BCN AdvantageSM HMO-POS and HMO BCN Advantage Comprehensive Formulary Prior Authorization / Step Therapy Program 2020 Plan Year Updated 12/1/2020

BCN Advantage HMO-POS and HMO monitor the use of certain 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.

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H5883_20IndPAST_C FVNR 1120 / DRUG CLASS CRITERIA Abilify Maintena® Coverage requires trial of oral aripiprazole. (aripiprazole) Coverage duration: Lifetime.

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.

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MEDICATION/ DRUG CLASS CRITERIA Alpha-1 Proteinase Inhibitors Requires documentation of a congenital deficiency of alpha-1 antitrypsin, Zemaira® demonstrated by a homozygous phenotype of AAT, and must have symptomatic 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA 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.

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.

Anti-diabetic agents Coverage requires the 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)

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MEDICATION/ DRUG CLASS CRITERIA 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.

Antidepressants Coverage requires a claim for at least one generic antidepressant agent in the past Paxil® suspension (paroxetine) 120 days. Trintellix® (voritoxetine) Fetzima™ (levomilnacipran) Coverage duration: 1 year. Fetzima™ titration pack (levominacipran) Viibryd® (vilazodone HCl)

Antipsychotic Agents Coverage requires the trial of at least one generic antipsychotic agent. Caplyta® (lumateperone) Adasuve® (loxapine) Coverage duration: Lifetime. Fanapt® (iloperidone) Geodon® (ziprasidone) Latuda® (lurasidone) Saphris® (asenapine) Secuado® (asenapine) Vraylar™ (cariprazine) Zyprexa® Relprevv™ (olanzapine)

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MEDICATION/ DRUG CLASS CRITERIA 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.

Aristada™ Coverage requires the 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.

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MEDICATION/ DRUG CLASS CRITERIA Avonex® All medically accepted indications not otherwise excluded from Part D. ( 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA 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.

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.

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

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

Daliresp® Coverage is provided for the treatment of severe chronic obstructive pulmonary (roflumilast) disease (COPD) associated with chronic bronchitis in patients with a history of exacerbations. Patient is receiving: 1. inhaled long-acting beta-2 agonist [for example, formoterol , salmeterol] AND 2. inhaled long-acting anticholinergic agent [for example, tiotropium] AND 3. inhaled corticosteroid [for example, fluticasone] OR If patient experienced intolerance or has contraindications to use of these medications.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

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

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MEDICATION/ DRUG CLASS CRITERIA 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA Erivedge® All medically accepted indications not otherwise excluded from Part D. (vismodegib) Prescribers restrictions: Prescribed by or in consultation with 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 subject 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA 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. () Coverage duration: 1 year.

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 requires patient has tried and failed at least one bisphosphonate except when: 1. 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) OR 2. Documented intolerance to a bisphosphonate

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year with a maxiumim of 2 years of total therapy.

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

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MEDICATION/ DRUG CLASS CRITERIA 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.

Gilotrif® All medically accepted indications not otherwise excluded from Part D. (afatinib) 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 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.

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MEDICATION/ DRUG CLASS CRITERIA 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.

High Risk Drugs High risk tricyclic antidepressants are approved if patient has a history of use. Elavil® (g) amitriptyline hydrochloride Anafranil™ (g) (clomipramine For patients initiating therapy, the high risk tricyclic antidepressant is approved if at hydrochloride) least one of the suggested alternatives (nortriptyline, desipramine, citalopram, doxepin hydrochloride escitalopram, mirtazapine, sertraline, venlafaxine) with less sedation and fewer Tofranil™ (g) (imipramine hydrochloride) anticholinergic effects have been tried and failed or are not appropriate or imipramine pamoate contraindicated for the intended use. thioridazine hydrochloride Surmontil® (g) (trimipramine maleate) Thioridizine is covered for patients who have a history of use. For patients inititating therapy, thioridizine is covered if patient has a failure of or intolerance to at least one other safer alternative antipsychotic such as aripiprazole or quetiapine.

All medically accepted indications not otherwise excluded from Part D.

Age Restriction: Authorization is required for members 65 years of age and older.

Coverage duration: 1 year.

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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.

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

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

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MEDICATION/ DRUG CLASS CRITERIA 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® AQ in the past 120 days. (ciclesonide) 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.

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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.

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.

Kuvan® Renewal requires initial therapy at least 2 months and a 30% or greater reduction in (sapropterin hydrochloride) phenylalanine from baseline.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: Initial: 2 months. Renewal: 1 year.

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

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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 the 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.

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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.

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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)

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.

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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 Part 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.

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MEDICATION/ DRUG CLASS CRITERIA Orencia® Coverage for the diagnosis of rheumatoid arthritis requires trial of two of the (abatacept) following preferred agents: etanercept (Enbrel®), adalimumab (Humira®), or tofacitinib (Xeljanz®/Xeljanz® XR).

Coverage for the diagnosis of juvenile idiopathic arthritis requires trial of both of the following preferred agents: etanercept (Enbrel®) and adalimumab (Humira®).

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

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: 1 year.

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

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.

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

Pancreaze® Coverae requires the trial of or intolerance to Creon®. (pancrelipase microtablets) Coverage duration: Lifetime.

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.

Polivy™ All medically accepted indications not otherwise excluded from Part D. (polatuzumab vedotin) Coverage duration: 1 year.

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MEDICATION/ DRUG CLASS CRITERIA 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. Requires: Patient has tried and (denosumab) failed at least one bisphosphonate except when: 1. There is a contraindication to a bisphosphonate (oral and intravenous) 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 hypocalcemia.

Coverage duration: 1 year.

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

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)

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MEDICATION/ DRUG CLASS CRITERIA 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) Exclusion criteria: Coverage is not provided for patients with known or suspected mechanical gastrointestinal obstruction.

Age restriction: Patients 18 years of age and older.

Coverage duration: 3 months.

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.

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MEDICATION/ DRUG CLASS CRITERIA 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 or in consultation with an oncologist or hematologist.

Coverage duration: 1 year.

Rexulti® Coverage requires the trial of 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.

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

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MEDICATION/ DRUG CLASS CRITERIA 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.

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.

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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.

Sylatron™ All medically accepted indications not otherwise excluded from Part D. (peginterferon alfa-2b) Prescriber restrictions: Prescribing physician must be an oncologist.

Coverage duration: 1 year.

Symlin® Coverage is provided for patients that have failed intensive treatment with insulin (pramlintide) monotherapy and for concurrent use with an insulin product.

All medically accepted indications not otherwise excluded from Part D.

Coverage duration: Lifetime.

Tabloid® All medically accepted indications not otherwise excluded from Part D. (thioguanine) Prescriber restrictions: Prescribing physician must be an oncologist or hematologist.

Coverage duration: 1 year.

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MEDICATION/ DRUG CLASS CRITERIA 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA 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. () 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.

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.

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

Uloric® Coverage requires the trial of or contraindication to 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA 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 ) Coverage duration: 1 year.

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

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

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

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MEDICATION/ DRUG CLASS CRITERIA Xenazine® (g) Coverage requires documentation of the patient’s CYP2D6 genotype for doses () 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.

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.

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MEDICATION/ DRUG CLASS CRITERIA Xyrem® Exclusion criteria: Coverage is not provided for patients taking sedative hypnotics (sodium oxybate) or in patients with succinic semialdehyde dehydrogenase deficiency.

All medically accepted indications not otherwise excluded from Part D.

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

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) Coverage duration: 1 year.

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MEDICATION/ DRUG CLASS CRITERIA 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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