CENTENE PHARMACY AND THERAPEUTICS 4Q18 October – November

Drug Name Steps Steps Part B and Part D Step-through through through Drugs by Indication Part B Part D (*prior authorization required)

Tocilizumab No Yes PART B STEP: (Actemra) Not applicable

PART D STEP: • Rheumatoid arthritis: methotrexate, sulfasalazine, hydroxychloroquine, d-penicillamine, azathioprine or auranofin • Giant cell arteritis: methotrexate or azathioprine • Polyarticular juvenile idiopathic arthritis: methotrexate, sulfasalazine, or leflunomide • Systemic juvenile idiopathic arthritis: methotrexate, leflunomide, or a systemic corticosteroid

OnabotulinumtoxinA No Yes PART B STEP: (Botox) Not applicable

PART D STEP: • Chronic migraine: 2 migraine preventative therapies (antiepileptic drugs: divalproex sodium, sodium valproate, topiramate; beta-blockers: metoprolol, propranolol, timolol; antidepressants: amitriptyline, venlafaxine) • Overactive bladder and urinary incontinence: at least one oral beta-3 agonist (oxybutynin chloride, tolterodine tartrate, mirabegron) • Chronic anal fissure: nitroglycerin 0.2% ointment Certolizumab No Yes PART B STEP: (Cimzia) Not applicable

PART D STEP: • Crohn’s disease: one immunomodulator (azathioprine, 6-mercaptopurine, methotrexate) • Rheumatoid arthritis: methotrexate, sulfasalazine, hydroxychloroquine, d-penicillamine, azathioprine, or auranofin • Ankylosing spondylitis: two NSAIDs • Plaque psoriasis: methotrexate, cyclosporine, or acitretin

CENTENE PHARMACY AND THERAPEUTICS 4Q18 October – November

Drug Name Steps Steps Part B and Part D Step-through through through Drugs by Indication Part B Part D (*prior authorization required)

Eteplirsen (Exondys No Yes PART B STEP: 51) Not applicable

PART D STEP: • Oral corticosteroids Aflibercept (Eylea) Yes No PART B STEP: Intravitreal bevacizumab

PART D STEP: Not applicable Corticotropin (H.P. Yes Yes PART B STEP: Acthar) • Multiple sclerosis: corticosteroids

PART D STEP: • Multiple sclerosis: corticosteroids • Nephrotic syndrome: oral corticosteroids and two of the following agents: tacrolimus, cyclosporine, mycophenolate Tisagenlecleucel Yes Yes PART B STEP: (Kymriah) • Two prior lines of systemic therapy* (IV chemotherapy) (*prior authorization required – note some IV chemo may not require prior authorization)

PART D STEP: • Large B-Cell lymphoma: Two prior lines of systemic therapy* (Revlimid*, Rituxan* ) (*prior authorization is required) Ranibizumab Yes No PART B STEP: (Lucentis) • Intravitreal bevacizumab

PART D STEP: Not applicable

CENTENE PHARMACY AND THERAPEUTICS 4Q18 October – November

Drug Name Steps Steps Part B and Part D Step-through through through Drugs by Indication Part B Part D (*prior authorization required)

Pegaptanib Yes No PART B STEP: (Macugen) • Intravitreal bevacizumab

PART D STEP: Not applicable Ocrelizumab Yes Yes PART B STEP: (Ocrevus) • One* of the following: Avonex, Betaseron, Plegridy, Copaxone, Glatopa, Extavia, or Rebif (*prior authorization is required for all)

PART D STEP: • One* of the following: Aubagio, Tecfidera, Gilenya, Avonex, Betaseron, Plegridy, Copaxone, Glatopa, Extavia, or Rebif (*prior authorization is required for all) Infliximab No Yes PART B STEP: (Remicade, Not applicable Renflexis, Inflectra) PART D STEP: • Crohn’s disease: one immunomodulator (azathioprine, 6-mercaptopurine, methotrexate) • Ulcerative colitis: azathioprine, 6-mercaptopurine, or an aminosalicylate (sulfasalazine) • Rheumatoid arthritis: methotrexate, sulfasalazine, hydroxychloroquine, d-penicillamine, azathioprine, or auranofin • Ankylosing spondylitis: two NSAIDs • Plaque psoriasis: methotrexate, cyclosporine, or acitretin

CENTENE PHARMACY AND THERAPEUTICS 4Q18 October – November

Drug Name Steps Steps Part B and Part D Step-through through through Drugs by Indication Part B Part D (*prior authorization required)

Rituximab (Rituxan), Yes Yes PART B STEP: rituximab- Rituxan Hycela: hyaluronidase • Rituxan (at least 1 prior dose) (Rituxan Hycela) Rituxan: • Granulomatosis with polyangiitis and microscopic polyangiitis: glucocorticoid

PART D STEP: Rituxan Hycela: • Rituxan (at least 1 prior dose)

Rituxan: • Rheumatoid arthritis: a tumor factor necrosis inhibitor* (Enbrel and Humira are preferred) and one of the following: methotrexate, sulfasalazine, hydroxychloroquine, d-penicillamine, azathioprine, or auranofin (*prior authorization is required) • Granulomatosis with polyangiitis and microscopic polyangiitis: glucocorticoid Natalizumab Yes Yes PART B STEP: (Tysabri) • Crohn’s disease: Humira* or Inflectra* (*prior authorization is required) • Multiple sclerosis: one* of the following: Avonex, Betaseron, Plegridy, glatiramer, Copaxone, Glatopa, Extavia, or Rebif (*prior authorization is required for all)

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PART D STEP: • Crohn’s disease: one immunomodulator (e.g., azathioprine, 6-mercaptopurine, methotrexate), and Humira* or Inflectra* (*prior authorization is required)

CENTENE PHARMACY AND THERAPEUTICS 4Q18 October – November

Drug Name Steps Steps Part B and Part D Step-through through through Drugs by Indication Part B Part D (*prior authorization required)

• Multiple sclerosis: one* of the following: Aubagio, Tecfidera, Gilenya, Avonex, Betaseron, Plegridy, glatiramer, Copaxone, Glatopa, Extavia, or Rebif (*prior authorization is required for all) Verteporfin Yes No PART B STEP: (Visudyne) • Intravitreal bevacizumab

PART D STEP: Not applicable Axicabtagene Yes Yes PART B STEP: ciloleucel (Yescarta) • Two prior lines of systemic therapy* (IV chemotherapy) (*prior authorization required – note some IV chemo may not require prior authorization)

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PART D STEP: • Large B-Cell lymphoma: Two prior lines of systemic therapy* ( Revlimid*, Rituxan*) (*prior authorization is required) Burosumab-twza No Yes PART B STEP: (Crysvita) Not applicable

PART D STEP: • Calcitriol and oral phosphate

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