October/November 2020 P & T Updates

* Indicates prior authorization (PA) or step therapy (ST) Commercial †Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Triple Tier 4th Tier Traditional Prior Qty Brand Name Status Detailed Limits Formulary Alternatives Formulary Applicable Formulary Auth Limit BLOOD GLUCOSE TEST STRIPS (ALL - - - - - Yes 200 strips per 30 days None BRANDS) Treatment: pyrimethamine* Non Non Non DARAPRIM No Yes No - Prophylaxis: pyrimethamine*, Formulary Formulary Formulary trimethoprim-sulfamethoxazole DOJOLVI Formulary 3 Yes 2 Yes No - None

ENOXAPARIN Formulary 1 No 1 No Yes 30 day supply per fill None

Non Non Non 3 syringes (9 mL) per FIRAZYR No Yes Yes icatibant* Formulary Formulary Formulary 30 days *, alendronate, Non Non Non FORTEO No Yes Yes 2.4 mL per 30 days ibandronate, risedronate, Formulary Formulary Formulary Tymlos*

10 or 14 day reader: 1 One Touch Ultra 2, One Touch FREESTYLE LIBRE reader every 2 years UltraMini, One Touch Verio, One Formulary 2 No 2 Yes Yes 2.0 14 day sensor: 2 Touch Verio IQ, One Touch Verio sensors per 28 days Flex

GAVRETO Formulary 3† No 2 Yes Yes 4 capsules per day Retevmo* INQOVI Formulary 3 No 2 Yes Yes 5 tablets per 28 days None Non Non Non JADENU No Yes Yes 34 day supply per fill deferasirox* Formulary Formulary Formulary *, Uptravi*, Orenitram*, treprostinil*, Non Non Non 30 tablets per 30 LETAIRIS No Yes Yes Tyvaso*, Ventavis*, Adempas*, Formulary Formulary Formulary days Opsumit*, *, tadalafil*, sildenafil* 100 mg tablets: 90 tablets per 30 days Non Non Non posaconazole*, fluconazole, NOXAFIL No Yes Yes 200 mg/5 mL Formulary Formulary Formulary itraconazole*, voriconazole* suspension: 20 mL per day 14 tablets per 28 ONUREG Formulary 3† No 2 Yes Yes None days Non Non Non REVATIO No Yes Yes 34 day supply per fill sildenafil* Formulary Formulary Formulary SANTYL Formulary 2 No 2 Yes No - None OINTMENT 20 mg tablets: Initial Fill – 280 tablets, Subsequent Fills – amoxicillin-clavulanic acid, 120 tablets clarithromycin, ethambutol, SIRTURO Formulary 3 Yes 2 Yes Yes 100 mg tablets: isoniazid, levofloxacin, Initial Fill – 56 pyrazinamide, rifampin, Avelox tablets, Subsequent Fills – 24 tablets

12/16/2020

* Indicates prior authorization (PA) or step therapy (ST) Commercial (cont.) †Depending on your specific benefits and in which state you reside, some drugs on this list may have no cost sharing. Triple Tier 4th Tier Traditional Prior Qty Brand Name Status Detailed Limits Formulary Alternatives Formulary Applicable Formulary Auth Limit 240 mg: 60 capsules dimethyl fumarate*, glatiramer, Non Non Non per 30 days Aubagio 14 mg, Avonex, TECFIDERA No Yes Yes Formulary Formulary Formulary 120 mg: 14 capsules Betaseron, Extavia, Gilenya, per 7 days Plegridy, Rebif bosentan*, Uptravi*, Orenitram*, treprostinil*, Tyvaso*, Ventavis*, Non Non Non 2 tablets per day, 30 TRACLEER No Yes Yes Adempas*, Opsumit*, Formulary Formulary Formulary day supply per fill ambrisentan*, tadalafil*, sildenafil* TRULICITY Formulary 2 No 2 No Yes 0.072 mL per day Ozempic, Victoza, Rybelsus Maintenance Dose: UPLIZNA Medical 3 Yes 2 Yes Yes None 30 mL per 180 days Non Non Non VALCYTE No Yes No - valganciclovir Formulary Formulary Formulary modafinil, dextroamphetamine/amphetami Non Non Non WAKIX No Yes Yes 2 tablets per day ne immediate release, Formulary Formulary Formulary methylphenidate immediate release modafinil, dextroamphetamine/amphetami 18 mL per day, 30 day XYREM Formulary 3 Yes 2 Yes Yes ne immediate release, supply per fill methylphenidate immediate release Non Non Non 90 capsules per 30 ZAVESCA No Yes Yes miglustat* Formulary Formulary Formulary days dimethyl fumarate*, glatiramer, Maintenance dose Aubagio 14 mg, Avonex, ZEPOSIA Formulary 2 Yes 2 No Yes 0.92 mg : 1 capsule Betaseron, Extavia, Gilenya, per day Plegridy, Rebif Beginning January 1, 2021 medical benefit specialty medications will be assigned a prescription benefit drug tier when dispensed by a specialty pharmacy. There are no changes to the clinical management criteria (e.g., prior authorization) for these medications.

Please note that if your plan does not include coverage, you will no longer be able to receive your medical benefit specialty medications through a specialty pharmacy. These medications will need to be administered from provider stock and billed through your medical benefit.

Please contact the pharmacy customer service team at 800-988-4861, Monday through Friday, 8 a.m. to 5 p.m., with any questions.

12/16/2020

CHIP * Indicates prior authorization (PA) or step therapy (ST) Prior Qty Brand Name Status Tier Detailed Limits Formulary Alternatives Auth Limit Treatment: pyrimethamine* Non Non DARAPRIM Yes No - Prophylaxis: pyrimethamine*, Formulary Formulary trimethoprim-sulfamethoxazole DOJOLVI Formulary 2 Yes No - None ENOXAPARIN Formulary 1 No Yes 30 day supply per fill None

Non Non 3 syringes (9 mL) per 30 FIRAZYR Yes Yes icatibant* Formulary Formulary days

Non Non teriparatide*, alendronate, ibandronate, FORTEO Yes Yes 2.4 mL per 30 days Formulary Formulary risedronate, Tymlos*

10 or 14 day reader: 1 One Touch Ultra 2, One Touch UltraMini, reader every 2 years FREESTYLE LIBRE 2.0 Formulary 2 Yes Yes One Touch Verio, One Touch Verio IQ, 14 day sensor: 2 sensors One Touch Verio Flex per 28 days GAVRETO Formulary 2 Yes Yes 4 capsules per day Retevmo* INQOVI Formulary 2 Yes Yes 5 tablets per 28 days None

Non Non JADENU Yes Yes 34 day supply per fill deferasirox* Formulary Formulary

ambrisentan*, Uptravi*, Orenitram*, treprostinil*, Tyvaso*, Ventavis*, Non Non LETAIRIS Yes Yes 30 tablets per 30 days Adempas*, Formulary Formulary Opsumit*, bosentan*, tadalafil*, sildenafil* 100 mg tablets: 90 tablets Non Non per 30 days posaconazole*, fluconazole, NOXAFIL Yes Yes Formulary Formulary 200 mg/5 mL suspension: itraconazole*, voriconazole* 20 mL per day ONUREG Formulary 2 Yes Yes 14 tablets per 28 days None

Non Non REVATIO Yes Yes 34 day supply per fill sildenafil* Formulary Formulary

SANTYL OINTMENT Formulary 2 Yes No - None

20 mg tablets: Initial Fill – 280 tablets, Subsequent amoxicillin-clavulanic acid, Fills – 120 tablets clarithromycin, ethambutol, isoniazid, SIRTURO Formulary 2 Yes Yes 100 mg tablets: Initial Fill levofloxacin, pyrazinamide, rifampin, – 56 tablets, Subsequent Avelox Fills – 24 tablets 240 mg: 60 capsules per 30 dimethyl fumarate*, glatiramer, Aubagio Non Non days TECFIDERA Yes Yes 14 mg, Avonex, Betaseron, Extavia, Formulary Formulary 120 mg: 14 capsules per 7 Gilenya, Plegridy, Rebif days bosentan*, Uptravi*, Orenitram*, Non Non 2 tablets per day, 30 day treprostinil*, Tyvaso*, Ventavis*, TRACLEER Yes Yes Formulary Formulary supply per fill Adempas*, Opsumit*, ambrisentan*, tadalafil*, sildenafil* TRULICITY Formulary 2 No Yes 0.072 mL per day Ozempic, Victoza, Rybelsus Maintenance Dose: 30 mL UPLIZNA Medical 2 Yes Yes None per 180 days

12/16/2020

CHIP (cont.) * Indicates prior authorization (PA) or step therapy (ST) Prior Qty Brand Name Status Tier Detailed Limits Formulary Alternatives Auth Limit Non Non VALCYTE Yes No - valganciclovir Formulary Formulary

modafinil, Non Non dextroamphetamine/amphetamine WAKIX Yes Yes 2 tablets per day Formulary Formulary immediate release, methylphenidate immediate release modafinil, 18 mL per day, 30 day dextroamphetamine/amphetamine XYREM Formulary 2 Yes Yes supply per fill immediate release, methylphenidate immediate release

Non Non ZAVESCA Yes Yes 90 capsules per 30 days miglustat* Formulary Formulary glatiramer, Aubagio 14 mg, Avonex, Maintenance dose 0.92 ZEPOSIA Formulary 2 No Yes Betaseron, Extavia, Gilenya, Plegridy, mg : 1 capsule per day Rebif, Tecfidera Beginning January 1, 2021 medical benefit specialty medications will be assigned a prescription benefit drug tier when dispensed by a specialty pharmacy. There are no changes to the clinical management criteria (e.g., prior authorization) for these medications.

Please note that if your plan does not include prescription drug coverage, you will no longer be able to receive your medical benefit specialty medications through a specialty pharmacy. These medications will need to be administered from provider stock and billed through your medical benefit.

Please contact the pharmacy customer service team at 800-988-4861, Monday through Friday, 8 a.m. to 5 p.m., with any questions.

12/16/2020

GHP Family * Indicates prior authorization (PA) or step therapy (ST) GHP Family Qty Brand Name Status Formulary Prior Auth Detailed Limits Formulary Alternative(s) Limit Tier Non Non DOJOLVI Yes No not applicable Formulary Formulary INQOVI Formulary Brand Yes Yes 5 per 28 days not applicable Non Non condoms, female condoms, PHEXXI Yes No Formulary Formulary contraceptives per PDL

Geisinger Gold * Indicates prior authorization (PA) or step therapy (ST) $0 Deductible Standard Prior Qty Brand Name Status Detailed Limits Formulary Alternative(s) Formulary Formulary Auth Limit Revlimid*, Pomalyst*, Velcade*, 25% Kyprolis*, Ninlaro*, Darzalex*, BLENREP Formulary Specialty Yes No coinsurance Empliciti*, Farydak*, Sarclisa*, Xpovio* 25% DOJOLVI Formulary Specialty Yes No none coinsurance 25% GAVRETO Formulary Specialty Yes Yes 120 capsules/30 days Caprelsa*, Cometriq*, Retevmo* coinsurance 25% INQOVI Formulary Specialty Yes Yes 5 tablets per 28 days decitabine, azacitidine coinsurance 25% ONUREG Formulary Specialty Yes Yes 14 tablets/28 days none coinsurance 7 day starter: 7 capsules/180 days, Aubagio, Avonex, Betaseron, 25% starter pack: 37 Copaxone, Extavia, Gilenya, ZEPOSIA Formulary Specialty No Yes coinsurance capsules/180 days, Glatiramer, Mavenclad*, Mayzent, 0.92 mg capsule: 1 Plegridy, Rebif, Tecfidera capsule/day

12/16/2020

Marketplace * Indicates prior authorization (PA) or step therapy (ST) Qty Brand Name Status Tier Prior Auth Detailed Limits Formulary Alternatives Limit 10 mg/0.8 mL: 22.4 mL per 28 days 2.5 mg/0.5 mL: 14 mL per 28 Non Non ARIXTRA Yes Yes days fondaparinux Formulary Formulary 5 mg/0.4 mL: 11.2 mL per 28 days 7.5 mg/0.6: 16.8 mL per 28 days

Non Non CLOVIQUE Yes No - trientine* Formulary Formulary Treatment: pyrimethamine* Non Non DARAPRIM Yes No - Prophylaxis: pyrimethamine*, Formulary Formulary trimethoprim-sulfamethoxazole DEFERASIROX Formulary 2 Yes Yes 34 day supply per fill None DOJOLVI Formulary 5 Yes No - None

30mg/0.3mL: 18 mL per 30 days 40 mg/0.4 mL: 24 mL per 30 days 60 mg/0.6 mL: 36 mL per 30 days 80 mg/0.8 mL: 48 per 30 days ENOXAPARIN Formulary 2 No Yes None 100 mg/mL: 60 mL per 30 days 120 mg/0.8 mL: 48 mL per 30 days 150 mg/mL: 60 mL per 30 days

Non Non FIRAZYR Yes Yes 3 syringes (9 mL) per 30 days icatibant* Formulary Formulary teriparatide*, alendronate, Non Non FORTEO Yes Yes 2.4 mL per 30 days ibandronate, risedronate, Formulary Formulary Tymlos* 10 or 14 day reader: 1 reader One Touch Ultra 2, One Touch every 2 years UltraMini, One Touch Verio, One FREESTYLE LIBRE 2.0 Formulary 3 Yes Yes 14 day sensor: 2 sensors per 28 Touch Verio IQ, One Touch Verio days Flex GAVRETO Formulary 4 Yes Yes 4 capsules per day Retevmo*

Non Non 90 mg - 400 mg tablets: 1 tablet HARVONI Yes Yes Mavyret*, ledipasvir/sofosbuvir* Formulary Formulary per day, 28 day supply per fill

Non Non HEPSARA Yes Yes 34 day supply per fill adefovir Formulary Formulary INQOVI Formulary 4 Yes Yes 5 tablets per 28 days None Non Non JADENU Yes Yes 34 day supply per fill deferasirox* Formulary Formulary ambrisentan*, Uptravi*, Orenitram*, treprostinil*, Non Non LETAIRIS Yes Yes 30 tablets per 30 days Tyvaso*, Ventavis*, Adempas*, Formulary Formulary Opsumit*, bosentan*, tadalafil*, sildenafil*

12/16/2020

Marketplace (cont.) * Indicates prior authorization (PA) or step therapy (ST) Qty Brand Name Status Tier Prior Auth Detailed Limits Formulary Alternatives Limit 30mg/0.3mL: 18 mL per 30 days 40 mg/0.4 mL: 24 mL per 30 days 60 mg/0.6 mL: 36 mL per 30 days Non Non LOVENOX Yes Yes 80 mg/0.8 mL: 48 per 30 days enoxaparin Formulary Formulary 100 mg/mL: 60 mL per 30 days 120 mg/0.8 mL: 48 mL per 30 days 150 mg/mL: 60 mL per 30 days

100 mg tablets: 90 tablets per 30 days Non Non posaconazole*, fluconazole, NOXAFIL Yes Yes 200 mg/5 mL suspension: 20 mL per Formulary Formulary itraconazole*, voriconazole* day OCTREOTIDE Formulary 2 No Yes 34 day supply per fill None ONUREG Formulary 4 Yes Yes 14 tablets per 28 days None Non Non REVATIO Yes Yes 34 day supply per fill sildenafil* Formulary Formulary SANTYL OINTMENT Formulary 3 Yes No - None SILDENAFIL Formulary 2 Yes Yes 34 day supply per fill None

20 mg tablets: Initial Fill – 280 tablets, amoxicillin-clavulanic acid, Subsequent Fills – 120 tablets clarithromycin, ethambutol, isoniazid, SIRTURO Formulary 5 Yes Yes 100 mg tablets: Initial Fill – 56 tablets, levofloxacin, pyrazinamide, rifampin, Subsequent Fills – 24 tablets Avelox

dimethyl fumarate*, glatiramer, Non Non 240 mg: 60 capsules per 30 days TECFIDERA Yes Yes Aubagio 14 mg, Avonex, Betaseron, Formulary Formulary 120 mg: 14 capsules per 7 days Extavia, Gilenya, Plegridy, Rebif Non Non 2 tablets per day, 30 day supply per TRACLEER Yes Yes sildenafil* Formulary Formulary fill TRULICITY Formulary 3 No Yes 0.072 mL per day Ozempic, Victoza, Rybelsus Maintenance Dose: 30 mL per 180 UPLIZNA Medical 5 Yes Yes None days Non Non VALCYTE Yes No - valganciclovir Formulary Formulary VALGANCICLOVIR Formulary 2 No Yes 34 day supply per fill None modafinil, Non Non dextroamphetamine/amphetamine WAKIX Yes Yes 2 tablets per day Formulary Formulary immediate release, methylphenidate immediate release modafinil, dextroamphetamine/amphetamine XYREM Formulary 5 Yes Yes 18 mL per day, 30 day supply per fill immediate release, methylphenidate immediate release Non Non ZAVESCA Yes Yes 90 capsules per 30 days miglustat* Formulary Formulary glatiramer, Aubagio 14 mg, Avonex, Maintenance dose 0.92 mg : 1 capsule ZEPOSIA Formulary 5 No Yes Betaseron, Extavia, Gilenya, Plegridy, per day Rebif, Tecfidera Beginning January 1, 2021 medical benefit specialty medications will be assigned a prescription benefit drug tier when dispensed by a specialty pharmacy. There are no changes to the clinical management criteria (e.g., prior authorization) for these medications.

Please note that if your plan does not include prescription drug coverage, you will no longer be able to receive your medical benefit specialty medications through a specialty pharmacy. These medications will need to be administered from provider stock and billed through your medical benefit.

Please contact the pharmacy customer service team at 800-988-4861, Monday through Friday, 8 a.m. to 5 p.m., with any questions.

12/16/2020