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Medicare Plus Blue PPO Assure & PDP Option B. Prior Authorization/Step Therapy

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BCN AdvantageSM HMO-POS Group Comprehensive Formulary 2020 Plan Year Updated 12/1/2020 BCN Advantage HMO-POS Group monitors the use of certain medications to ensure our members receive the most appropriate and cost-effective drug therapy. Prior authorization (PA) for these drugs means that either clinical and/or administrative criteria must be met before coverage is provided. Drugs subject to step therapy (ST) may require previous treatment with one or more formulary drugs prior to coverage. Drugs that must meet clinical/administrative criteria are identified in the formulary list with (PA) or (ST). If drugs listed below have a (g) noted, the PA or ST criteria may also apply to the generic version of the drug. In some cases, the brand name drug is listed for reference and the generic drug is covered. Please refer to the Formulary to verify if your drugs are covered. Your physician can contact our pharmacy help desk to request prior authorization or step therapy for these drugs. The clinical criteria for authorization are based on current medical information and the recommendations of the Blues’ Pharmacy and Therapeutics Committee, a group of physicians, pharmacists and other experts. Please call the customer service number on the back of your BCN Advantage member ID card if you have questions about your drug coverage or a drug claim. MEDICATION/ DRUG CLASS CRITERIA Abilify Maintena® Coverage requires trial of oral aripiprazole. (aripiprazole) Coverage duration: Lifetime. Actemra® Subcutaneous All medically accepted indications not otherwise excluded from Part D. (tocilizumab) Coverage duration: 1 year. g = generic available Page 1 of 35 FORM ID# 20163 12/1/2020 H5883_Grp20PAST_C FVNR 1120 MEDICATION/ DRUG CLASS CRITERIA Adempas® All medically accepted indications not otherwise excluded from Part D. (riociguat) Coverage duration: 1 year. Afinitor® All medically accepted indications not otherwise excluded from Part D. (everolimus) Coverage duration: 1 year. Afinitor Disperz® All medically accepted indications not otherwise excluded from Part D. (everolimus) Coverage duration: 1 year. Alecensa® All medically accepted indications not otherwise excluded from Part D. (alectinib) Coverage duration: Lifetime. Alpha-1 Proteinase Inhibitors Requires documentation of a congenital deficiency of alpha-1 antitrypsin, Prolastin® demonstrated by a homozygous phenotype of AAT, and must have symptomatic Zemaira® emphysema and serum levels of alpha-1 antitrypsin that are less than 80mg/dl and must have deteriorating pulmonary function, as demonstrated by a decline in the fev1 (less than 65% of predictive value). For reauthorization must provide serum levels of alpha-1 antitrypsin that are above threshold of 80mg/dl. All medically accepted indications not otherwise excluded from Part D. Age restrictions: Patients 18 years of age or older. Coverage duration: Initial approval is for 6 months. Reauthorization is for 1 year. g = generic Page 2 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Alunbrig™ All medically accepted indications not otherwise excluded from Part D. (brigatinib) Coverage duration: 1 year. Amitiza® All medically accepted indications not otherwise excluded from Part D. (lubiprostone) Age restrictions: Patients 18 years of age or older. Coverage duration: 1 year. Ampyra® (g) Initial requests require documentation of a 25 foot timed walk test. (dalfampridine) Renewal of therapy requires documentation that the member has shown an improvement in walking distance of a 25 foot timed walk test compared to pretreatment. All medically accepted indications not otherwise excluded from Part D. Prescriber restrictions: Prescribing physician is a neurologist. Exclusion criteria: Patients with a history of seizure or moderate to severe renal impairment defined by a CrCl of 50ml/min or less. Coverage duration: Initial approval is for 3 months. Reauthorization is for 1 year. g = generic Page 3 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Anabolic Steroids All medically accepted indications not otherwise excluded from Part D. Anadrol-50® (oxymetholone) Oxandrin® (g) (oxandrolone) Exclusion criteria: Coverage will not be provided if anabolic steroids are used to enhance athletic performance or for anti-aging purposes. Coverage duration: 1 year. Androgel® (g) All medically accepted indications not otherwise excluded from Part D. (testosterone) Coverage duration: 1 year. Anticonvulsants Coverage requires trial or intolerance to at least 2 generic anticonvulsants. Oxtellar XR® (oxcarbazine) Coverage duration: Lifetime. Anti-diabetic Injectable Agents Coverage will be provided for patients who are currently taking or who have tried Byetta® (exenatide) and failed one of the following: metformin, a sulfonylurea or a thiazolidinedione, or Bydureon®, Bydureon® BCise™ one of the following: a combination of metformin and a sulfonylurea or a (exenatide) combination of metformin and a thiazolidinedione. Victoza® (liraglutide) All medically accepted indications not otherwise excluded from Part D. Exclusion criteria: Coverage will not be provided for a non-Type 2 diabetes diagnosis or for weight loss in patients with or without diabetes. Coverage duration: Lifetime. Anti-diabetic agents Coverage requires trial or intolerance to at least 1 of the following: metformin, a Farxiga ™ (dapagliflozin) sulfonylurea, pioglitazone or a DPP-4 inhibitor. Invokana® (canagliflozin) Invokamet®, Invokamet® XR Coverage duration: Lifetime. (canagliflozin + metformin) Xigduo XR™ (dapagliflozin + metformin) g = generic Page 4 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Antidepressants Coverage requires the trial of at least 2 formulary generic antidepressants. Trintellix® (voritoxetine) Desvenlafaxine ER Coverage duration: Lifetime. Fetzima™ (levomilnacipran) Fetzima™ titration pack (levominacipran) Viibryd® (vilazodone HCl) Antipsychotic Agents Coverage requires that the member has had a trial of at least one generic Caplyta® (lumateperone) antipsychotic agent. Latuda® (lurasidone) Saphris® (asenapine) Coverage duration: Lifetime. Secuado® (asenapine) Vraylar™ (cariprazine) Zyprexa® Relprevv™ (olanzapine) Apidra® Coverage requires the trial or intolerance to Novolin® 70/30, Novolin® N, (insulin glulisine) Novolin® R, Novolog® 70/30 or Novolog®. Coverage duration: Lifetime. Arcalyst® All medically accepted indications not otherwise excluded from Part D. (rilonacept) Age restrictions: Patients 12 years of age and older. Coverage duration: 1 year. Arikayce® All medically accepted indications not otherwise excluded from Part D. (amikacin liposome inhalation suspension) Coverage duration: 1 year. g = generic Page 5 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Aristada™ Coverage requires trial or intolerance to Abilify Maintena or oral aripiprazole. (aripiprazole lauroxil) Coverage duration: Lifetime. Aristada Initio™ Coverage requires trial of oral aripiprazole. (aripiprazole lauroxil) Coverage duration: Lifetime. Aubagio® All medically accepted indications not otherwise excluded from Part D. (teriflunomide) Coverage duration: 1 year. Auryxia® All medically accepted indications not otherwise excluded from Part D. (ferric citrate) Coverage duration: 1 year. Avonex® All medically accepted indications not otherwise excluded from Part D. (interferon beta-1a) Coverage duration: Lifetime. Ayvakit™ All medically accepted indications not otherwise excluded from Part D. (avapritinib) Coverage duration: 1 year. Balversa™ All medically accepted indications not otherwise excluded from Part D. (erdafitinib) Coverage duration: 1 year. g = generic Page 6 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Berinert® All medically accepted indications not otherwise excluded from Part D. (C1 inhibitor, human) Coverage duration: 1 year. Betaseron® All medically accepted indications not otherwise excluded from Part D. (interferon beta-1b) Coverage duration: Lifetime. Blenrep All medically accepted indications not otherwise excluded from Part D. (belantamab mafodotin-blmf) Coverage duration: 1 year. Bosulif® All medically accepted indications not otherwise excluded from Part D. (bosutinib) Coverage duration: 1 year. Braftovi™ All medically accepted indications not otherwise excluded from Part D. (encorafenib) Coverage duration: 1 year. Briviact® All medically accepted indications not otherwise excluded from Part D. (brivaracetam) Coverage duration: 1 year. Brukinsa™ All medically accepted indications not otherwise excluded from Part D. (zanubrutinib) Coverage duration: 1 year. Cablivi® All medically accepted indications not otherwise excluded from Part D. (caplacizumab-yhdp) Coverage duration: 1 year. g = generic Page 7 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Cabometyx™ All medically accepted indications not otherwise excluded from Part D. (cabozantinib) Coverage duration: 1 year. Calquence® All medically accepted indications not otherwise excluded from Part D. (acalabrutinib) Coverage duration: 1 year. Cayston® All medically accepted indications not otherwise excluded from Part D. (aztreonam) Coverage duration: 1 year. Cholbam® All medically accepted indications not otherwise excluded from Part D. (cholic acid) Coverage duration: Lifetime. g = generic Page 8 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Cimzia® Coverage will be provided for the diagnosis of rheumatoid arthritis when there has (certolizumab pegol) been a trial of two of the following preferred agents: tocilizumab
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