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Home , Brolucizumab, Caplacizumab, Copanlisib, Crizanlizumab, Epoetin alfa, Epoetin beta

Effective Date: 08/01/2021 DRUGS REQUIRING PRIOR AUTHORIZATION IN THE MEDICAL BENEFIT Page 1

Therapeutic Category Trade Name Generic Name HCPCS Procedure Code HCPCS Procedure Code Description Anti-infectives Antiretrovirals, HIV CABENUVA cabotegravir-rilpivirine C9077 Injection, cabotegravir and rilpivirine, 2mg/3mg Antithrombotic Agents von Willebrand Factor-Directed Antibody CABLIVI -yhdp C9047 Injection, caplacizumab-yhdp, 1 mg Cardiology Antilipemic EVKEEZA -dgnb C9079 Injection, evinacumab-dgnb, 5 mg Cardiology Hemostatic Agent BERINERT c1 esterase J0597 Injection, C1 esterase inhibitor (human), Berinert, 10 units Cardiology Hemostatic Agent CINRYZE c1 esterase J0598 Injection, C1 esterase inhibitor (human), Cinryze, 10 units Cardiology Hemostatic Agent FIRAZYR J1744 Injection, icatibant, 1 mg Cardiology Hemostatic Agent HAEGARDA c1 esterase J0599 Injection, C1 esterase inhibitor (human), (Haegarda), 10 units Cardiology Hemostatic Agent ICATIBANT (generic) icatibant J1744 Injection, icatibant, 1 mg Cardiology Hemostatic Agent KALBITOR J1290 Injection, ecallantide, 1 mg Cardiology Hemostatic Agent RUCONEST c1 esterase J0596 Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units Injection, -flyo, 1 mg (code may be used for when drug administered under Cardiology Hemostatic Agent TAKHZYRO lanadelumab-flyo J0593 direct supervision of a physician, not for use when drug is self-administered) Cardiology Pulmonary Arterial Hypertension EPOPROSTENOL (generic) epoprostenol J1325 Injection, epoprostenol, 0.5 mg Cardiology Pulmonary Arterial Hypertension FLOLAN epoprostenol J1325 Injection, epoprostenol, 0.5 mg Cardiology Pulmonary Arterial Hypertension REMODULIN treprostinil J3285 Injection, treprostinil, 1 mg Cardiology Pulmonary Arterial Hypertension TREPROSTINIL (generic) treprostinil J3285 Injection, treprostinil, 1 mg Cardiology Pulmonary Arterial Hypertension VELETRI epoprostenol J1325 Injection, epoprostenol, 0.5 mg Central Nervous System Antidepressants SPRAVATO esketamine S0013 Esketamine, nasal spray, 1 mg Central Nervous System Antidepressants ZULRESSO brexanolone J1632 Injection, brexanolone, 1 mg Central Nervous System Antipsychotics ABILIFY MAINTENA aripiprazole ER J0401 Injection, aripiprazole, extended release, 1 mg Central Nervous System AIMOVIG -aooe J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Injection, -vfrm, 1 mg (code may be used for Medicare when drug administered Central Nervous System Migraine AJOVY fremanezumab-vfrm J3031 under the direct supervision of a physician, not for use when drug is self-administered) Central Nervous System Migraine EMGALITY -gnlm J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Central Nervous System Migraine VYEPTI -jjmr iv J3032 Injection, eptinezumab-jjmr, 1 mg Central Nervous System Miscellaneous RADICAVA edaravone J1301 Injection, edaravone, 1 mg Central Nervous System Muscular Dystrophy EXONDYS 51 J1428 Injection, eteplirsen, 10 mg Central Nervous System Muscular Dystrophy VILTEPSO J1427 Injection, viltolarsen, 10 mg Central Nervous System Muscular Dystrophy VYONDYS 53 J1429 Injection, golodirsen, 10 mg Central Nervous System Neurological Agents ONPATTRO patisiran sodium J0222 Injection, patisiran, 0.1 mg Central Nervous System Neurological Agents TEGSEDI inotersen J3490/C9399 (Hospital Outpt Use Only) Unclassified drugs/Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Central Nervous System Neurotoxins BOTOX onabotulinumtoxinA J0585 Injection, onabotulinumtoxinA, 1 unit Central Nervous System Neurotoxins BOTOX COSMETIC onabotulinumtoxinA J0585 Injection, onabotulinumtoxinA, 1 unit Central Nervous System Neurotoxins DYSPORT abobotulinumtoxinA J0586 Injection, abobotulinumtoxinA, 5 units Central Nervous System Neurotoxins MYOBLOC rimabotulinumtoxinB J0587 Injection, rimabotulinumtoxinB, 100 units Central Nervous System Neurotoxins XEOMIN incobotulinumtoxinA J0588 Injection, incobotulinumtoxinA, 1 unit Central Nervous System Parkinson's APOKYN apomorphine J0364 Injection, apomorphine HCl, 1 mg Endocrinology & Gonadotropins ELIGARD leuprolide J9217 Leuprolide acetate (for depot suspension), 7.5 mg Endocrinology & Metabolism Gonadotropins FENSOLVI leuprolide acet J1951 Injection, leuprolide acetate for depot suspension (fensolvi), 0.25 mg Endocrinology & Metabolism Gonadotropins FIRMAGON degarelix J9155 Injection, degarelix, 1 mg Endocrinology & Metabolism Gonadotropins LEUPROLIDE (generic) leuprolide J9218 Leuprolide acetate, per 1 mg Endocrinology & Metabolism Gonadotropins LUPANETA PACK leuprolide J3490/C9399 (Hospital Outpt Use Only) Unclassified drugs/Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Endocrinology & Metabolism Gonadotropins LUPRON DEPOT leuprolide J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg LUPRON DEPOT leuprolide J9217 Leuprolide acetate (for depot suspension), 7.5 mg Endocrinology & Metabolism Gonadotropins LUPRON DEPOT-PED leuprolide J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg LUPRON DEPOT-PED leuprolide J9217 Leuprolide acetate (for depot suspension), 7.5 mg Endocrinology & Metabolism Gonadotropins SUPPRELIN LA histrelin acetate J9226 Histrelin implant (Supprelin LA), 50 mg Endocrinology & Metabolism Gonadotropins TRELSTAR triptorelin J3315 Injection, triptorelin pamoate, 3.75 mg Endocrinology & Metabolism Gonadotropins TRIPTODUR triptorelin J3316 Injection, triptorelin, extended-release, 3.75 mg Endocrinology & Metabolism Gonadotropins VANTAS histrelin J9225 Histrelin implant (Vantas), 50 mg Endocrinology & Metabolism Growth and Related Therapy GENOTROPIN somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy HUMATROPE somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy NORDITROPIN FLEXPRO somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy NUTROPIN AQ somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy OMNITROPE somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy SEROSTIM somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy ZOMACTON somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Growth Hormones and Related Therapy ZORBTIVE somatropin J2941 Injection, somatropin, 1 mg Endocrinology & Metabolism Miscellaneous ACTHAR corticotropin J0800 Injection, corticotropin, up to 40 units Endocrinology & Metabolism TEPEZZA -trbw J3241 Injection, teprotumumab-trbw, 10 mg Endocrinology & Metabolism Osteoporosis EVENITY -aqqg J3111 Injection, romosozumab-aqqg, 1 mg Endocrinology & Metabolism Osteoporosis FORTEO J3110 Injection, teriparatide, 10 mcg Endocrinology & Metabolism Osteoporosis PROLIA J0897 Injection, denosumab, 1 mg Endocrinology & Metabolism Osteoporosis TERIPARATIDE (Brand) teriparatide (recombinant) J3110 Injection, teriparatide, 10 mcg Endocrinology & Metabolism Osteoporosis TYMLOS J3490/C9399 (Hospital Outpt Use Only) Unclassified drugs/Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Endocrinology & Metabolism Somatostatins BYNFEZIA octreotide acetate J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg Endocrinology & Metabolism Somatostatins OCTREOTIDE (generic) octreotide J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg Endocrinology & Metabolism Somatostatins SANDOSTATIN octreotide J2354 Injection, octreotide, nondepot form for subcutaneous or intravenous injection, 25 mcg Endocrinology & Metabolism Somatostatins SANDOSTATIN LAR octreotide J2353 Injection, octreotide, depot form for intramuscular injection, 1 mg Endocrinology & Metabolism Somatostatins SIGNIFOR LAR pasireotide J2502 Injection, pasireotide long acting, 1 mg Endocrinology & Metabolism Somatostatins SOMATULINE DEPOT lanreotide J1930 Injection, lanreotide, 1 mg -Related Alpha-1 proteinase inhibitor ARALAST NP alpha-1 proteinase inhibitor J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg Enzyme-Related Alpha-1 proteinase inhibitor GLASSIA alpha-1 proteinase inhibitor J0257 Injection, alpha 1 proteinase inhibitor (human), (GLASSIA), 10 mg Enzyme-Related Alpha-1 proteinase inhibitor PROLASTIN-C alpha-1 proteinase inhibitor J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg Enzyme-Related Alpha-1 proteinase inhibitor ZEMAIRA alpha-1 proteinase inhibitor J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg Enzyme-Related Enzyme Replacement CEREZYME J1786 Injection, imiglucerase, 10 units Enzyme-Related Enzyme Replacement ELELYSO taliglucerase J3060 Injection, , 10 units

Revised: 07/28/2021 Effective Date: 08/01/2021 DRUGS REQUIRING PRIOR AUTHORIZATION IN THE MEDICAL BENEFIT Page 2

Therapeutic Category Drug Class Trade Name Generic Name HCPCS Procedure Code HCPCS Procedure Code Description Enzyme-Related Enzyme Replacement STRENSIQ J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Enzyme-Related Enzyme Replacement VIMIZIM elosulfase J1322 Injection, elosulfase alfa, 1 mg Enzyme-Related Enzyme Replacement VPRIV velaglucerase J3385 Injection, , 100 units Enzyme-Related Treatment Agents PALYNZIQ -pqpz J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Gastroenterology Hepatic Agents GIVLAARI J0223 Injection, givosiran, 0.5 mg Hematology ADAKVEO J0791 Injection, crizanlizumab-tmca, 5 mg Immunology Hematopoietic Agents ARANESP J0881 or Injection, darbepoetin alfa, 1 mcg (non-ESRD use) or ARANESP darbepoetin alfa J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on ) Immunology Hematopoietic Agents ENSPRYNG -mwge J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Hematopoietic Agents EPOGEN J0885 or Injection, epoetin alfa, (for non-ESRD use), 1000 units or EPOGEN epoetin alfa Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) Immunology Hematopoietic Agents FULPHILA Q5108 Injection, pegfilgrastim-jmdb, , (Fulphila), 0.5 mg Immunology Hematopoietic Agents GRANIX tbo- J1447 Injection, tbo-filgrastim, 1 mcg methoxy polyethylene glycol- Immunology Hematopoietic Agents MIRCERA J0888 or Injection, , 1 mcg, (for non-ESRD use) or epoetin methoxy polyethylene glycol- MIRCERA J0887 Injection, epoetin beta, 1 mcg, (for ESRD on dialysis) epoetin Immunology Hematopoietic Agents NEULASTA pegfilgrastim J2505 Injection, pegfilgrastim, 6 mg Immunology Hematopoietic Agents NEULASTA ONPRO pegfilgrastim J2505 Injection, pegfilgrastim, 6 mg Immunology Hematopoietic Agents NEUPOGEN filgrastim J1442 Injection, filgrastim (G-CSF), excludes , 1 mcg Immunology Hematopoietic Agents NIVESTYM filgrastim-aafi soln Q5110 Injection, filgrastim-aafi, biosimilar, (Nivestym), 1 mcg Immunology Hematopoietic Agents NPLATE J2796 Injection, romiplostim, 10 micrograms Immunology Hematopoietic Agents NYVEPRIA pegfilgrastim-apgf soln Q5122 Injection, pegfilgrastim-apgf, biosimilar, (nyvepria), 0.5 mg Immunology Hematopoietic Agents PROCRIT epoetin alfa J0885 or Injection, epoetin alfa, (for non-ESRD use), 1000 units or PROCRIT epoetin alfa Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) Immunology Hematopoietic Agents REBLOZYL luspatercept-aamt J0896 Injection, luspatercept-aamt, 0.25 mg Immunology Hematopoietic Agents RETACRIT epoetin alfa-epbx Q5106 or Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for non-ESRD use), 1000 units or RETACRIT epoetin alfa-epbx Q5105 Injection, epoetin alfa-epbx, biosimilar, (Retacrit) (for ESRD on dialysis), 100 units Immunology Hematopoietic Agents SOLIRIS J1300 Injection, eculizumab, 10 mg Immunology Hematopoietic Agents UDENYCA pegfilgrastim-cbqv Q5111 Injection, pegfilgrastim-cbqv, biosimilar, (Udenyca), 0.5 mg Immunology Hematopoietic Agents ULTOMIRIS -cwvz J1303 Injection, ravulizumab-cwvz, 10 mg Immunology Hematopoietic Agents UPLIZNA -cdon iv soln J1823 Injection, inebilizumab-cdon, 1 mg Immunology Hematopoietic Agents ZARXIO filgrastim Q5101 Injection, filgrastim-sndz, biosimilar, (Zarxio), 1 mcg Immunology Hematopoietic Agents ZIEXTENZO pegfilgrastim-bmez Q5120 Injection, pegfilgrastim-bmez, biosimilar, (ZIEXTENZO), 0.5 mg Immunology Hepatitis C Agents PEG-INTRON peginterferon alfa-2b S0148 Injection, PEGylated alfa-2B, 10 mcg Immunology Immune Globulins ASCENIV immune globulin J1554 Injection, immune globulin (asceniv), 500 mg Immunology Immune Globulins BIVIGAM immune globulin J1556 Injection, immune globulin (Bivigam), 500 mg Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 Immunology Immune Globulins CARIMUNE immune globulin J1566 mg Immunology Immune Globulins CUTAQUIG immune globulin J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Immune Globulins CUVITRU immune globulin J1555 Injection, immune globulin (Cuvitru), 100 mg Immunology Immune Globulins CYTOGAM cytomegalovirus immune globulin J0850 Injection, cytomegalovirus immune globulin intravenous (human), per vial Injection, immune globulin, (Flebogamma/Flebogamma Dif), intravenous, nonlyophilized (e.g., Immunology Immune Globulins FLEBOGAMMA DIF immune globulin J1572 liquid), 500 mg Immunology Immune Globulins GAMASTAN immune globulin J1460 or Injection, gamma globulin, intramuscular, 1 cc or GAMASTAN immune globulin J1560 Injection, gamma globulin, intramuscular, over 10 cc Immunology Immune Globulins GAMMAGARD LIQUID immune globulin J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 Immunology Immune Globulins GAMMAGARD S/D immune globulin J1566 mg Immunology Immune Globulins GAMMAKED immune globulin J1561 Injection, immune globulin, (Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg Immunology Immune Globulins GAMMAPLEX immune globulin J1557 Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg Immunology Immune Globulins GAMUNEX-C immune globulin J1561 Injection, immune globulin, Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg Immunology Immune Globulins HIZENTRA immune globulin J1559 Injection, immune globulin (Hizentra), 100 mg Immunology Immune Globulins HYQVIA hyaluron immune globulin J1575 Injection, immune globulin/, 100 mg immuneglobulin Immunology Immune Globulins OCTAGAM immune globulin J1568 Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg Injection, immune globulin, intravenous, non-lyophilized (e.g. liquid), not otherwise specified, 500 Immunology Immune Globulins PANZYGA immune globulin (human)-ifas J1599 mg Immunology Immune Globulins PRIVIGEN immune globulin J1459 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg Immunology Immune Globulins XEMBIFY immune globulin J1558 Injection, immune globulin (xembify), 100 mg Immunology Immunomodulators ACTEMRA J3262 Injection, tocilizumab, 1 mg Immunology Immunomodulators AVSOLA -axxq Q5121 Injection, infliximab-axxq, biosimilar, (AVSOLA), 10 mg Injection, , 1 mg (code may be used for Medicare when drug administered Immunology Immunomodulators CIMZIA certolizumab J0717 under the direct supervision of a physician, not for use when drug is self-administered) Immunology Immunomodulators COSENTYX J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Injection, , 25 mg (code may be used for Medicare when drug administered under the Immunology Immunomodulators ENBREL etanercept J1438 direct supervision of a physician, not for use when drug is self-administered) Immunology Immunomodulators ENTYVIO J3380 Injection, vedolizumab, 1 mg Immunology Immunomodulators HUMIRA J0135 Injection, adalimumab, 20 mg Immunology Immunomodulators ILUMYA -asmn J3245 Injection, tildrakizumab, 1 mg Immunology Immunomodulators INFLECTRA infliximab Q5103 Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg Immunology Immunomodulators KEVZARA J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Immunomodulators KINERET anakinra J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the Immunology Immunomodulators ORENCIA abatacept J0129 direct supervision of a physician, not for use when drug is self-administered) Immunology Immunomodulators REMICADE infliximab J1745 Injection, infliximab, excludes biosimilar, 10 mg Immunology Immunomodulators RENFLEXIS infliximab-abda Q5104 Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg Immunology Immunomodulators SILIQ J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY)

Revised: 07/28/2021 Effective Date: 08/01/2021 DRUGS REQUIRING PRIOR AUTHORIZATION IN THE MEDICAL BENEFIT Page 3

Therapeutic Category Drug Class Trade Name Generic Name HCPCS Procedure Code HCPCS Procedure Code Description Immunology Immunomodulators SIMPONI J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Immunomodulators SIMPONI ARIA golimumab J1602 Injection, golimumab, 1 mg, for intravenous use Immunology Immunomodulators SKYRIZI -rzaa J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Immunomodulators STELARA IV J3358 Ustekinumab, for intravenous injection, 1 mg Immunology Immunomodulators STELARA SC ustekinumab J3357 Ustekinumab, for subcutaneous injection, 1 mg Immunology Immunomodulators TALTZ J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Immunomodulators TREMFYA J1628 Injection, guselkumab, 1 mg Immunology ARCALYST rilonacept J2793 njection, rilonacept, 1 mg Immunology Miscellaneous BENLYSTA J0490 Injection, belimumab, 10 mg Immunology Miscellaneous CRYSVITA -twza J0584 Injection, burosumab-twza 1 mg Immunology Monoclonal Antibody CINQAIR J2786 Injection, reslizumab, 1 mg Immunology Monoclonal Antibody DUPIXENT J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Monoclonal Antibody FASENRA J0517 Injection, benralizumab, 1 mg Immunology Monoclonal Antibody NUCALA J2182 Injection, mepolizumab, 1 mg Immunology Monoclonal Antibody XOLAIR J2357 Injection, omalizumab, 5 mg Immunology Multiple Sclerosis AVONEX interferon beta-1a Q3027 or Injection, interferon beta-1a, 1 mcg for intramuscular use or AVONEX interferon beta-1a J1826 Injection, interferon beta-1a, 30 mcg Injection interferon beta-1b, 0.25 mg (code may be used for Medicare when drug administered Immunology Multiple Sclerosis BETASERON interferon beta-1b J1830 under the direct supervision of a physician, not for use when drug is self-administered Immunology Multiple Sclerosis COPAXONE glatiramer J1595 Injection, glatiramer acetate, 20 mg Injection interferon beta-1b, 0.25 mg (code may be used for Medicare when drug administered Immunology Multiple Sclerosis EXTAVIA interferon beta-1b J1830 under the direct supervision of a physician, not for use when drug is self-administered

Immunology Multiple Sclerosis GLATIRAMER ACETATE (generic) glatiramer J1595 Injection, glatiramer acetate, 20 mg Immunology Multiple Sclerosis GLATOPA glatiramer J1595 Injection, glatiramer acetate, 20 mg Immunology Multiple Sclerosis KESIMPTA J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Multiple Sclerosis LEMTRADA J0202 Injection, alemtuzumab, 1 mg Immunology Multiple Sclerosis (generic) mitoxantrone J9293 Injection, mitoxantrone hydrochloride, per 5 mg Immunology Multiple Sclerosis OCREVUS J2350 Injection, ocrelizumab, 1 mg Immunology Multiple Sclerosis PLEGRIDY peginterferon beta J3590/C9399 (Hospital Outpt Use Only) Unclassified biologics/ Unclassified drugs or biologicals (Hospital Outpatient Use ONLY) Immunology Multiple Sclerosis REBIF interferon beta-1a Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use Immunology Multiple Sclerosis TYSABRI J2323 Injection, natalizumab, 1 mg Immunosuppressive Agents Monoclonal Antibody GAMIFANT -lzsg J9210 Injection, emapalumab-lzsg, 1 mg collagenase Miscellaneous Collagenase XIAFLEX J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg histolyticum Miscellaneous Musculoskeletal Agents SPINRAZA J2326 Injection, nusinersen, 0.1 mg Miscellaneous Musculoskeletal Agents ZOLGENSMA -xioi J3399 Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10 Miscellaneous Viscosupplements DUROLANE sodium hyaluronate J7318 Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg Miscellaneous Viscosupplements EUFLEXXA sodium hyaluronate J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose Miscellaneous Viscosupplements GEL-ONE sodium hyaluronate J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose Miscellaneous Viscosupplements GELSYN-3 sodium hyaluronate J7328 Hyaluronan or derivative, GELSYN-3, for intra-articular injection, 0.1 mg Miscellaneous Viscosupplements GENVISC 850 sodium hyaluronate J7320 Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg Miscellaneous Viscosupplements HYALGAN sodium hyaluronate J7321 Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose Miscellaneous Viscosupplements HYMOVIS sodium hyaluronate J7322 Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg Miscellaneous Viscosupplements MONOVISC hyaluronan J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose Miscellaneous Viscosupplements ORTHOVISC sodium hyaluronate J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose Miscellaneous Viscosupplements SUPARTZ FX sodium hyaluronate J7321 Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose Miscellaneous Viscosupplements SYNVISC sodium hyaluronate J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg Miscellaneous Viscosupplements SYNVISC-ONE sodium hyaluronate J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg Miscellaneous Viscosupplements TRILURON sodium hyaluronate J7332 Hyaluronan or derivative, Triluron, for intra-articular injection, 1 mg Miscellaneous Viscosupplements TRIVISC sodium hyaluronate J7329 Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg Miscellaneous Viscosupplements VISCO-3 sodium hyaluronate J7321 Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose Miscellaneous Wound Care REGRANEX S0157 Becaplermin gel 0.01%, 0.5 gm Oncology Rescue/ KHAPZORY levoleucovorin J0642 Injection, levoleucovorin (Khapzory), 0.5 mg Oncology (Injectable) Alkylating Agents BELRAPZO J9036 Injection, bendamustine hydrochloride, (Belrapzo/bendamustine), 1 mg Oncology (Injectable) Alkylating Agents BENDEKA bendamustine J9034 Injection, bendamustine HCl (Bendeka), 1 mg Oncology (Injectable) Alkylating Agents TREANDA bendamustine J9033 Injection, bendamustine HCl (Treanda), 1 mg Oncology (Injectable) Alkylating Agents YONDELIS J9352 Injection, trabectedin, 0.1 mg Oncology (Injectable) Alkylating Agents ZEPZELCA lurbinectedin J9223 Injection, lurbinectedin, 0.1 mg Oncology (Injectable) Antifolate FOLOTYN J9307 Injection, pralatrexate, 1 mg Oncology (Injectable) Antifolate TECENTRIQ J9022 Injection, atezolizumab, 10 mg Oncology (Injectable) Antimicrotubular HALAVEN J9179 Injection, eribulin mesylate, 0.1 mg Oncology (Injectable) Antimicrotubular JEVTANA J9043 Injection, cabazitaxel, 1 mg Lisocabtagene maraleucel, up to 110 million autologous anti-cd19 car-positive viable t cells, Oncology (injectable) CAR-T Therapy BREYANZI lisocabtagene maraleucel C9076 including leukapheresis and dose preparation procedures, per therapeutic dose Tisagenlecleucel, up to 600 million car-positive viable t cells, including leukapheresis and dose Oncology (injectable) CAR-T Therapy KYMRIAH tisagenlecleucel Q2042 preparation procedures, per therapeutic dose Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, Oncology (injectable) CAR-T Therapy TECARTUS brexucabtagene autoleucel Q2053 including leukapheresis and dose preparation procedures, per therapeutic dose Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR positive T cells, including Oncology (injectable) CAR-T Therapy YESCARTA axicabtagene ciloleucel Q2041 leukapheresis and dose preparation procedures, per therapeutic dose Oncology (Injectable) Interleukins ELZONRIS tagraxofusp-erzs J9269 Injection, tagraxofusp-erzs, 10 mcg Oncology (Injectable) Interleukins PROLEUKIN aldesleukin J9015 Injection, aldesleukin, per single use vial Oncology (Injectable) Kinase and Molecular Target Inhibitors ALIQOPA copanlisib J9057 Injection, copanlisib, 1 mg Oncology (Injectable) Kinase and Molecular Target Inhibitors BESPONSA J9229 Injection, inotuzumab ozogamicin, 0.1 mg Oncology (Injectable) Kinase and Molecular Target Inhibitors (generic) bortezomib J9044 Injection, bortezomib, not otherwise specified, 0.1 mg Oncology (Injectable) Kinase and Molecular Target Inhibitors KYPROLIS J9047 Injection, carfilzomib, 1 mg Oncology (Injectable) Kinase and Molecular Target Inhibitors PORTRAZZA J9295 Injection, necitumumab, 1 mg

Revised: 07/28/2021 Effective Date: 08/01/2021 DRUGS REQUIRING PRIOR AUTHORIZATION IN THE MEDICAL BENEFIT Page 4

Therapeutic Category Drug Class Trade Name Generic Name HCPCS Procedure Code HCPCS Procedure Code Description Oncology (Injectable) Kinase and Molecular Target Inhibitors VELCADE bortezomib J9041 Injection, bortezomib (velcade), 0.1 mg Oncology (Injectable) Kinase and Molecular Target Inhibitors VYXEOS J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine Oncology (Injectable) Kinase and Molecular Target Inhibitors ZALTRAP ziv- J9400 Injection, ziv-aflibercept, 1 mg Oncology (Injectable) Miscellaneous AVASTIN C9257 Injection, bevacizumab, 0.25 mg Oncology (Injectable) Miscellaneous BELEODAQ J9032 Injection, belinostat, 10 mg Oncology (Injectable) Miscellaneous COSELA trilaciclib C9078 Injection, trilaciclib, 1 mg Oncology (Injectable) Miscellaneous DACOGEN J0894 Injection, decitabine, 1 mg Oncology (Injectable) Miscellaneous DECITABINE (generic) decitabine J0894 Injection, decitabine, 1 mg Oncology (Injectable) Miscellaneous ISTODAX J9315 Injection, romidepsin, 1 mg Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, Oncology (Injectable) Miscellaneous PROVENGE sipuleucel-T Q2043 including leukapheresis and all other preparatory procedures, per infusion Oncology (Injectable) Miscellaneous ROMIDEPSIN romidepsin C9065 Injection, romidepsin, non-lyophilized (e.g. liquid), 1 mg Oncology (Injectable) Miscellaneous SYNRIBO omacetaxine J9262 Injection, omacetaxine mepesuccinate, 0.01 mg Oncology (Injectable) Monoclonal Antibody ADCETRIS brentuximab J9042 Injection, , 1 mg Oncology (Injectable) Monoclonal Antibody ARZERRA ofatumumab J9302 Injection, ofatumumab, 10 mg Oncology (Injectable) Monoclonal Antibody BAVENCIO J9023 Injection, avelumab, 10 mg Oncology (Injectable) Monoclonal Antibody BLENREP -blmf J9037 Injection, belantamab mafodontin-blmf, 0.5 mg Oncology (Injectable) Monoclonal Antibody BLINCYTO J9039 Injection, blinatumomab, 1 mcg Oncology (Injectable) Monoclonal Antibody CYRAMZA J9308 Injection, ramucirumab, 5 mg Oncology (Injectable) Monoclonal Antibody DANYELZA naxitamab-gqgk J9348 Injection, naxitamab-gqgk, 1 mg Oncology (Injectable) Monoclonal Antibody DARZALEX J9145 Injection, daratumumab, 10 mg Oncology (Injectable) Monoclonal Antibody DARZALEX FASPRO daratumumab-hyaluronidase-fihj J9144 Injection, daratumumab 10 mg and hyaluronidase-fihj Oncology (Injectable) Monoclonal Antibody EMPLICITI J9176 Injection, elotuzumab, 1 mg Oncology (Injectable) Monoclonal Antibody ENHERTU fam- deruxtecan-nxki J9358 Injection, fam--nxki, 1 mg Oncology (Injectable) Monoclonal Antibody ERBITUX J9055 Injection, cetuximab, 10 mg Oncology (Injectable) Monoclonal Antibody GAZYVA J9301 Injection, obinutuzumab, 10 mg Oncology (Injectable) Monoclonal Antibody HERCEPTIN trastuzumab J9355 Injection, trastuzumab, excludes biosimilar, 10 mg Oncology (Injectable) Monoclonal Antibody HERCEPTIN HYLECTA trastuzumab and hyaluronidase- J9356 Injection, trastuzumab, 10 mg and hyaluronidase-oysk Oncology (Injectable) Monoclonal Antibody HERZUMA trastuzumab-pkrb Q5113 Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg Oncology (Injectable) Monoclonal Antibody IMFINZI J9173 Injection, durvalumab, 10 mg Oncology (Injectable) Monoclonal Antibody KADCYLA ado- J9354 Injection, ado-trastuzumab emtansine, 1 mg Oncology (Injectable) Monoclonal Antibody KANJINTI trastuzumab-anns Q5117 Injection, trastuzumab-anns, biosimilar, (Kanjinti), 10 mg Oncology (Injectable) Monoclonal Antibody KEYTRUDA J9271 Injection, pembrolizumab, 1 mg Oncology (Injectable) Monoclonal Antibody LIBTAYO -rwlc J9119 Injection, cemiplimab-rwlc, 1 mg Oncology (Injectable) Monoclonal Antibody LUMOXITI -tdfk J9313 Injection, moxetumomab pasudotox-tdfk, 0.01 mg Oncology (Injectable) Monoclonal Antibody MONJUVI -cxix J9349 Injection, tafasitamab-cxix, 2 mg Oncology (Injectable) Monoclonal Antibody MVASI bevacizumab-awwb Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg Oncology (Injectable) Monoclonal Antibody MYLOTARG gemtuzumab J9203 Injection, , 0.1 mg Oncology (injectable) Monoclonal Antibody OGIVRI trastuzumab-dkst Q5114 Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg Oncology (Injectable) Monoclonal Antibody ONTRUZANT trastuzumab-dttb Q5112 Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg Oncology (Injectable) Monoclonal Antibody OPDIVO J9299 Injection, nivolumab, 1 mg Oncology (Injectable) Monoclonal Antibody PADCEV -ejfv J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg Oncology (Injectable) Monoclonal Antibody PERJETA J9306 Injection, pertuzumab, 1 mg Oncology (Injectable) Monoclonal Antibody PHESGO pertuzumab-trastuz-hyaluron-zzxf J9316 Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg Oncology (injectable) Monoclonal Antibody POLIVY -piiq J9309 Injection, polatuzumab vedotin-piiq, 1 mg Oncology (Injectable) Monoclonal Antibody POTELIGEO -kpkc J9204 Injection, mogamulizumab-kpkc, 1 mg Oncology (Injectable) Monoclonal Antibody RIABNI -arrx Q5123 Injection, rituximab-arrx, biosimilar, (riabni), 10 mg Oncology (Injectable) Monoclonal Antibody RITUXAN rituximab J9312 Injection, rituximab, 10 mg Oncology (Injectable) Monoclonal Antibody RITUXAN HYCELA rituximab-hyaluronidase J9311 Injection, rituximab 10 mg and hyaluronidase Oncology (Injectable) Monoclonal Antibody RUXIENCE rituximab-pvvr Q5119 Injection, rituximab-pvvr, biosimilar, (RUXIENCE), 10 mg Oncology (Injectable) Monoclonal Antibody SARCLISA -irfc iv J9227 Injection, isatuximab-irfc, 10 mg Oncology (Injectable) Monoclonal Antibody SYLVANT J2860 Injection, siltuximab, 10 mg Oncology (Injectable) Monoclonal Antibody TRAZIMERA trastuzumab-qyyp Q5116 Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg Oncology (Injectable) Monoclonal Antibody TRODELVY -hziy J9317 Injection, sacituzumab govitecan-hziy, 2.5 mg Oncology (Injectable) Monoclonal Antibody TRUXIMA rituximab-abbs iv soln Q5115 Injection, rituximab-abbs, biosimilar, (Truxima), 10 mg Not otherwise classified, antineoplastic drugs/ Unclassified drugs or biologicals (Hospital Oncology (Injectable) Monoclonal Antibody UNITUXIN J9999/C9399 (Hospital Outpt Use Only) Outpatient Use ONLY) Oncology (Injectable) Monoclonal Antibody XGEVA denosumab J0897 Injection, denosumab, 1 mg Oncology (Injectable) Monoclonal Antibody YERVOY J9228 Injection, ipilimumab, 1 mg Oncology (Injectable) Monoclonal Antibody ZIRABEV bevacizumab-bvzr Q5118 Injection, bevacizumab-bvcr, biosimilar, (Zirabev), 10 mg Oncology (Injectable) Radiopharmaceuticals LUTATHERA lutetium Lu 177 dotatate A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi Oncology (Injectable) Topoisomerase I Inhibitors ONIVYDE HCl liposome J9205 Injection, irinotecan liposome, 1 mg Oncology (Injectable) Viral Agents IMLYGIC talimogene laherparepvec J9325 Injection, talimogene laherparepvec, per 1 million plaque forming units Oncology (Oral) Kinase and Molecular Target Inhibitors GLEEVEC S0088 Imatinib, 100 mg Oncology (Oral) Kinase and Molecular Target Inhibitors IMATINIB (generic) imatinib S0088 Imatinib, 100 mg Oncology (Oral) Kinase and Molecular Target Inhibitors IRESSA J8565 Gefitinib, oral, 250 mg Miscellaneous LUXTURNA voretigene neparvovec-rzyl J3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes Ophthalmology Vascular Endothelial (VEGF) BEOVU -dbll J0179 Injection, brolucizumab-dbll, 1 mg Ophthalmology Vascular Endothelial Growth Factor (VEGF) EYLEA aflibercept J0178 Injection, aflibercept, 1 mg Ophthalmology Vascular Endothelial Growth Factor (VEGF) LUCENTIS J2778 Injection, ranibizumab, 0.1 mg Dornase alfa, inhalation solution, FDA-approved final product, noncompounded, administered Respiratory Cystic fibrosis PULMOZYME dornase alfa J7639 through DME, unit dose form, per mg Urology Miscellaneous OXLUMO sodium J0224 Injection, lumasiran, 0.5 mg

Revised: 07/28/2021