicable.  Therapeutic Equivalent Guidelines: Drug Coverage Ribapak (ribavirin) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications J3490, Ribasphere Capsule J3590 and N/A N/A Pharmacy N/A (ribavirin) J8499  Therapeutic Equivalent Risperdal Guidelines: Drug Coverage (risperidone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Ritalin  Prior Authorization/ Tablet J8499 PBM Pharmacy N/A (methylphenidate) Notification Guidelines: Ritalin  Prior Authorization/ Ritalin LA Notification Guidelines: Ritalin (methylphenidate LA hydrochloride Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A [extended Guidelines: Drug Coverage release]) (brand Criteria - New and Therapeutic and generic) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Ritalin SR  Prior Authorization/ (methylphenidate Tablet J8499 PBM Notification Guidelines: Ritalin Pharmacy N/A [controlled- SR release])  eviCore Guidelines: Injectable Chemotherapy Drugs: Oxford’s Application of NCCN Clinical *For Oncology and Non- Rituxan Infusion J9310 Medical Practice Guidelines Medical Oncology Use: Precertification (rituximab) Management*  Precertification Guidelines: is required. o Maximum Dosage Policy o Rituxan® (Rituximab) **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require  Supply Limit Guidelines: Rizatriptan Tablet J8499 PBM** Pharmacy* precertification. Triptans Supply Limits *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Rocaltrol Capsule, S0169 N/A N/A Pharmacy N/A (calcitriol) Liquid *Benefit Notes: Not covered for cosmetic conditions. Not all J3490 and groups have selected the Rogaine (minoxidil) Varies PBM N/A Pharmacy* S0139 standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Therapeutic Equivalent Rosadan kit Guidelines: Drug Coverage Cream/Gel J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Rosula (sodium Topical Guidelines: Drug Coverage sulfacetamide J3490 PBM Pharmacy N/A Wash Criteria - New and Therapeutic 10%/sulfur 4%) Equivalent Medications Rosuvastatin Tablet J8499 N/A N/A Pharmacy N/A (generic Crestor)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Rozerem  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (ramelteon) Rozerem (ramelteon) J8999 PBM  Prior Authorization/ Rubraca Pharmacy N/A Tablet Notification Guidelines: (rucaparib) Rubraca Ruconest (C1  Prior Authorization/ J0596 and esterase inhibitor Injection PBM Notification Guidelines: Pharmacy N/A J3490 [Recombinant]) Ruconest Rybix ODT (tramadol Tablet J8499 N/A N/A Pharmacy N/A hydrochloride)  Prior Authorization/ Rydapt Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (midostaurin) Rydapt  Therapeutic Equivalent Rytary (carbidopa Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A and levodopa) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Ryvent Guidelines: Drug Coverage (carbinoxamine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic maleate) Equivalent Medications Ryzolt (tramadol hydrochloride Tablet J8499 N/A N/A Pharmacy N/A Extended release) Oral  Prior Authorization/ Sabril (vigabatrin) J8499 PBM Pharmacy N/A Solution Notification Guidelines: Sabril Safyral  Therapeutic Equivalent (drospirenone/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A ethinyl estradiol/ Criteria - New and Therapeutic levomefolate) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Saizen (somatropin) Saizen Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sancuso  Therapeutic Equivalent (granisetron Guidelines: Drug Coverage Patch J3490 PBM Pharmacy N/A transdermal Criteria - New and Therapeutic system) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Sanctura (trospium) (brand  Therapeutic Equivalent and generic) and Guidelines: Drug Coverage Sanctura XR Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (trospium chloride) Equivalent Medications (brand and generic)  Therapeutic Equivalent Sandimmune J7502, Guidelines: Drug Coverage (cyclosporine) Capsule J7515, PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) J8499 Equivalent Medications Sandostatin  Prior Authorization/ SQ or IV (octreotide J2354 PBM Notification Guidelines: Pharmacy N/A Injection acetate) Sandostatin **Precertification is required through eviCore for oncology Oxford’s Sandostatin LAR  Precertification Guidelines: indications. Medical Depot (octreotide IM Injection J2353 Sandostatin, Sandostatin LAR Medical *Precertification is required Management*/ acetate) DEPOT (octreotide acetate) through Oxford’s Medical eviCore** Management for all other indications. Saphris Oral J8499 N/A N/A Pharmacy N/A (asenapine) Savaysa Tablet J8499 N/A N/A Pharmacy N/A (edoxaban) Savella Tablet J8499 N/A N/A Pharmacy N/A (milnacipran) Seebri Neohaler Inhalation J3490 N/A N/A Pharmacy N/A (glycopyrrolate) Powder Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Selrx (selenium Shampoo J3490 N/A N/A N/A equivalent are excluded from sulfide) coverage. Refer to the member specific benefit plan document as applicable.  Prior Authorization/ Selzentry Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Maraviroc) Selzentry Sensipar  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (cinacalcet) Necessity Guidelines: Sensipar

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Sernivo spray Topical Guidelines: Drug Coverage (betamethasone J3490 PBM Pharmacy N/A Spray Criteria - New and Therapeutic dipropionate) Equivalent Medications Seroquel  Therapeutic Equivalent (quetiapine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A fumarate) (brand Criteria - New and Therapeutic only) Equivalent Medications *Step Therapy coverage criteria is for groups on the Essential PDL Seroquel XR  Step Therapy Guidelines: only. More information about if Tablet J8499 PBM Pharmacy (quetiapine) Seroquel XR* this program applies can be found on myuhc.com or by calling customer service.  Prior Authorization/Medical Serostim Injection, J2941 PBM Necessity Guidelines: Pharmacy N/A (somatropin) SQ Injection Serostim (somatropin) Signifor  Prior Authorization/ (pasireotide SQ Injection J3490 PBM Notification Guidelines: Pharmacy N/A diaspartate) Signifor  Prior Authorization/Medical Sildenafil citrate Tablet J8499 PBM Necessity Guidelines: Revatio Pharmacy N/A (generic Revatio) (sildenafil citrate)  Therapeutic Equivalent Silenor (doxepin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Medical Necessity Guidelines: Siliq  Therapeutic Equivalent Siliq (brodalumab) Injection J3490 PBM Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Simbrinza 1-0.2% Opthalmic Guidelines: Drug Coverage (Brimonidine and J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic Brinzolamide) Equivalent Medications  Prior Authorization/ Simponi SQ Injection J3490 PBM Notification Guidelines: Pharmacy N/A (golimumab) Simponi (golimumab)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Hospital Outpatient Facility: Administration of Simponi Aria in a hospital outpatient facility (including any ambulatory Oxford’s infusion suite associated with the Simponi Aria  Precertification Guidelines: Infusion J1602 Medical Medical hospital) requires precertification (golimumab) Simponi Aria Management* with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Simvastatin  Prior Authorization/ (generic Zocor) Notification Guidelines: - *Applies to New York Lines of Tablet J8499 PBM* Pharmacy 5mg, 10mg, 20mg, Cardiovascular Disease Business only 40mg Prevention Zero Cost Share* Singulair  Therapeutic Equivalent (montelukast Tablet, Guidelines: Drug Coverage J3490 PBM Pharmacy N/A sodium) (Brand Granule Criteria - New and Therapeutic only) Equivalent Medications Singulair Chewable  Therapeutic Equivalent Tablet (montelukast Chewable Guidelines: Drug Coverage J3490 PBM Pharmacy N/A sodium) (brand Tablet Criteria - New and Therapeutic only) Equivalent Medications Sirturo Tablet J8499 N/A N/A Pharmacy N/A (bedaquiline)  Therapeutic Equivalent Guidelines: Drug Coverage Sitavig (acyclovir) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Skelaxin (Brand Guidelines: Drug Coverage Oral J8999 PBM Pharmacy N/A only) (metaxalone) Criteria - New and Therapeutic Equivalent Medications *Coverage is limited to Members with coverage for contraceptives Skyla through their prescription drug (Levonorgestrel- plan. If the Member does not Releasing Intrauterine  Benefit Guidelines: have contraceptive coverage Q0090 N/A Pharmacy* Intrauterine Device Contraceptives through their prescription drug Contraceptive plan, then these are not covered. System) 13.5mg Members should refer to their Certificate of Coverage or Prescription Drug Rider language

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes for coverage guidelines. Sodium  Therapeutic Equivalent Sulfacetamide/ Toplical Guidelines: Drug Coverage Sulfur 9%-4.5% J3490 PBM Pharmacy N/A Lotion Criteria - New and Therapeutic Kit (generic Equivalent Medications Sumadan Kit) *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the Solage (mequinol) Varies J3490 PBM N/A Pharmacy* standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Prior Authorization/ Solaraze Topical Gel J3490 PBM Notification Guidelines: Pharmacy N/A (diclofenac) Solaraze Soliqua (insulin  Prior Authorization/ glargine/ Injection J3490 PBM Notification Guidelines: Pharmacy N/A lixisenatide) Soliqua *Precertification Note: Precertification is not required for the drug itself [Soliris (eculizumab)], but precertification may be required for the site of care of the injection. When administered in: Provider’s Office or Freestanding Ambulatory  Medical Management Infusion Suite (not associated Guidelines: Maximum Dosage with a hospital): Administration Policy Oxford’s of Soliris in a provider’s office or Soliris  Precertification Guidelines: Injection J1300 Medical Medical freestanding ambulatory infusion (eculizumab) o Soliris (eculizumab) Management* suite not associated with a o Specialty Medication hospital does not require Administration - Site of Care precertification. Review Guidelines Home: Administration of Soliris in the home requires precertification for the home care services (not for the Soliris itself). Refer to: Home Health Care Hospital Outpatient Facility: Administration of Soliris in a hospital outpatient facility

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee. Refer to: Specialty Medication Administration - Site of Care Review Guidelines.  Prior Authorization/Medical Necessity Guidelines: Solodyn Solodyn  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A (minocycline HCL) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Regulatory Guidelines: Soltamox Soltamox Oral J8999 PBM  Therapeutic Equivalent Pharmacy N/A (tamoxifen citrate) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Soma 250mg  Therapeutic Equivalent (carisoprodol)/ J3490, Guidelines: Drug Coverage Tablet PBM Pharmacy N/A carisoprodol J8499 Criteria - New and Therapeutic 250mg (generic) Equivalent Medications Somac, Pantoloc, Protium, Pantecta, Tablet J8499 N/A N/A Pharmacy N/A and Pantoheal (Pantoprazole) Somatuline Depot IM Injection J1930 N/A N/A Medical N/A (lanreotide)  Prior Authorization/Medical Somavert Injection, J3590 PBM Necessity Guidelines: Pharmacy N/A (pegvisomant) SQ Injection Somavert Sonata (zaleplon) Tablet J8499 N/A N/A Pharmacy N/A Soolantra  Step Therapy Guidelines: Cream J3490 PBM Pharmacy N/A (ivermectin) Soolantra  Therapeutic Equivalent Sorilux Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (calcipotriene) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Sotylize (sotalol Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A hydrochloride) Solution Solid Oral Dosage Forms

Sovaldi  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (sofosbuvir) Necessity Guidelines: Sovaldi

Spinraza Intrathecal J3490 Oxford’s  Precertification Guidelines: (Nusinersen) Injection Medical Medical N/A Spinraza (Nusinersen) Management Spiriva Respimat Inhaler J3490 N/A N/A Pharmacy N/A (tiotropium) Sporanox Capsule J1835 N/A N/A Pharmacy N/A (itraconazole)  Prior Authorization/Medical Necessity Guidelines: Spritam Spritam  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A (levetiracetam) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sprix Nasal Spray (ketorolac Nasal Spray J3490 N/A N/A Pharmacy N/A tromethamine) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/Medical years or older. All other oral Sprycel (dasatinib) Oral J8999 PBM* Pharmacy** Necessity Guidelines: Sprycel chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent SSS 10-4 (sodium Guidelines: Drug Coverage polystyrene Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfonate) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Notification Guidelines: Erectile Dysfunction Agents Staxyn (vardenafil) Oral J3490 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Medical Management Guidelines: Maximum Dosage *Precertification through PBM if PBM* Policy obtained at a pharmacy. Sub- Oxford’s  Precertification Guidelines: Stelara Pharmacy* (Pharmacy Benefit) cutaneous J3357 Medical Stelara (Ustekinumab) (ustekinumab) /Medical** **No precertification if provided Injection Management  Prior Authorization/ in an office or outpatient setting. ** Notification Guidelines: (Medical Benefit) Stelara Injection for Subcutaneous Use Oxford’s  Precertification Guidelines: Stelara Intravenous Q9989 Medical o Maximum Dosage Policy Medical N/A (ustekinumab) Infusion Management o Stelara (Ustekinumab)  Prior Authorization/ Stendra (avanafil) Tablet J3490 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents  Therapeutic Equivalent Stiolto Respimat Guidelines: Drug Coverage (olodaterol/ Inhaler J3490 PBM Pharmacy N/A Criteria - New and Therapeutic tiotropium) Equivalent Medications  Prior Authorization/ Stivarga Tablet J8999 PBM Notification Guidelines: Pharmacy N/A (regorafenib) Stivarga Strattera Capsule J8499 N/A N/A Pharmacy N/A (atomoxetine)  Prior Authorization/ Strensiq (asfotase Injection J3490 PBM Notification Guidelines: Pharmacy N/A alfa) Strensiq Striant  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (testosterone) Necessity Guidelines: Striant Stribild® (elvitegravir/ cobicistat/  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A emtricitabine/ Stribild tenofovir disoproxil fumarate)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Striverdi Respimat Inhalation J3490 N/A N/A Pharmacy N/A (olodaterol) Spray  Prior Authorization/Medical Suboxone Sublingual Necessity Guidelines: (buprenorphine/ J3490 PBM Pharmacy N/A Film, Tablet Buprenorphine/Naloxone naloxone) Products  Prior Authorization/ Notification Guidelines: New Jersey Small Members Subsys should refer to their Certificate of Subsys (fentanyl Oral Spray J3490 PBM*  Therapeutic Equivalent Pharmacy* Coverage for precertification sublingual spray) Guidelines: Drug Coverage guidelines and quantity limit Criteria - New and Therapeutic guidelines. Equivalent Medications Succimer (DMSA), *Oral chelation agents do not (dimercaptosuccini Oral Agent J3490 N/A* N/A Pharmacy require precertification. c acid)  Therapeutic Equivalent Sumadan (sodium Guidelines: Drug Coverage sulfacetamide and Topical Kit J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfur) Equivalent Medications Sumadan Cleanser (sodium sulfacetamide and  Therapeutic Equivalent sulfur) in a Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A Moisturizing Wash Criteria - New and Therapeutic Novasome® Equivalent Medications Vehicle) (brand only) Sumadan XLT Kit (sulfacetamide  Therapeutic Equivalent sodium, sulfur, Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A avobenzone, Criteria - New and Therapeutic octinoxate, and Equivalent Medications octisalate) **Precertification Notes: Precertification through the PBM is only required for quantity Tablet, J3490, requests exceeding the Triptan Nasal  Supply Limit Guidelines: Sumatriptan J8499, and PBM** Pharmacy* Ceiling Limit. Spray, Triptans Supply Limits J3030 Injection NJ Plans do not require precertification. *Benefit Note: New York Plans and Products, Members should

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Supply Limit Guidelines: Triptans Supply Limits Sumavel Dosepro J3490 and  Therapeutic Equivalent Injection PBM** Pharmacy* (Sumatriptan) J8499 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sumaxin TS and  Therapeutic Equivalent Sumaxin CP Guidelines: Drug Coverage (sodium Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfacetamide and Equivalent Medications sulfur) *Precertification with review by a Intra- Oxford’s Medical Director or their Supartz (sodium  Precertification Guidelines: Articular J7321 Medical Medical Designee is required in all sites of hyaluronate) Sodium Hyaluronate Injection Management* service for J7321, J7324 and J7326. *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Supprelin LA Oxford’s  Precertification Guidelines: Precertification Guidelines: (histrelin acetate SC Implant J9226 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone implant) Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Suprax Chewable Tablet J3490 N/A N/A Pharmacy N/A Tablet (cefixime) Sustenna Extended (paliperidone Release J2426 N/A N/A Medical N/A palmitate extended Injection release) Precertification Note: *Precertification through the PBM is only required for those Oral  Prior Authorization/ Oncology Drugs specifically listed Sutent (sunitinib) Oral PBM* Notification Guidelines: Pharmacy** in a Coverage Criteria/Guideline Sutent when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Sylatron  Prior Authorization/ (peginterferon Injection J3490 PBM Notification Guidelines: Pharmacy N/A alfa-2b) Sylatron Symbicort (budesonide/ formoterol Aerosol J3490 N/A N/A Pharmacy N/A fumarate dehydrate) Oxford’s Synagis  Precertification Guidelines: Injection J3490 Medical Medical N/A (palivizumab) Synagis (palivizumab) Management Synalar 0.01%  Therapeutic Equivalent solution Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (fluocinolone Solution Criteria - New and Therapeutic acetonide) (brand) Equivalent Medications Synalar 0.025%  Therapeutic Equivalent Topical cream/ointment Guidelines: Drug Coverage Cream/ J3490 PBM Pharmacy N/A (fluocinolone Criteria - New and Therapeutic Ointment acetonide) (brand) Equivalent Medications  Therapeutic Equivalent Synalar Kit Guidelines: Drug Coverage (fluocinolone Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetonide) Equivalent Medications  Therapeutic Equivalent Synalar TS Guidelines: Drug Coverage (fluocinolone Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetonide) Equivalent Medications Synarel (nafarelin Nasal Spray J3490 N/A N/A Pharmacy N/A acetate)  Therapeutic Equivalent Syndros Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (dronabinol) solution Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Precertification is not required Synvisc and Intra- Oxford’s in the office for Oxford's  Precertification Guidelines: Synvisc-One Articular J7325 Medical Medical preferred products of Euflexxa, Sodium Hyaluronate (Hylan G-F-20) Injection Management* Synvisc or Synvisc-One (J7323 and J7325). Synjardy  Therapeutic Equivalent (empagliflozin/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A metformin Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Prior Authorization/ Syprine (trientine Oral Agent J3490 PBM Notification Guidelines: Pharmacy N/A hydrochloride) Syprine Taclonex Ointment  Therapeutic Equivalent (Brand Only) Guidelines: Drug Coverage (calcipotriene/ Ointment J3490 PBM Pharmacy N/A Criteria - New and Therapeutic betamethasone Equivalent Medications dipropionate)  Prior Authorization/ Tafinlar N/A Capsule J8499 PBM Notification Guidelines: Pharmacy (dabrafenib) Tafinlar  Prior Authorization/ Tagrisso Tablet J8999 PBM Notification Guidelines: Pharmacy N/A (osimertinib) Tagrisso  Prior Notification/Medical Taltz (ixekizumab) Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Taltz Capsule, Tamiflu Powder or J3490 and (oseltamivir N/A N/A Pharmacy N/A Oral J8499 phosphate) Suspension  Prior Authorization/ Tamoxifen Oral J8999 PBM Regulatory Guidelines: Pharmacy N/A Tamoxifen Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed  Prior Authorization/ in a Coverage Criteria/Guideline Tarceva (erlotinib) Oral J8999 PBM Notification Guidelines: Pharmacy** when the Member is age 19 Tarceva years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Targadox Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (doxycycline) Criteria - New and Therapeutic Equivalent Medications Targretin Gel Topical Gel J3490 N/A N/A Pharmacy N/A (bexarotene) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline  Prior Authorization/ when the Member is age 19 Notification Guidelines: years or older. All other oral Tasigna (nilotinib) Oral J8999 PBM* Tasigna Pharmacy** chemotherapy drugs do not  Step Therapy Guidelines: require precertification. Tasigna Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Tasmar Guidelines: Drug Coverage (tolcapone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives through their prescription drug  Benefit Guidelines: Taytulla plan. If the Member does not Contraceptives (norethindrone have contraceptive coverage  Therapeutic Equivalent acetate and ethinyl Tablet J8499 PBM Pharmacy* through their prescription drug Guidelines: Drug Coverage estradiol, and plan, then these are not covered. Criteria - New and Therapeutic ferrous fumarate) Members should refer to their Equivalent Medications Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes **Precertification Note: Precertification is not required for Members under 30 years of age. Precertification for NJ Small LOBs  Prior Authorization/ is based on the Member's Tazorac Varies J3490 PBM** Notification Guidelines: Pharmacy* benefit. (taxarotene) Tazorac (taxarotene) *Benefit Note: Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Prior Authorization/ Tecfidera (dimethyl Tablet J8499 PBM Notification Guidelines: Pharmacy N/A fumarate) Tecfidera (dimethyl fumarate) Technivie  Prior Authorization/Medical (ombitasvir/ Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A paritaprevir/ Technivie ritonavir) Teflaro (ceftaroline Injection J0712 N/A N/A Medical N/A fosamil)  Therapeutic Equivalent Tekamlo (aliskiren/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A amlodipine) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Temodar years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (temozolomide) chemotherapy drugs do not Temodar require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Tenoretic (atenolol/ Guidelines: Drug Coverage chlorthalidone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Tenormin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (atenolol) (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Terbinex Guidelines: Drug Coverage (terbinafine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications Test Strips and Meters (Diabetic): • Abbott Diabetic Test Strips and A4253 – Meters Test strips  Prior Authorization/ *The Test Strips Oxford policy Notification Guidelines: applies to New York and • Bayer Diabetic Test Strip PBM Pharmacy o Test Strips Connecticut plans and products Test Strips and E0607 - o Diabetic Test Strips (NJ) only. Meters Meter • Roche Diabetic Test Strips and Meters Testim  Prior Authorization/Medical Gel J3490 PBM Pharmacy N/A (testosterone gel) Necessity Guidelines: Testim Testosterone cypionate and Injection J3490 N/A N/A Medical N/A estradiol cypionate Testosterone enanthate and Injection J3490 N/A N/A Medical N/A estradiol valerate Testosterone Powder J3490 PBM N/A Pharmacy N/A powder  Prior Authorization/Medical Necessity Guidelines: Topical Testosterone Androgens topical gel (generic Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A Testim) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Necessity Guidelines: Topical Testosterone Androgens topical gel (generic Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A Vogelxo) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Topical Testosterone Androgens topical gel Topical Gel J3490 PBM  Therapeutic Equivalent Pharmacy N/A (manufacturer of Guidelines: Drug Coverage Perrigo Israel) Criteria - New and Therapeutic Equivalent Medications Testred (methyl- Capsule J3490 N/A N/A Pharmacy N/A testosterone) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Thalomid years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (thalidomide) chemotherapy drugs do not Thalomid require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Thyrogen Injection J3490 N/A N/A Medical N/A (thyrotropin alfa)  Therapeutic Equivalent Tirosint Guidelines: Drug Coverage (levothyroxine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Tivorbex Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (indomethacin) Criteria - New and Therapeutic Equivalent Medications TNKase J3490 and Intravenous N/A N/A Medical N/A (tenecteplase) J3101

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Tobi™ Nebulizer Solution  Prior Authorization/ (Tobramycin Inhalation Notification Guidelines: TOBI Inhalation Powder or  Therapeutic Equivalent J3490 PBM Pharmacy N/A Solution) and Inhalation Guidelines: Drug Coverage Tobi® Podhaler™ Solution Criteria - New and Therapeutic (Tobramycin Equivalent Medications Inhalation Powder)  Therapeutic Equivalent Tobradex ST Guidelines: Drug Coverage (tobramycin- Ointment J3490 PBM Pharmacy N/A Criteria - New and Therapeutic dexamethasone) Equivalent Medications  Prior Authorization/ Notification Guidelines: Tobramycin Tobramycin nebulized solution Inhalation nebulized solution J3490 PBM  Therapeutic Equivalent Pharmacy N/A Solution (generic Tobi) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Tolak 4% cream Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (fluorouracil) Cream Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Tolterodine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Detrol) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Topamax Tablet or J8499 PBM Necessity Guidelines: Pharmacy N/A (topiramate) Capsule Topamax  Therapeutic Equivalent Topicort Spray Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (Desoximetasone) Spray Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Toujeo Solostar Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A (insulin glargine) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Tracleer Tablet J3490 PBM Necessity Guidelines: Tracleer Pharmacy N/A (bosentan) (bosentan)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Tramadol  Therapeutic Equivalent Tramadol Tablet/ extended- Guidelines: Drug Coverage extended-release J8499 Pharmacy N/A Capsule release Criteria - New and Therapeutic (generic ryzolt) (generic ryzolt) Equivalent Medications Travoprost Ophthalmic  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (generic Travatan) Solution Travoprost (generic Travatan) *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Precertification Guidelines: Trelstar Injection J3315 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes.  Therapeutic Equivalent Tremfya Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A (guselkumab) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Tresiba Flex Touch Injection J3490 PBM Notification Guidelines: Pharmacy N/A (insulin degludec) Tresiba  Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Tretin-X 0.075% 0.075% S0117 and PBM  Therapeutic Equivalent Pharmacy N/A cream (tretinoin) Cream J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Tretin-X 0.0375% 0.0375% J3490 PBM  Therapeutic Equivalent Pharmacy N/A cream (tretinoin) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Tretin-X Kit Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A (tretinoin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Tretinoin (generic Topical S0117, PBM Notification Guidelines: Retin- Pharmacy N/A Retin-A) cream) Cream J3490 A and Retin-A Micro (tretinoin)  Prior Authorization/ Notification Guidelines: Retin- A and Retin-A Micro (tretinoin) Tretinoin (generic S0117, Topical Gel PBM  Therapeutic Equivalent Pharmacy N/A Retin-A) gel J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Treximet Guidelines: Drug Coverage (sumatriptan Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic naproxen) Equivalent Medications Trezix  Therapeutic Equivalent (acetaminophen/ Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A caffeine/ Criteria - New and Therapeutic dihydrocodeine) Equivalent Medications Triamcinolone Injection J3300 N/A N/A Medical N/A acetonide  Therapeutic Equivalent Trianex Guidelines: Drug Coverage Ointment J3490 PBM Pharmacy N/A (triamcinolone) Criteria - New and Therapeutic Equivalent Medications Tribenzor  Therapeutic Equivalent (amlodipine, Guidelines: Drug Coverage olmesartan, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic medoxomil, Equivalent Medications hydrochlorothiazide) Tricor/Fenofibrate 48mg and 145mg  Therapeutic Equivalent (generic Tricor) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (fenofibrate) and Criteria - New and Therapeutic Trilipix (fenofibrate Equivalent Medications acid)  Therapeutic Equivalent Triglide Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (fenofibrate) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Benefit Notes: Not covered for cosmetic conditions. Not all Tri-Luma groups have selected the Varies J3490 N/A N/A Pharmacy* (hydroquinone) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Trileptal  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (oxcarbazepine) Necessity Guidelines: Trileptal  Therapeutic Equivalent Trilipix (fenofibrate Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A acid) Criteria - New and Therapeutic Equivalent Medications Trintellix  Step Therapy Guideline: Tablet J8499 PBM Pharmacy N/A (vortioxetine) Trintellix *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Triphasil have contraceptive coverage (levonorgestrel  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug and ethinyl Contraceptives plan, then these are not covered. estradiol) Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Precertification is required for the diagnosis of gender dysphoria only; refer to Oxford’s  Precertification Guidelines: Triptodur Precertification Guidelines: Injection J3490 Medical Gonadotropin Releasing Medical (triptorelin) Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable gender dysphoria ICD-10 diagnosis codes. *Precertification is not required for intravenous chemotherapy drugs however, Oxford will  Medical Management provide a pre-service clinical Guidelines: Injectable Trisenox (arsenic review and coverage Injection J9017 N/A* Chemotherapy Drugs: Medical trioxide) determination upon request. In Application of NCCN Clinical the absence of precertification, Practice Guidelines Oxford will perform a post- service retrospective review upon claim submission for patients 19

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes years of age or older. Triumeq (dolutegravir/ Tablet J8499 N/A N/A Pharmacy N/A abacavir/ lamivudine)  Prior Authorization/Medical Trokendi XR Capsule J8499 PBM Necessity Guidelines: Trokendi Pharmacy N/A (topiramate) XR Troxyca ER  Prior Authorization/Medical (oxycodone hcl Capsules J8499 PBM Necessity Guidelines: Troxyca Pharmacy N/A and naltrexone) ER Trulance  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (plecanatide) Necessity Guidelines: Trulance Trulicity Injection J3490 N/A N/A Pharmacy N/A (dulaglutide) Truvada (emtricitabine and Tablet J8499 N/A N/A Pharmacy N/A tenofovir disoproxil fumarate)  Therapeutic Equivalent Tuzistra XR Oral Guidelines: Drug Coverage (codeine/ J8499 PBM Pharmacy N/A suspension Criteria - New and Therapeutic chlorpheniramine) Equivalent Medications  Therapeutic Equivalent Twynsta Guidelines: Drug Coverage (Telmisartan, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic amlodipine) Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Tykerb (lapatinib) Oral J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Tykerb require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Tymlos Injection J3490 PBM Notification Guidelines: Pharmacy N/A (abaloparatide) Tymlos Tysabri Intravenous J2323 N/A N/A Medical N/A (natalizumab)  Prior Authorization/Medical Tyvaso Inhalation J7686 PBM Necessity Guidelines: Tyvaso Pharmacy N/A (treprostinil) Solution (treprostinil) Uceris Tablet J8499 N/A N/A Pharmacy N/A (budesonide) Uceris foam Topical J3490 N/A N/A Pharmacy N/A  Step Therapy Guidelines: Uloric (febuxostat) Tablet J8499 PBM Pharmacy N/A Uloric Note: Prescription drugs for which there is a therapeutic Ultrasal-ER 28.5% over-the-counter (OTC) Topical topical solution J8499 N/A N/A Pharmacy equivalent are excluded from Solution (salicylic acid) coverage. Refer to the member specific benefit plan document as applicable. Ultravate  Prior Authorization/Medical Topical (Halobetasol J3490 PBM Necessity Guidelines: Pharmacy N/A cream Propionate) Ultravate Ultravate X  Therapeutic Equivalent Combination Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Package Criteria - New and Therapeutic (halobetasol) Equivalent Medications Ultresa  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (pancrelipase) Ultresa  Therapeutic Equivalent Umecta emulsion, Foam/ Guidelines: Drug Coverage foam, suspension J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic (urea) Equivalent Medications Umecta Kit (nail  Therapeutic Equivalent film pen/film Nail Film Guidelines: Drug Coverage suspension) (urea Pen/Film J3490 PBM Pharmacy N/A Criteria - New and Therapeutic nail film and Suspension Equivalent Medications hyaluronic acid)  Therapeutic Equivalent Topical Guidelines: Drug Coverage Umecta PD (urea) J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Uptravi (selexipag) Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Uptravi Uramaxin GT 45%  Therapeutic Equivalent (urea in Guidelines: Drug Coverage Foam J3490 PBM Pharmacy N/A ammonium Criteria - New and Therapeutic lactate) Equivalent Medications  Therapeutic Equivalent Uramaxin GT Kit Guidelines: Drug Coverage urea plus Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic moisturizer) Equivalent Medications  Therapeutic Equivalent Urevaz 44% cream Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (urea) Cream Criteria - New and Therapeutic Equivalent Medications Utibron Neohaler Inhalation (indacaterol/ J3490 N/A N/A Pharmacy N/A Powder glycopyrrolate)  Therapeutic Equivalent Guidelines: Drug Coverage Utopic (urea) 41% Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Vagifem (estradiol) Vaginal Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (brand only) Insert Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Valchlor Gel Topical J3490 PBM Notification Guidelines: Pharmacy N/A (mechlorethamine) Valchlor Gel  Therapeutic Equivalent Valcyte Guidelines: Drug Coverage (valganciclovir) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Valium (diazepam) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Valsartan (generic Capsule J8499 N/A N/A Pharmacy N/A Diovan)  Therapeutic Equivalent Valtrex Guidelines: Drug Coverage (valacyclovir) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Valturna 150- 160mg, 300mg - Tablet J8499 N/A N/A Pharmacy N/A 320mg (aliskiren and valsartan) Vanatol LQ  Prior Authorization/Medical (butalbital/ Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A acetaminophen/ Solution Solid Oral Dosage Forms caffeine *Benefit Notes: Not covered for cosmetic conditions. Not all Vaniqa groups have selected the Varies J3490 PBM N/A Pharmacy* (eflornithine) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Therapeutic Equivalent Vanos Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (fluocinonide) Criteria - New and Therapeutic Equivalent Medications *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Vantas (histrelin Precertification Guidelines: SC Implant J9225 Medical Gonadotropin Releasing Medical implant) Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Vantrela ER  Prior Authorization/Medical (hydrocodone Tablets J8499 PBM Necessity Guidelines: Vantrela Pharmacy N/A bitartrate) ER Varubi (rolapitant) Tablet J8670 N/A N/A Pharmacy N/A  Prior Authorization/ Vascepa (omega- Capsule J3490 PBM Notification Guidelines: Pharmacy N/A 3-acid ethyl esters) Vascepa Vascepa 0.5 gram  Prior Authorization/ only (omega-3- Capsule J3490 PBM Notification Guidelines: Pharmacy N/A acid ethyl esters) Vascepa  Therapeutic Equivalent Vaseretic (enalapril/ Guidelines: Drug Coverage hydrochlorothiazide) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Vasotec (enalapril) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Vecamyl Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (mecamylamine) Vecamyl (mecamylamine) Vectical (calcitriol) Topical J3490 N/A N/A Pharmacy N/A Velphoro (sucroferric Tablet J8499 N/A N/A Pharmacy N/A oxyhydroxide) Veltassa Oral  Prior Authorization/Medical J8499 PBM Pharmacy N/A (patiromer) Suspension Necessity Guidelines: Veltassa  Therapeutic Equivalent Veltin (clindamycin Guidelines: Drug Coverage phosphate and Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic tretinoin) Equivalent Medications Vemlidy (tenofovir  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A alafenamide) Vemlidy  Prior Authorization/ Venclexta Tablet J8999 PBM Notification Guidelines: Pharmacy N/A (venetoclax) Venclexta Venlafaxine ER  Therapeutic Equivalent (venlafaxine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride Criteria - New and Therapeutic extended release) Equivalent Medications *The I-neb AAD System (K0730) for administration of Ventavis®  Prior Authorization/Medical Pharmacy (iloprost) requires precertification Inhalation Ventavis (iloprost) Q4074 PBM* Necessity Guidelines: Ventavis and DME through Oxford's Medical Solution (iloprost) (Medical) Management Department and coverage is provide under the Medical benefit.  Therapeutic Equivalent Veramyst Guidelines: Drug Coverage (fluticasone Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic furoate) Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Verdeso (desonide) Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications Vermox Oral  Prior Authorization/Medical J8499 PBM Pharmacy N/A (mebendazole) Suspension Necessity Guidelines: Vermox

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Versacloz Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (clozapine) suspension Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Vesicare Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (solifenacin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Viagra (sildenafil Tablet J3490 PBM Notification Guidelines: Pharmacy N/A citrate) Erectile Dysfunction Agents Vibativ Injection J3095 N/A N/A Medical N/A (telavancin) Viberzi  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (eluxadoline) Necessity Guidelines: Viberzi  Therapeutic Equivalent Vicodin 5/300mg Guidelines: Drug Coverage (hydrocodone and Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic acetaminophen) Equivalent Medications Vicodin ES  Therapeutic Equivalent 7.5/300mg Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (hydrocodone and Criteria - New and Therapeutic acetaminophen) Equivalent Medications Vicodin HP  Therapeutic Equivalent 10/300mg Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (hydrocodone and Criteria - New and Therapeutic acetaminophen) Equivalent Medications Viekira Pak Viekira XR  Prior Authorization/Medical (ombitasvir, Oral J8499 PBM Necessity Guidelines: Viekira Pharmacy N/A paritaprevir (ABT- Pak 450) and ritonavir) Note: Prescription drugs for which there is a therapeutic Vimovo (naproxen over-the-counter (OTC) sodium plus proton Tablet J3490 N/A N/A N/A equivalent are excluded from pump inhibitor) coverage. Refer to the member specific benefit plan document as applicable. Vimpat C9254 and Injection N/A N/A Medical N/A (Lacosamide) J3490

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Tablet J8499 PBM Necessity Guidelines: Vimpat Pharmacy N/A (Lacosamide) Viokace  Step Therapy Guidelines: Tablet J3490 PBM Pharmacy N/A (pancrelipase) Viokace  Therapeutic Equivalent Viramune Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (nevirapine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Viramune XR Guidelines: Drug Coverage 400mg (Brand Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic Only) (nevirapine) Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Virasal (salicylic Topical J3490 N/A N/A Pharmacy equivalent are excluded from acid) (brand only) coverage. Refer to the member specific benefit plan document as applicable. Visudyne Infusion J3396 N/A N/A Medical N/A (verteporfin) Vitamin B-12 Injection J3420 N/A N/A Medical N/A Vitekta Tablet J8499 N/A N/A Pharmacy N/A (elvitegravir) Vitrasert- Ganciclovir Vitreal Eye Implant J3490 N/A N/A Medical N/A Implant Vituz (hydrocodone  Therapeutic Equivalent bitartrate, and Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A chlorpheniramine Solution Criteria - New and Therapeutic maleate) Equivalent Medications Vivitrol Injection J2315 N/A N/A Medical N/A (Naltrexone)  Therapeutic Equivalent Vivlodex Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (meloxicam) Criteria - New and Therapeutic Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Necessity Guidelines: Vogelxo Vogelxo  Therapeutic Equivalent Topical J3490 PBM Pharmacy N/A (testosterone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Vosevi Necessity Guidelines: Vosevi (Sofosbuvir/  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A Velpatasvir/ Guidelines: Drug Coverage Voxilaprevir) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Votrient years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (pazopanib) chemotherapy drugs do not Votrient require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Medical Management VPRIV Guidelines: Enzyme Injection J3385 N/A Medical N/A (velaglucerase) Replacement Therapy (ERT) for Gaucher Disease Vraylar  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (cariprazine) Vraylar  Therapeutic Equivalent Vusion Guidelines: Drug Coverage (miconazole/zinc Ointment J3490 PBM Pharmacy N/A Criteria - New and Therapeutic oxide) Equivalent Medications  Therapeutic Equivalent Vytone Guidelines: Drug Coverage (hydrocortisone/ Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic lodoquinol) Equivalent Medications  Prior Authorization/ Vyvanse Tablet J3490 N/A Notification Guidelines: Pharmacy N/A (lisdexamfetamine) Vyvanse (lisdexamfetamine)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes *Coverage is limited to Members Weight Loss: with coverage for weight loss Adipex-P , medications through their diethylpropion, prescription drug plan. If the benzphetamine, Member does not have weight Belviq, loss medication coverage through  Prior Authorization/Medical their prescription drug plan, then Belviq XR, Tablet or J8499 PBM Necessity Guidelines: Weight Pharmacy* these are not covered. Members Contrave, Capsule Loss should refer to their Certificate of phendimetrazine, Coverage, or Prescription Drug phentermine, Rider language for coverage Qsymia, guidelines. Saxenda, ** Prior Authorization Guidelines Xenical only apply to New York plans and products

 Therapeutic Equivalent Wellbutrin Guidelines: Drug Coverage (bupropion) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications

 Therapeutic Equivalent Wellbutrin SR Guidelines: Drug Coverage (brand only) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (bupropion) Equivalent Medications  Therapeutic Equivalent Wellbutrin XL Guidelines: Drug Coverage (bupropion Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic extended release) Equivalent Medications Winstrol Tablet J8499 N/A N/A Pharmacy N/A (stanozolol)  Therapeutic Equivalent Xadago Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (safinamide) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral  Prior Authorization/ Oncology Drugs specifically listed Xalkori (crizotinib) Oral J8999 PBM* Notification Guidelines: Pharmacy** in a Coverage Criteria/Guideline Xalkori when the Member is age 19 years or older. All other oral chemotherapy drugs do not require precertification.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Xanax Guidelines: Drug Coverage (alprazolam) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Xanax XR Guidelines: Drug Coverage (alprazolam) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Xartemis XR  Therapeutic Equivalent 7.5/325mg Guidelines: Drug Coverage (oxycodone Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride and Equivalent Medications acetaminophen) Xatmep Oral J8610,  Prior Authorization/Medical PBM Pharmacy N/A (methotrexate) Solution J8999 Necessity Guidelines: Xatmep Xeljanz  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (tofacitinib) Necessity Guidelines: Xeljanz  Prior Authorization/Medical Xeljanz XR Tablet J8499 PBM Necessity Guidelines: Xeljanz Pharmacy N/A XR  Therapeutic Equivalent Xenazine Guidelines: Drug Coverage (tetrabenazine) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications Xeomin Oxford’s  Precertification Guidelines: (incobotulinumtoxin SQ Injection J0588 Medical Medical N/A Botulinum Toxins A and B A) Management  Therapeutic Equivalent Xerese (acyclovir Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A or hydrocortisone) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Xermelo Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (telotristat ethyl) Xermelo Xiaflex (collagenase Injection J0775 N/A N/A Medical N/A clostridium histolyticum)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Xifaxan (rifaximin) Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Xifaxan The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Xigduo XR Diabetes Medications SGLT2 to New York and Connecticut (Dapagliflozin and Tablet J3490 PBM* Inhibitors (CT/NY) Pharmacy plans and products. Metformin HCl)  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Ophthalmic  Prior Authorization/Medical Xiidra (lifitegrast) J3490 PBM Pharmacy N/A solution Necessity Guidelines: Xiidra Xodol 10/300  Therapeutic Equivalent (hydrocodone/ Guidelines: Drug Coverage Tablet J8499 PBM* Pharmacy N/A acetaminophen)(br Criteria - New and Therapeutic and and generic) Equivalent Medications Xodol 5/300  Therapeutic Equivalent (hydrocodone / Guidelines: Drug Coverage acetaminophen) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand and Equivalent Medications generic) Xodol 7.5/300  Therapeutic Equivalent (hydrocodone / Guidelines: Drug Coverage acetaminophen) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand and Equivalent Medications generic)  Medical Management Oxford’s Guidelines: Maximum Dosage Xolair SQ Injection J2357 Medical Policy Medical N/A (omalizumab) Management  Precertification Guidelines: Xolair (omalizumab) Xopenex Nebules  Therapeutic Equivalent (levalbuterol Inhalation Guidelines: Drug Coverage hydrochloride) J3490 PBM Pharmacy N/A Solution Criteria - New and Therapeutic Generic Xopenex Equivalent Medications nebules  Prior Authorization/Medical Xtampza ER Capsule J8499 PBM Necessity Guidelines: Xtampza Pharmacy N/A (oxycodone) ER

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes

 Prior Authorization/ Xtandi Notification Guidelines: Xtandi Capsule J8999 PBM Pharmacy N/A (enzalutamide)  Step Therapy Guidelines: Xtandi

 Therapeutic Equivalent Xultophy (insulin Guidelines: Drug Coverage degludec and Injection J3490 PBM Pharmacy N/A Criteria - New and Therapeutic liraglutide) Equivalent Medications  Prior Authorization/ Xuriden (uridine Oral J8499 PBM Notification Guidelines: Pharmacy N/A triacetate) Granules Xuriden  Prior Authorization/Medical Xyrem (Sodium Oral J8499 PBM Necessity Guidelines: Xyrem Pharmacy N/A Oxybate) Solution (sodium oxybate) *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Yasmin 28 have contraceptive coverage  Benefit Guidelines: (drospirenone- Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives ethinyl estradiol) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Yosprala (aspirin/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A omeprazole) Criteria - New and Therapeutic Equivalent Medications Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM.  eviCore Guidelines: White Precertification is not required. Zarxio (filgrastim- Injection Q5101 eviCore* Blood Cell Colony Stimulating See Notes sndz) *Medical Benefit: If provided in Factors* a hospital, MD's office, or in conjunction with home health care. Precertification through eviCore is required. Zavesca® Capsule J8499 N/A N/A Pharmacy N/A (miglustat)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Zecuity 6.5mg/4 hr Transdermal Guidelines: Drug Coverage patch (sumatriptan J3490 PBM Pharmacy N/A Patch Criteria - New and Therapeutic iontophoretic) Equivalent Medications Note: Prescription drugs for which there is a therapeutic Zegerid over-the-counter (OTC) (omeprazole/ Capsule J8499 N/A N/A Not covered equivalent are excluded from sodium coverage. Refer to member bicarbonate) specific benefit plan document as applicable. Zegerid suspension  Prior Authorization/Medical Oral (omeprazole/ J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Suspension sodium bicarbonate) Solid Oral Dosage Forms  Prior Authorization/ Zejula (niraparib) Tablet J3490 PBM Pharmacy N/A Notification Guidelines: Zejula Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Zelboraf years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (vemurafenib) chemotherapy drugs do not Zelboraf require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Supply Limit Guidelines: Zembrace Triptans Supply Limits SymTouch  Therapeutic Equivalent Injection J3490 PBM Pharmacy N/A (sumatriptan Guidelines: Drug Coverage succinate) Criteria - New and Therapeutic Equivalent Medications Zemplar Injection J2501 N/A N/A Pharmacy N/A (paricalcitol)  Prior Authorization/ Zenatane Capsule J8499 PBM Notification Guidelines: Pharmacy N/A Zenatane

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/ Notification Guidelines: Zenzedi Zenzedi (dextroamphetami Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A ne sulfate) Guidelines: Drug Coverage Criteria - New And Therapeutic Equivalent Medications Zepatier (elbasvir/  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A grazoprevir) Necessity Guidelines: Zepatier Zestoretic  Therapeutic Equivalent (lisinopril/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochlorothiazide) Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Zestril (lisinopril) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Zetia (ezetimibe) Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Zetonna Inhalation J8499 N/A N/A Pharmacy N/A (ciclesonide) Solution A9542 and Injection N/A N/A Medical N/A Zevalin A9543 (ibritumomab Powder tiuxetan) J3490 N/A N/A Pharmacy N/A Packet  Therapeutic Equivalent Ziana (clindamycin Guidelines: Drug Coverage phosphate and Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Tretinoin Equivalent Medications  Prior Authorization/ Zinbryta Injection J7513 PBM Notification Guidelines: Pharmacy N/A (daclizumab) Zinbryta Zioptan Opthalmic  Step Therapy Guidelines: J8499 PBM Pharmacy N/A (tafluprost) Solution Zioptan (tafluprost)  Therapeutic Equivalent Zipsor 25mg Guidelines: Drug Coverage (diclofenac Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic pottassium) Equivalent Medications

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Capsule, Zithromax Oral J3490 and N/A N/A Pharmacy N/A (azithromycin) Solution or J8499 Tablet Oral Q0179 and Zofran N/A N/A Pharmacy N/A (ondansetron Solution S0181 hydrochloride) IV Injection J2405 N/A N/A Medical N/A Zofran and Zofran Tablet J8499 N/A N/A Pharmacy N/A ODT (ondansetron) Zohydro ER  Prior Authorization/Medical (hydrocodone Tablet J8499 PBM Necessity Guidelines: Zohydro Pharmacy N/A bitartrate extended ER release) *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Precertification Guidelines: Zoladex SC Implant J9202 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes.  Medical Management Zoledronic acid Injection J3489 N/A Guidelines: Maximum Dosage Medical N/A Policy  Therapeutic Equivalent Zoloft (sertraline) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Zolpidem extended Tablet J8499 N/A N/A Pharmacy N/A release (zolpidem) Zolpimist  Step Therapy Guidelines: Oral Spray J8499 PBM Pharmacy N/A (zolpidem tartrate) Zolpimist (zolpidem tartrate) Zolvit (hydrocodone Liquid J8499 N/A N/A Pharmacy N/A bitartrate and acetaminophen)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Prior Authorization/Medical Necessity Guidelines: Zomacton Zomacton Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Medical Management Zometa (zoledronic Injection J3489 N/A Guidelines: Maximum Dosage Medical N/A acid) Policy **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Zomig and Zomig- Tablet and J8499 and  Supply Limit Guidelines: PBM** Pharmacy* precertification. ZMT (zolmitriptan) Nasal Spray J3590 Triptans Supply Limits *Benefit Note: New York Plans and Products, Members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Therapeutic Equivalent Zonacort Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (dexamethasone) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Topical Zonalon (Doxepin) J3490 PBM Notification Guidelines: Pharmacy N/A Cream Zonalon  Therapeutic Equivalent Zonatuss J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A (benzonatate) J8499 Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Zonegran Capsule J8499 PBM Necessity Guidelines: Pharmacy N/A (zonisamide) Zonegran Zontivity Tablet J8499 N/A N/A Pharmacy N/A (vorapaxar)  Prior Authorization/Medical Zorbtive Injection J2941 PBM Necessity Guidelines: Zorbtive Pharmacy N/A (somatropin) (somatropin)

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes  Therapeutic Equivalent Zorvolex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (diclofenac) Criteria - New And Therapeutic Equivalent Medications  Therapeutic Equivalent Zovirax cream Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (acyclovir) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Zovirax Ointment Topical J3490 PBM Pharmacy N/A Necessity Guidelines: Zovirax Zubsolv (buprenorphine/ Tablet J8499 N/A N/A Pharmacy N/A naloxone)  Therapeutic Equivalent Zuplenz Tablet or Guidelines: Drug Coverage J8499 PBM* Pharmacy N/A (Ondansetron) Film Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Zurampic Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (lesinurad) Zurampic Zutripro (Brand Only) (hydrocodone  Therapeutic Equivalent bitartrate, Oral Guidelines: Drug Coverage chlorpheniramine J8499 PBM* Pharmacy N/A Solution Criteria - New and Therapeutic maleate and Equivalent Medications pseudoephedrine hcl) Tablet,  Prior Authorization/Medical *Benefits for Tobacco Cessation Nasal Necessity Guidelines: Tobacco for Health Care Reform apply to Zyban (bupropion) J3490 PBM Pharmacy Spray, Cessation for Health Care all plans subject to health care Inhaler Reform reform.  Therapeutic Equivalent Zyclara Guidelines: Drug Coverage Cream J3490 PBM* Pharmacy N/A (Imiquimod) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Zydelig (idelalisib) Tablet J8499 PBM Notification Guidelines: Pharmacy N/A Zydelig  Prior Authorization/ Zykadia (ceritinib) Capsule J8999 PBM Notification Guidelines: Pharmacy N/A Zykadia Zylfo and Zylfo CR  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (zileuton) Zylfo

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Form Code(s) Routing Coverage Criteria/Guidelines Type Notes Zymaxid (Gatifloxacin Ophthalmic J3490 N/A N/A Pharmacy N/A ophthalmic Solution solution)  Therapeutic Equivalent Zyprexa Guidelines: Drug Coverage (olanzapine) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Zyprexa Zydis Guidelines: Drug Coverage (olanzapine) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Zyrtec (cetirizine) Oral J8499 N/A N/A N/A equivalent are excluded from solution Solution coverage. Refer to the member specific benefit plan document as applicable. Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 Zytiga (abiraterone  Prior Authorization/ years or older. All other oral Oral J8999 PBM* Pharmacy** acetate) Notification Guidelines: Zytiga chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Zyvox (linezolid) Tablet/Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (brand) Suspension Criteria - New and Therapeutic Equivalent Medications CPT® is a registered trademark of the American Medical Association

POLICY HISTORY/REVISION INFORMATION

Date Action/Description  Updated Prior Authorization/Notification Guidelines: Interim New Product Coverage Criteria; refer to the policy for complete details  Revised coverage guidelines for the following medications/drugs: Medication/Drug Status Summary of Changes Alecensa (Alectinib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Alecensa for complete details Cinqair (Reslizumab) Updated  Updated reference link to reflect title change for Precertification Guidelines: Respiratory Interleukins (Cinqair and Nucala); previously titled Precertification Guidelines: Respiratory Interleukins (IL) Policy Daklinza (Daclatasvir) Revised  Reformatted and revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Daklinza for complete details Entyvio (Vedolizumab) Revised  Added medical management guidelines; refer to Medical Management Guidelines: Maximum Dosage Policy for complete details Epclusa (Sofosbuvir/Velpatasfir) Revised  Reformatted and revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Epclusa for complete details Haegarda [C1 Esterase Inhibitor Revised  Added prior authorization/notification guidelines; refer to Prior Subcutaneous (Human)] Authorization/Notification Guidelines: Haegarda for complete details Harvoni™ (Ledipasvir/Sofosbuvir) Revised  Reformatted and revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: 11/01/2017 Harvoni for complete details Humira (Adalimumab) Updated  Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Humira for complete details Inflectra (Infliximab) Updated  Updated list of applicable HCPCS codes; added modifier ZB (Pfizer) to Q5102 Incivek (Telaprevir) Removed  Removed coverage guidelines Kalydeco (Ivacaftor) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Kalydeco for complete details Kymriah (Tisagenlecleucel) – [CAR-T New  Added coverage guidelines to indicate: (Chimeric Antigen Receptor) Cell o Chimeric Antigen Receptor (CAR)-T Cell Therapy may be eligible Therapy] for coverage as an autologous stem cell therapy under a member’s Transplantation Services benefit o Coverage determinations are based on the Optum Transplant Review Guidelines: Hematopoietic Stem Cell Transplantation criteria for covered transplants o Precertification through Optum is required for all sites of service o Refer to the following policies for complete details: . eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines . Optum Transplant Review Guidelines: Hematopoietic Stem

Date Action/Description Cell Transplantation Mavyret (Glecaprevir and Pibrentasvir) Revised  Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Mavyret for complete details Minocycline Extended-Release (Generic Revised  Added prior authorization/medical necessity guidelines; refer to Prior Solodyn) Authorization/Medical Necessity Guidelines: Solodyn for complete details  Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nucala (Mepolizumab) Updated  Updated reference link to reflect title change for Precertification Guidelines: Respiratory Interleukins (Cinqair and Nucala); previously titled Precertification Guidelines: Respiratory Interleukins (IL) Olysio (Simeprevir) Revised  Reformatted and revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Olysio for complete details Orencia (Abatacept): SQ Injection Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Orencia for complete details  Revised step therapy guidelines; refer to Step Therapy Guidelines: Orencia for complete details Oxistat (Oxiconazole Nitrate) Updated  Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Oxistat for complete details Rebetol (Ribavirin) Revised  Removed prior authorization/notification guidelines and corresponding reference link to policy titled Prior Authorization/Notification Guidelines: Rebetol (Ribavirin) Renflexis (Infliximab) Revised  Added medical management guidelines; refer to Medical Management Guidelines: Maximum Dosage Policy for complete details Repronex (Menotropins) Removed  Removed coverage guidelines Sensipar (Cinacalcet) Updated  Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Sensipar for complete details Soliris (Eculizumab) Revised  Added medical management guidelines; refer to Medical Management Guidelines: Maximum Dosage Policy for complete details Solodyn (Minocycline HCL) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Solodyn for complete details Sovaldi (Sofosbuvir) Revised  Reformatted and revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Sovaldi for complete details Stelara (Ustekinumab): Sub- Revised  Added medical management guidelines; refer to Medical Management Cutaneous Injection Guidelines: Maximum Dosage Policy for complete details Stelara (Ustekinumab): Intraveneous Updated  Updated list of applicable CPT/HCPCS codes; replaced J3590 with Infusion Q9989 Technivie (Ombitasvir/Paritaprevir/ Revised  Reformatted and revised prior authorization/medical necessity

Date Action/Description Ritonavir) guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Technivie for complete details Triptodur (Triptorelin) New  Added coverage guidelines to indicate precertification is required for the diagnosis of gender dysphoria through Oxford’s Medical Management; refer to Precertification Guidelines: Gonadotropin Releasing Hormone Analogs for complete details Tymlos (Abaloparatide) Revised  Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Victrelis (Boceprevir) Removed  Removed coverage guidelines Viekira Pak Revised  Reformatted and revised prior authorization/medical necessity Viekira XR (Ombitasvir, Paritaprevir guidelines; refer to Prior Authorization/Medical Necessity Guidelines: (ABT-450) and Ritonavir) Viekira Pak for complete details Vosevi (Sofosbuvir/Velpatasvir/ Revised  Added prior authorization/medical necessity guidelines; refer to Prior Voxilaprevir) Authorization/Medical Necessity Guidelines: Vosevi for complete details Xolair (Omalizumab) Revised  Added medical management guidelines; refer to Medical Management Guidelines: Maximum Dosage Policy for complete details Xatmep (Methotrexate) Revised  Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Xeljanz (Tofacitinib) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xeljanz for complete details Xeljanz XR Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xeljanz for complete details Xolair (omalizumab) Revised  Added medical management guidelines; refer to Medical Management Guidelines: Maximum Dosage Policy for complete details Xtandi (Enzalutamide) Revised  Revised step therapy guidelines; refer to Step Therapy Guidelines: Xtandi for complete details Zepatier (Elbasvir/Grazoprevir) Revised  Reformatted and revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zepatier for complete details Zovirax Ointment Updated  Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zovirax for complete details  Archived previous policy version PHARMACY 098.166 T0