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 (Actemra®) SC, etanercept (Enbrel®), adalimumab (Humira®), or tofacitinib (Xeljanz®/Xeljanz® XR).

Coverage will be provided for the diagnosis of ankylosing spondylitis when there has been a trial of two of the following preferred agents: secukinumab (Cosentyx ®), etanercept (Enbrel®), or adalimumab (Humira®).

Coverage will be provided for the diagnosis of psoriatic arthritis when there has been a trial of two of the following preferred agents: secukinumab (Cosentyx ®), etanercept (Enbrel®), adalimumab (Humira®), apremilast (Otezla®), ustekinumab (Stelara®), or tofacitinib (Xeljanz®/Xeljanz® XR).

Coverage will be provided for the diagnosis of Crohn’s disease when there has been a trial of adalimumab (Humira®) or ustekinumab (Stelara®).

Coverage will be provided for the diagnosis of moderate to severe plaque psoriasis when there has been a trial of two of the following preferred agents: secukinumab (Cosentyx®), etanercept (Enbrel®), adalimumab (Humira®), ustekinumab (Stelara®), or apremilast (Otezla®).

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

Cometriq® All medically accepted indications not otherwise excluded from Part D. (cabozantinib s-malate) Coverage duration: 1 year.

Copaxone® All medically accepted indications not otherwise excluded from Part D. (glatiramer acetate) Coverage duration: Lifetime.

g = generic Page 9 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Copiktra™ All medically accepted indications not otherwise excluded from Part D. (duvelisib) Coverage duration: 1 year.

Cosentyx® All medically accepted indications not otherwise excluded from Part D. (secukinumab) Coverage duration: 1 year.

Cotellic™ All medically accepted indications not otherwise excluded from Part D. (cobimetinib) Coverage duration: Lifetime.

Crinone® All medically accepted indications not otherwise excluded from Part D. (progesterone) Coverage duration: 1 year.

Daurismo™ All medically accepted indications not otherwise excluded from Part D. (glasdegib) Coverage duration: 1 year.

Dojolvi™ All medically accepted indications not otherwise excluded from Part D. (triheptanoin) Coverage duration: 1 year.

Doptelet® All medically accepted indications not otherwise excluded from Part D. (avatrombopag) Coverage duration: 1 year.

Enbrel® All medically accepted indications not otherwise excluded from Part D. (etanercept) Coverage duration: 1 year.

g = generic Page 10 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Enhertu® All medically accepted indications not otherwise excluded from Part D. (fam-trastuzumab deruxtecan-nxki) Coverage duration: 1 year.

Enspryng™ All medically accepted indications not otherwise excluded from Part D. (satralizumab-mwge) Coverage duration: 1 year.

Epclusa® All medically accepted indications not otherwise excluded from Part D. (sofosbuvir/velpatasvir) Coverage duration: Criteria will be applied consistent with current AASLD/IDSA guidance.

Epidiolex® All medically accepted indications not otherwise excluded from Part D. (cannabidiol) Coverage duration: 1 year.

Erivedge® All medically accepted indications not otherwise excluded from Part D. (vismodegib) Prescribers restrictions: Prescribing Physician is an Oncologist or Dermatologist.

Coverage duration: 1 year.

Erleada™ All medically accepted indications not otherwise excluded from Part D. (apalutamide) Coverage Duration: 1 year.

Erythropoiesis Stimulating Agents Erythropoiesis stimulating agents are suject to Part B versus Part D review. Aranesp® (darbepoetin), Epogen® (epoetin alfa), All medically accepted indications not otherwise excluded from Part D. Procrit® (epoetin alfa) Coverage duration: 3 months.

g = generic Page 11 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Esbriet® All medically accepted indications not otherwise excluded from Part D. (pirfenidone) Coverage duration: 1 year.

Extavia® Coverage requires trial of at least one of the following: Interferon Beta-1B (Interferon beta-1B) (Betaseron®), Interferon Beta-1A (Avonex®), Peginterferon Beta-1A (Plegridy®) or Interferon Beta-1A (Rebif®)

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: Lifetime.

Farydak® All medically accepted indications not otherwise excluded from Part D. (panobinostat) Coverage duration: 1 year.

Fintepla® All medically accepted indications not otherwise excluded from Part D. (fenfluramine) Coverage duration: 1 year.

Firazyr® All medically accepted indications not otherwise excluded from Part D. (icatibant acetate) Age restrictions: Patients 18 years of age and older.

Coverage duration: 1 year.

Firdapse® All medically accepted indications not otherwise excluded from Part D. (amifampridine) Coverage duration: 1 year.

g = generic Page 12 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Forteo® Coverage requires documentation of bone mineral density that is 2.5 standard (teriparatide) deviations or more below the mean (T-score at or below -2.5).

Coverage also requires that the patient has tried and failed at least one bisphosphonate except when: 1. There is a contraindication to an oral and intravenous bisphosphonate (such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration), 2. There is documented intolerance to a bisphosphonate.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: One year with a maximum two years of therapy.

Galafold™ All medically accepted indications not otherwise excluded from Part D. (migalastat) Coverage duration: 1 year.

Gattex® Coverage requires documentation of dependence on parenteral support for 12 (teduglutide) months or greater.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

Gavreto™ All medically accepted indications not otherwise excluded from Part D. (pralsetinib) Coverage duration: 1 year.

Gilenya® All medically accepted indications not otherwise excluded from Part D. (fingolimod hydrochloride) Coverage duration: 1 year.

g = generic Page 13 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Gilotrif® All medically accepted indications not otherwise excluded from Part D. (afatinib) Coverage duration: 1 year.

Gleevec® (g) All medically accepted indications not otherwise excluded from Part D. (imatinib mesylate) Coverage duration: 1 year.

Growth Hormone All medically accepted indications not otherwise excluded from Part D. (somatropin), Humatrope®, Norditropin® , Nutropin®, Prescriber restrictions: For pediatric patients, all indications must be prescribed Omnitrope®, Serostim® by a pediatric endocrinologist or pediatric nephrologist.

Coverage duration: Pediatrics: 1 year, Adults: Lifetime.

Haegarda® All medically accepted indications not otherwise excluded from Part D. (C1 Inhibitor, Human) Age restrictions: Patients 6 years of age and older.

Coverage duration: 1 year.

Harvoni™ All medically accepted indications not otherwise excluded from Part D. (ledipasvir/sofosbuvir) Coverage duration: Criteria will be applied consistent with current AASLD/IDSA guidance.

Hemady™ All medically accepted indications not otherwise excluded from Part D. (dexamethasone) Coverage duration: 1 year.

Hetlioz™ All medically accepted indications not otherwise excluded from Part D. (tasimelteon) Coverage duration: 1 year.

g = generic Page 14 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Humalog® Coverage requires the trial of or intolerance to Novolog® 70/30 or Novolog®. (insulin lispro) Coverage duration: Lifetime.

Humira® All medically accepted indications not otherwise excluded from Part D. (adalimumab) Coverage duration: 1 year.

Humulin® Insulin Coverage requires a trial of or intolerance to Novolin® 70/30, Novolin® N or (Humulin® R, Humulin® N, Humulin® Novolin® R. 70/30) Coverage duration: Lifetime.

Ibrance® All medically accepted indications not otherwise excluded from Part D. (palbociclib) Coverage duration: 1 year.

Iclusig® All medically accepted indications not otherwise excluded from Part D. (ponatinib) Coverage duration: 1 year.

Idhifa® All medically accepted indications not otherwise excluded from Part D. (enasidenib) Coverage duration: 1 year.

Ilaris® All medically accepted indications not otherwise excluded from Part D. (canakinumab) Coverage duration: 1 year.

Imbruvica™ All medically accepted indications not otherwise excluded from Part D. (ibrutinib) Coverage duration: 1 year.

g = generic Page 15 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Increlex® All medically accepted indications not otherwise excluded from Part D. (mecasermin) Coverage duration: 1 year.

Inlyta® All medically accepted indications not otherwise excluded from Part D. (axitinib) Coverage duration: 1 year.

Inqovi® All medically accepted indications not otherwise excluded from Part D. (decitabine and cedazuridine) Coverage duration: 1 year.

Inrebic® All medically accepted indications not otherwise excluded from Part D. (fedratinib) Coverage duration: 1 year.

Intranasal Steroids Coverage requires a claim for 30 days of a generic nasal steroid spray or Beconase Omnaris® (ciclesonide) AQ in the past 120 days.

Coverage duration: 1 year.

Invega Sustenna® Coverage requires the trial of oral paliperidone or oral risperidone. (paliperidone palmitate) Coverage duration: Lifetime.

Invega Trinza™ Coverage requires the trial of oral paliperidone or oral risperidone. (paliperidone palmitate) Coverage duration: Lifetime.

Jakafi® All medically accepted indications not otherwise excluded from Part D. (ruxolitinib) Prescriber restrictions: prescribing physician is an oncologist or hematologist.

Coverage duration: 1 year. g = generic Page 16 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Jynarque™ All medically accepted indications not otherwise excluded from Part D. (tolvaptan) Coverage duration: 1 year.

KalydecoTM All medically accepted indications not otherwise excluded from Part D. (ivacaftor) Coverage duration: Lifetime.

Kineret® Coverage for the diagnosis of rheumatoid arthritis requires a trial of two of the (anakinra) following preferred agents: tocilizumab (Actemra®) SC, etanercept (Enbrel®), adalimumab (Humira®), or tofacitinib (Xeljanz®/Xeljanz® XR).

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

Kisqali® All medically accepted indications not otherwise excluded from Part D. (ribociclib) Kisqali® Femara® Co-Pack Coverage duration: 1 year. (ribociclib & letrozole)

Korlym™ All medically accepted indications not otherwise excluded from Part D. (mifepristone) Coverage duration: 1 year.

Koselugo™ All medically accepted indications not otherwise excluded from Part D. (selumetinib) Coverage duration: 1 year.

Lenvima™ All medically accepted indications not otherwise excluded from Part D. (lenvatinib) Coverage duration: 1 year.

g = generic Page 17 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Libtayo® All medically accepted indications not otherwise excluded from Part D. (cemiplimab-rwlc) Coverage duration: 1 year.

Lidoderm® Patch (g) All medically accepted indications not otherwise excluded from Part D. (lidocaine) Coverage duration: 1 year.

Livalo® Coverage requires that the member has had a trial of at least one generic statin. (pitavastatin) Coverage duration: Lifetime.

Lonsurf® All medically accepted indications not otherwise excluded from Part D. (trifluridine and tipiracil) Coverage duration: Lifetime.

Lorbrena® All medically accepted indications not otherwise excluded from Part D. (lorlatinib) Coverage duration: 1 year.

Lotronex® (g) All medically accepted indications not otherwise excluded from Part D. (alosetron) Coverage duration: 1 year.

Lumoxiti™ All medically accepted indications not otherwise excluded from Part D. (moxetumomab pasudotox-tdfk) Coverage duration: 1 year.

LynparzaTM All medically accepted indications not otherwise excluded from Part D. (olaparib) Coverage duration: 1 year.

g = generic Page 18 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Megace® (g) All medically accepted indications not otherwise excluded from Part D. (megestrol) Coverage duration: Lifetime.

MekinistTM All medically accepted indications not otherwise excluded from Part D. (trametinib) Coverage duration:. Lifetime.

Mektovi® All medically accepted indications not otherwise excluded from Part D. (binimetinib) Coverage duration: 1 year.

Monjuvi™ All medically accepted indications not otherwise excluded from Part D. (tafasitamab-cxix) Coverage duration: 1 year.

MovantikTM Coverage is provided for diagnosis of opioid induced chronic constipation with (naloxegol oxalate) chronic, non-cancer pain. Member must be stable on opioid therapy for a minimum of 2 weeks.

All medically accepted indications not otherwise excluded from Part D.

Age restrictions: Patients 18 years of age or older.

Coverage duration: Initial=3 months Renewal=1 year

Myalept All medically accepted indications not otherwise excluded from Part D. (metreleptin) Prescriber restrictions: Prescribing physician is an endocrinologist.

Coverage duration: 1 year.

g = generic Page 19 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Narcolepsy Agents All medically accepted indications not otherwise excluded from Part D. Nuvigil® (g) (armodafinil) Provigil® (g) (modafanil) Coverage duration: Lifetime.

Narcotic analgesics All medically accepted indications not otherwise excluded from Part D. (fentanyl citrate) Abstral® Coverage duration: 1 year. Actiq® (g) Fentora® Lazanda™ Subsys™

Natpara® All medically accepted indications not otherwise excluded from Part D. (parathyroid hormone, recombinant) Coverage duration: 1 year.

Nerlynx™ All medically accepted indications not otherwise excluded from Part D. (neratinib) Coverage duration: 1 year.

Nexavar All medically accepted indications not otherwise excluded from Part D. (sorafenib) Coverage duration: 1 year.

Ninlaro® All medically accepted indications not otherwise excluded from Part D. (ixazomib) Coverage duration: Lifetime.

Nityr™ All medically accepted indications not otherwise excluded from Part D. (nitisinone) Coverage duration: 1 year.

g = generic Page 20 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Nubeqa™ All medically accepted indications not otherwise excluded from Part D. (darolutamide) Coverage duration: 1 year.

Nuedexta® All medically accepted indications not otherwise excluded from art D. (dextromethorphan hydrobromide/quinidine sulfate) Coverage duration: Lifetime.

Nuplazid™ All medically accepted indications not otherwise excluded from Part D. (pimavanserin) Coverage duration: 1 year.

Odomzo® All medically accepted indications not otherwise excluded from Part D. (sonidegib) Coverage duration: Lifetime.

Ofev® All medically accepted indications not otherwise excluded from Part D. (nintedanib) Coverage duration: Lifetime.

Onureg® All medically accepted indications not otherwise excluded from Part D. (azacitidine) Coverage duration: 1 year.

g = generic Page 21 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Orencia® Coverage for the diagnosis of rheumatoid arthritis requires trial of two of the (abatacept) following preferred agents: tocilizumab (Actemra®) SC, etanercept (Enbrel®), adalimumab (Humira®), or tofacitinib (Xeljanz®/Xeljanz® XR).

Coverage for the diagnosis of juvenile idiopathic arthritis requires trial of two of the following preferred agents: tocilizumab (Actemra®) SC, etanercept (Enbrel®) or adalimumab (Humira®).

Coverage for the diagnosis of psoriatic arthritis requires trial of two of the following preferred agents: secukinumab (Cosentyx®), etanercept (Enbrel®), adalimumab (Humira®), apremilast (Otezla®), ustekinumab (Stelara®), tofacitinib (Xeljanz®/Xeljanz® XR).

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

Orenitram ER™ Coverage is provided for the diagnosis of pulmonary arterial hypertension. (treprostinil diolamine) Requires trial and failure or contraindication to inhaled treprostinil and sildenafil.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: Lifetime.

Orkambi® All medically accepted indications not otherwise excluded from Part D. (ivacaftor/lumacaftor) Coverage duration: Lifetime.

Otezla All medically accepted indications not otherwise excluded from Part D. (apremilast) Coverage duration: 1 year.

g = generic Page 22 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Oxbryta™ All medically accepted indications not otherwise excluded from Part D. (voxelotor) Coverage duration: 1 year.

Oxervate™ All medically accepted indications not otherwise excluded from Part D. (cenegermin-bkbj) Coverage duration: 1 year.

Padcev™ All medically accepted indications not otherwise excluded from Part D. (enfortumab vedotin-ejfv) Coverage duration: 1 year.

Palynziq™ All medically accepted indications not otherwise excluded from Part D. (pegvaliase-pqpz) Coverage duration: 1 year.

Pemazyre™ All medically accepted indications not otherwise excluded from Part D. (pemigatinib) Coverage duration: 1 year.

Perseris™ Coverage requires a trial of oral risperidone. (risperidone) Coverage duration: Lifetime.

Piqray® All medically accepted indications not otherwise excluded from Part D. (alpelisib) Coverage duration: 1 year.

Plegridy All medically accepted indications not otherwise excluded from Part D. (peginterferon beta-1a) Coverage duration: 1 year.

g = generic Page 23 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Polivy™ All medically accepted indications not otherwise excluded from Part D. (polatuzumab vedotin) Coverage duration: 1 year.

Pomalyst All medically accepted indications not otherwise excluded from Part D. (pomalidomide) Coverage duration: Lifetime.

Praluent® All medically accepted indications not otherwise excluded from Part D. (alirocumab) Coverage duration: 1 year.

Prolia® Prolia® is subject to Part B versus Part D review. (denosumab) Coverage requires the patient has tried and failed at least one bisphosphonate except when: 1. There is a contraindication to an oral and intravenous bisphosphonate (such as a stricture or aclasia, inability to stand or sit upright for at least 30 minutes and increased risk of aspiration), 2. There is a documented intolerance to a bisphosphonate.

All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria: Coverage is not provided for a diagnosis of hypocalcemia.

Coverage duration: 1 year.

Promacta® All medically accepted indications not otherwise excluded from Part D. (eltrombopag) Coverage duration: 1 year.

g = generic Page 24 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Pulmonary Arterial Hypertension All medically accepted indications not otherwise excluded from Part D. (PAH) agents Adcirca® (g) (alyq™, tadalafil), Exclusion criteria: Coverage is not provided for sildenafil and tadalafil in situations Letairis® (g) (ambrisentan), where patients are receiving nitrate therapy. Opsumit® (macitentan), Revatio® (g) (sildenafil citrate), Coverage duration: 1 year. Tracleer® (bosentan)

Qinlock™ All medically accepted indications not otherwise excluded from Part D. (ripretinib) Coverage duration: 1 year.

Ravicti® All medically accepted indications not otherwise excluded from Part D. (glycerol phenylbutyrate) Coverage duration: Lifetime.

Rebif® All medically accepted indications not otherwise excluded from Part D. (interferon beta-1a) Coverage duration: Lifetime.

Relistor® All medically accepted indications not otherwise excluded from Part D. (methylnaltrexone) Age restrictions: Patients 18 years of age or older.

Exclusion criteria: Coverage is not provided for patients with known or suspected mechanical gastrointestinal obstruction.

Coverage duration: 3 months.

g = generic Page 25 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Repatha® All medically accepted indications not otherwise excluded from Part D. (evolocumab) Coverage duration: 1 year.

Retevmo™ All medically accepted indications not otherwise excluded from Part D. (selpercatinib) Coverage duration: 1 year.

Revcovi™ All medically accepted indications not otherwise excluded from Part D. (elapegademase-lvlr) Coverage duration: 1 year.

Revlimid® All medically accepted indications not otherwise excluded from Part D. (lenalidomide) Prescriber restrictions: Must be prescribed by an oncologist or hematologist.

Coverage duration: 1 year.

Rexulti® Coverage requires trial or intolerance to Abilify Maintena or oral aripiprazole. (brexpiprazole) Coverage duration: Lifetime.

Risperdal Consta® Coverage requires the trial of oral risperidone. (risperidone) Coverage duration: Lifetime.

Rozlytrek™ All medically accepted indications not otherwise excluded from Part D. (entrectinib) Coverage duration: 1 year.

Rubraca™ All medically accepted indications not otherwise excluded from Part D. (rucaparib) Coverage duration: 1 year.

g = generic Page 26 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Ruzurgi® All medically accepted indications not otherwise excluded from Part D. (amifampridine) Coverage duration: 1 year.

Rydapt® All medically accepted indications not otherwise excluded from Part D. (midostaurin) Coverage duration: 1 year.

Samsca® Coverage requires documentation that the member does not have underlying liver (tolvaptan) disease.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 month.

Sarclisa® All medically accepted indications not otherwise excluded from Part D. (isatuximab-irfc) Coverage duration: 1 year.

Savella® All medically accepted indications not otherwise excluded from Part D. (milnacipran) Coverage duration: Lifetime.

g = generic Page 27 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Simponi® Coverage is provided for the diagnosis of rheumatoid arthritis when there has been (golimumab) a trial of two of the following preferred agents: tocilizumab (Actemra®) SC, etanercept (Enbrel®), adalimumab (Humira®), tofacitinib (Xeljanz®/Xeljanz® XR).

Coverage is provided for the diagnosis of ankylosing spondylitis when there has been a trial of two of the following preferred agents: csecukinumab (Cosentyx®), etanercept (Enbrel®), adalimumab (Humira®).

Coverage is provided for the diagnosis of psoriatic arthritis when there has been a trial of two of the following preferred agents: secukinumab (Cosentyx®), etanercept (Enbrel®), adalimumab (Humira®), apremilast (Otezla®), ustekinumab (Stelara®), or tofacitinib (Xeljanz®/Xeljanz® XR).

Coverage is provided for the diagnosis of ulcerative colitis when there has been a trial of adalimumab (Humira®) or tofacitinib (Xeljanz®).

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

Sirturo™ Coverage is provided when used in combination with at least 3 other agents. (bedaquiline fumarate) All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

Somavert® All medically accepted indications not otherwise excluded from Part D. (pegvisomant) Coverage duration: 1 year.

Sovaldi® All medically accepted indications not otherwise excluded from Part D. (sofosbuvir) Coverage duration: Criteria will be applied consistent with current AASLD/IDSA guidance.

g = generic Page 28 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Sprycel® All medically accepted indications not otherwise excluded from Part D. (dasatinib) Coverage duration: 1 year.

Stelara® All medically accepted indications not otherwise excluded from Part D. (ustekinumab) Coverage duration: 1 year.

Sutent® All medically accepted indications not otherwise excluded from Part D. (sunitinib) Prescriber restrictions: Prescribing physician must be an oncologist.

Coverage duration: 1 year.

Tabrecta™ All medically accepted indications not otherwise excluded from Part D. (capmatinib) Coverage duration: 1 year.

Tafinlar® All medically accepted indications not otherwise excluded from Part D. (dabrafenib) Coverage duration: 1 year.

Tagrisso™ All medically accepted indications not otherwise excluded from Part D. (osimertinib) Coverage duration: Lifetime.

Talzenna™ All medically accepted indications not otherwise excluded from Part D. (talazoparib) Coverage duration: 1 year.

g = generic Page 29 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Tarceva® (g) All medically accepted indications not otherwise excluded from Part D. (erlotinib) Prescriber restrictions: must be prescribed by an Oncologist.

Coverage duration: 1 year.

Targretin® All medically accepted indications not otherwise excluded from Part D. (bexarotene) Prescriber restrictions: must be prescribed by an Oncologist or Dermatologist.

Coverage duration: 1 year.

Tasigna® All medically accepted indications not otherwise excluded from Part D. (nilotinib) Coverage duration: 1 year.

Tazverik™ All medically accepted indications not otherwise excluded from Part D. (tazemetostat) Coverage duration: 1 year.

Tecfidera™ All medically accepted indications not otherwise excluded from Part D. (dimethyl fumarate) Coverage duration: Lifetime.

Tegsedi™ All medically accepted indications not otherwise excluded from Part D. (inotersen) Coverage duration: 1 year.

Thalomid® All medically accepted indications not otherwise excluded from Part D. (thalidomide) Coverage duration: 1 year.

Tibsovo® All medically accepted indications not otherwise excluded from Part D. (ivosidenib) Coverage duration: 1 year. g = generic Page 30 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Trikafta™ All medically accepted indications not otherwise excluded from Part D. (elexacaftor/tezacaftor/ivacaftor) Coverage duration: Lifetime.

Trodelvy™ All medically accepted indications not otherwise excluded from Part D. (sacituzumab govitecan-hziy) Coverage duration: 1 year.

Tukysa™ All medically accepted indications not otherwise excluded from Part D. (tucatinib) Coverage duration: 1 year.

Turalio™ All medically accepted indications not otherwise excluded from Part D. (pexidartinib) Coverage duration: 1 year.

Uloric® Coverage requires trial or contraindication of allopurinol. (febuxostat) Coverage duration: Lifetime.

Uptravi® All medically accepted indications not otherwise excluded from Part D. (selexipag) Coverage duration: 1 year.

VecamylTM All medically accepted indications not otherwise excluded from Part D. (mecamylamine) Coverage duration: 1 year.

Venclexta™ All medically accepted indications not otherwise excluded from Part D. (venetoclax) Coverage duration: 1 year.

g = generic Page 31 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Verzenio™ All medically accepted indications not otherwise excluded from Part D. (abemaciclib) Coverage duration: 1 year.

Vitrakvi® All medically accepted indications not otherwise excluded from Part D. (larotrectinib) Coverage duration: 1 year.

Vizimpro® All medically accepted indications not otherwise excluded from Part D. (dacomitinib) Coverage duration: 1 year.

Vosevi® All medically accepted indications not otherwise excluded from Part D. (sofosbuvir/velpatasvir/voxilaprevir) Coverage duration: Criteria will be applied consistent with current AASLD/IDSA guidance.

Votrient® All medically accepted indications not otherwise excluded from Part D. (pazopanib) Prescriber restrictions: Must be prescribed by an oncologist.

Coverage duration: 1 year.

Vyndamax™ All medically accepted indications not otherwise excluded from Part D. (tafamidis) Coverage duration: 1 year.

Vyndaqel® All medically accepted indications not otherwise excluded from Part D. (tafamidis meglumine) Coverage duration: 1 year.

Xcopri® All medically accepted indications not otherwise excluded from Part D. (cenobamate) Coverage duration: 1 year. g = generic Page 32 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Xalkori® All medically accepted indications not otherwise excluded from Part D. (crizotinib) Coverage duration: 1 year.

Xeljanz®, Xeljanz® XR All medically accepted indications not otherwise excluded from Part D. (tofacitnib citrate) Coverage duration: 1 year.

Xenazine® (g) Documentation of the CYP2D6 genotype of the patient will be required for doses (tetrabenazine) above 50mg per day.

All medically accepted indications not otherwise excluded from Part D.

Exclusion criteria: Coverage will not be provided in the following situations, 1) Patients with hepatic function impairment, 2) Patients who are actively suicidal or who have untreated or inadequately treated depression, 3) Patients taking monoamine oxidase inhibitors or reserpine.

Coverage duration: 1 year.

Xgeva® All medically accepted indications not otherwise excluded from Part D. (denosumab) Coverage duration: 1 year.

Xolair® All medically accepted indications not otherwise excluded from Part D. (omalizumab) Coverage duration: 1 year.

Xospata® All medically accepted indications not otherwise excluded from Part D. (gilteritinib) Coverage duration: 1 year.

g = generic Page 33 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Xpovio™ All medically accepted indications not otherwise excluded from Part D. (selinexor) Coverage duration: 1 year.

Xtandi® All medically accepted indications not otherwise excluded from Part D. (enzalutamide) Coverage duration: 1 year.

Xyrem® All medically accepted indications not otherwise excluded from Part D. (sodium oxybate) Exclusion criteria: coverage is not provided for patients taking sedative hypnotics or in patients with succinic semialdehyde dehydrogenase deficiency

Coverage duration: 1 year.

Yonsa® All medically accepted indications not otherwise excluded from Part D. (abiraterone acetate) Coverage duration: 1 year.

Zejula™ All medically accepted indications not otherwise excluded from Part D. (niraparib) Coverage duration: Lifetime.

Zelboraf® All medically accepted indications not otherwise excluded from Part D. (vemurafenib) Exclusion criteria: Coverage will not be provided in combination with Yervoy®.

Coverage duration: 1 year.

Zenpep® Coverage requires trial or intolerance to Creon®. (pancrelipase delayed release) Coverage duration: Lifetime.

g = generic Page 34 of 35 FORM ID# 20163 12/1/2020 MEDICATION/ DRUG CLASS CRITERIA Zepzelca™ All medically accepted indications not otherwise excluded from Part D. (lurbinectedin) Coverage duration: 1 year.

Zolinza® All medically accepted indications not otherwise excluded from Part D. (vorinostat) Coverate duration: 1 year. Zydelig™ All medically accepted indications not otherwise excluded from Part D. (idelalisib) Coverage duration: 1 year.

Zykadia™ All medically accepted indications not otherwise excluded from Part D. (ceritinib) Coverage duration: Lifetime.

Zytiga® All medically accepted indications not otherwise excluded from Part D. (abiraterone) Coverage duration: 1 year.

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