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UnitedHealthcare® Oxford Clinical Policy

DRUG COVERAGE GUIDELINES Policy Number: PHARMACY 098.175 T0 Effective Date: June 1, 2018

Table of Contents Page Related Policies INSTRUCTIONS FOR USE ...... 1 Refer to Payment Guidelines below CONDITIONS OF COVERAGE ...... 1 DESCRIPTION OF SERVICES ...... 2 DEFINITIONS ...... 3 PAYMENT GUIDELINES ...... 3 POLICY HISTORY/REVISION INFORMATION ...... 161

INSTRUCTIONS FOR USE

This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

CONDITIONS OF COVERAGE

This policy applies to Oxford plan membership.

Note:  Not all Oxford groups have selected the same pharmacy benefits. Refer to the group's pharmacy plan number for specific exclusions, exceptions, and dispensing limitations.  New Jersey Small group plan members should refer to their Certificate of Coverage for precertification and quantity limit guidelines.  New Jersey members: Refer to the policy titled Supply Limits - New Jersey Benefit Maximum Limits.

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DESCRIPTION OF SERVICES

 The Drug Coverage Guidelines table of medications contains medications that: o Have a quantity limit in place; and/or o Require precertification through Oxford's Pharmacy Benefit Manager (PBM); and/or o Require precertification through Oxford's Medical Management; and/or o Are standard exclusions (such as weight loss medications, fluorides, vitamins)  Medications are listed alphabetically with an explanation of how precertification is obtained and under which benefit it is covered.  While a medication by itself may not require precertification, Home Care for the administration of a medication does require precertification. Exception: The first seven days of therapy with low molecular weight heparin are an exception to the Home Care precertification requirement.

Notes:  Opioid Overutilization: The Center for Disease Control (CDC) recommends that clinicians should prescribe the lowest effective dosage when opioids are started. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 equivalent doses (MED) or more per day, and should avoid increasing dosage to 90 MED or more per day or carefully justify a decision to titrate dosage to 90 MED or more per day. o This includes all salt forms, single and combination ingredient products, all long- and short-acting formulations, and all brand and generic formulations: codeine, dihydrocodeine, fentanyl, methadone, meperidine, morphine, hydrocodone, hydromorphone, , oxycodone, oxymorphone, pentazocine, tapentadol, tramadol. o For additional coverage criteria for the above drugs, please refer to: Utilization Review Guideline: Opioid Overutilization Cumulative Drug Utilization Review Criteria  Quantity duration (QD) and quantity level limitations (QLL) may be in place for certain medications. To request coverage for a greater quantity of a medication with a QLL, providers must call Oxford's Pharmacy Benefit Manager (PBM). For information regarding QD or QLL supply limits, refer to the following documents on UHCProvider.com > Drug Lists and Pharmacy > Supply Limits: o QD Supply Limits (defines the maximum quantity of medication that can be covered in a specified time period) o QLL Supply Limits (defines the maximum quantity of medication that is covered for one prescription or copayment)  Oxford's PBM provides a nationwide network of participating pharmacies that administers prescription drugs on a retail level. Groups that purchase the Pharmacy Rider and Medicare Members with a Pharmacy benefit will have their retail pharmacy benefit administered by the PBM.  For information regarding medication coverage related to the Member's pharmacy benefit, providers may contact Oxford's PBM.  For issues of medication coverage unrelated to the Member's pharmacy benefit (Intravenous infusions, intramuscular injections, etc), Oxford may be contacted directly.  Over-the-Counter (OTC) Medications: o New Jersey (NJ) Plans: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are not excluded from coverage. Refer to specific drug policies where applicable. o Connecticut (CT) and New York (NY) Plans: A product that is therapeutically equivalent to an over-the-counter (OTC) drug may be covered if it is determined to be medically necessary. In order for a prescription drug to be deemed "medically necessary" when there is an equivalent OTC drug available, the physician must show that there is something about the prescription drug that is superior to the OTC drug, and likely to be more beneficial to the Member than the OTC drug. Documentation supporting medical necessity must be submitted by the provider.  New FDA-approved drug products may require precertification immediately upon launch of the medication.  For information on coverage of recent FDA-approved drug products for which drug-specific criteria are unavailable, please refer to Interim New Product Coverage Criteria.  Review at Launch: The Review at Launch program provides Oxford the ability to review, evaluate, and implement programs for new to market medications. The medication may move to a covered status once the medication has been evaluated by the UnitedHealthcare Pharmacy and Therapeutics Committee and the appropriate system specifications have been implemented to ensure suitable utilization management strategies are in place. A medication will be subject to review at launch when the medication is listed on the Review at Launch Medication List. Please refer to the policy titled Review at Launch for New to Market Medications.

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 New Jersey Formulary Regulations: Members who are enrolled in a New Jersey group Product with a 3-Tier Prescription Drug Benefit and for whom the NJ Formulary Regulations apply should refer to Prior Authorization/Notification Non-Formulary (i.e., Tier 3 or higher) Copay Adjustment – New Jersey.

DEFINITIONS

For all of the definitions below, copayment/cost share will vary based on the Member’s plan design. Refer to the member's specific Certificate of Coverage, contract and/or Prescription Drug Rider as applicable.

Mail Order Pharmacy: A network pharmacy contracted to provide up to a 90-day supply of certain prescription medications (new or refill) by mail.

Retail Pharmacy: A network non-mail order pharmacy contracted to provide prescription medications (new or refill). Note: For Members enrolled in NY LOBs new and renewing on or after 01/12/12, if a retail pharmacy has contracted with the PBM, in advance, for the same rates and terms and conditions as the mail order or specialty pharmacy, covered prescriptions will be available at the same co-payment or other reimbursement level that would apply to the mail-order or non-retail specialty pharmacies (should any of these pharmacies be available in the service area).

Specialty Pharmacy: A network pharmacy contracted to provide coverage for specialty medications at an in-network benefit level for members enrolled on NY and NJ LOBs.

PAYMENT GUIDELINES

The following list of procedure codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type J0400 and IM injection N/A N/A Medical N/A J1942 Abilify  Therapeutic Equivalent () , oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A suspension Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Absorica (isotretinoin) Absorica Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A (isotretinoin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Necessity Guidelines: Abstral Tablet or (Fentanyl) Abstral (fentanyl) Sublingual J8499 PBM  Therapeutic Equivalent Pharmacy N/A Tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Acanya  Therapeutic Equivalent (clindamycin Guidelines: Drug Coverage phosphate 1.2% Topical J3490 PBM Criteria - New and Therapeutic Pharmacy N/A and benzoyl Equivalent Medications peroxide 2.5%) Acetaminophen/  Therapeutic Equivalent Caffeine/ Guidelines: Drug Coverage Dihydrocodeine Tablet J8499 PBM Criteria - New and Therapeutic Pharmacy N/A Bitartrate Equivalent Medications 325/30/16 mg  Therapeutic Equivalent Aciphex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (rabeprazole) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Aciphex Sprinkle Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (rabeprazole) Criteria - New and Therapeutic Equivalent Medications J0883 and Acova (argatroban) IV Injection N/A N/A Medical N/A J0884  Prior Authorization/ Notification Guidelines: SQ Injection J3490 PBM Actemra (tocilizumab) Pharmacy N/A  Step Therapy Guidelines: Actemra (tocilizumab) Hospital Outpatient Facility: Administration of Actemra in a Actemra  Precertification Guidelines: hospital outpatient facility (tocilizumab) o Actemra (tocilizumab) (including any ambulatory Oxford’s Injection for Intravenous infusion suite associated with the Injection J3262 Medical Infusion Medical hospital) requires precertification Management o Specialty Medication with review by a Medical Director Administration – Site of Care or their designee. Refer to: Review Guidelines Specialty Medication Administration – Site of Care Review Guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Acticlate Guidelines: Drug Coverage (doxycycline Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hyclate) Equivalent Medications  Prior Authorization/ Actimmune Notification Guidelines: (interferon SQ Injection J9216 PBM Pharmacy N/A Actimmune (interferon gamma- gamma-1b) 1b)  Prior Authorization/Medical Actiq (brand only) Lozenge J8499 PBM Necessity Guidelines: Actiq Pharmacy N/A (fentanyl citrate) (fentanyl citrate)  Therapeutic Equivalent Actos (brand only) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (pioglitazone) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Acuvail (ketorlac/ Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A tromethamine) Solution Criteria - New and Therapeutic Equivalent Medications Aczone 7.5% Topical Gel J3490 N/A N/A Pharmacy N/A () *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do Adagen not request one, a medical  Precertification Guidelines: (pegademase Injection J2504 N/A* Medical necessity review will be Replacement Therapy* bovine) conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required. Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Adapalene 0.1% Cream, Gel, J3490 N/A N/A N/A equivalent are excluded from (generic Differin) Lotion coverage. Refer to the member specific benefit plan document as applicable.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Adapalene 0.3% Gel J3490 N/A N/A N/A equivalent are excluded from (generic Differin) coverage. Refer to the member specific benefit plan document as applicable.  Prior Authorization/Medical Adcirca (tadalafill) Tablet J3490 PBM Necessity Guidelines: Adcirca Pharmacy N/A (tadalafill)  Prior Authorization/ Notification Guidelines: Adderall Adderall and Adderall XR (amphetamine/ Tablet S0160 PBM  Therapeutic Equivalent Pharmacy N/A dextroamphetamin) Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications Adderall XR  Prior Authorization/ amphetamine/ Tablet S0160 PBM Notification Guidelines: Pharmacy N/A dextroamphetamin Adderall and Adderall XR [extended release])  Prior Authorization/Medical Addyi () Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Addyi  Prior Authorization/Medical Adempas Pharmacy N/A Tablet J8499 PBM Necessity Guidelines: (riociguat) Adempas Adlyxin Injection J3490 N/A N/A Pharmacy N/A (lixisenatide)  Therapeutic Equivalent Adoxa (doxycycline Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A monohydrate) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Adrenaclick Pen Guidelines: Drug Coverage J0171 PBM Pharmacy N/A (epinephrine) Injection Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Adynovate Guidelines: Drug Coverage (antihemophillic Injection J3490 PBM Pharmacy N/A Criteria - New and Therapeutic factor) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Orally Adzenys XR Adzenys XR Disinter- (amphetamine J8499 PBM  Therapeutic Equivalent Pharmacy N/A grating extended-release Guidelines: Drug Coverage Tablet Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the member is age 19  Prior Authorization/ Afinitor years or older. All other oral Oral J7527 PBM* Notification Guidelines: Pharmacy** (everolimus) chemotherapy drugs do not Afinitor require precertification. Benefit Note: **NJ Small members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Afrezza (, Inhalation  Prior Authorization/Medical J3490 PBM Pharmacy N/A human) Powder Necessity Guidelines: Afrezza Afstyla (Antihemophilic  Prior Authorization/Medical Factor Injection J7210 PBM Pharmacy N/A Necessity Guidelines: Afstyla [Recombinant] Single Chain) Airduo RespiClick  Therapeutic Equivalent (Brand only) Guidelines: Drug Coverage (fluticasone Inhaler J3490 PBM Pharmacy N/A Criteria - New and Therapeutic propionate/ Equivalent Medications salmeterol)  Therapeutic Equivalent Aktipak gel Guidelines: Drug Coverage (erythromycin and Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic benzoyl peroxide) Equivalent Medications Akynzeo (netupitant/ Capsule J8499 N/A N/A Pharmacy N/A palonosetron) Albenza  Authorization/Medical Tablet J8499 PBM Pharmacy N/A (albendazole) Necessity Guidelines: Albenza

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Aldurazyme®  Precertification Guidelines: necessity review will be Intravenous J1931 N/A* Medical (laronidase) Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required.  Prior Authorization/ Alecensa Capsule J8999 PBM Notification Guideline: Pharmacy N/A () Alencensa *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the member does not Alesse (ethinyl have contraceptive coverage  Benefit Guidelines: and Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives ) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Allegra D (fexofenadine & pseudoephedrine), Tablet J8499 N/A N/A Pharmacy N/A Allegra suspension/ Allegra ODT  Therapeutic Equivalent Allzital (allzital Guidelines: Drug Coverage butalbital/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic acetaminophen) Equivalent Medications  Therapeutic Equivalent Alogliptin (Nesina Guidelines: Drug Coverage Authorized Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Generic) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Alogliptin/  Therapeutic Equivalent Metformin (Kazano Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Authorized Criteria - New and Therapeutic Generic) Equivalent Medications Alogliptin/  Therapeutic Equivalent Pioglitazone (Oseni Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Authorized Criteria - New and Therapeutic Generic) Equivalent Medications Injection Alpha J0475 and and N/A N/A Medical N/A (baclofen) J0476 Intrathecal  Therapeutic Equivalent Altoprev Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (lovastatin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Alunbrig Tablet J8499 PBM Notification Guidelines: Pharmacy N/A () Alunbrig  Therapeutic Equivalent Ambien ( Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A tartrate) Criteria - New and Therapeutic Equivalent Medications Ambien CR  Therapeutic Equivalent (zolpidem tartrate Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A extended- Criteria - New and Therapeutic release[ER]) Equivalent Medications *Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Amerge  Supply Limit Guidelines: Tablet J8499 PBM* Pharmacy** precertification. (naratriptan) Triptans Supply Limits **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Amevive Injection, SQ J0215 N/A N/A Medical N/A (alefacept) Injection

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Aminolevulinic acid Topical J7308 N/A N/A Medical N/A HCL  Prior Authorization/Medical Amitiza Capsule J8499 PBM Necessity Guidelines: Amitiza Pharmacy N/A (lubiprostone) (lubiprostone) Amlodipine/ Atorvastatin Tablet J8499 N/A N/A Pharmacy N/A (generic)  Prior Authorization/ Amnesteem Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (isotretinoin) Amnesteem  Prior Authorization/ Amphetamine/ Notification Guidelines: dextro- Adderall and Adderall XR amphetamine Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A extended-release Guidelines: Drug Coverage (generic Adderall Criteria - New and Therapeutic XR) Equivalent Medications **Precertification Note: Precertification through the PBM is required for Members age 19  Prior Authorization/ and older. Ampyra Tablet J8499 PBM** Notification Guidelines: Pharmacy* *Benefit Note: NJ Small (dalfampridine) Ampyra (dalfampridine) members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Amrix/ Guidelines: Drug Coverage cyclobenzaprine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic extended release Equivalent Medications Amturnide  Therapeutic Equivalent (aliskiren, Guidelines: Drug Coverage amlodipine, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloro- Equivalent Medications thiazide) Anabolin ( Injection J2320 N/A N/A Medical N/A deconoate) Anadrol-50 Tablet J8499 N/A N/A Pharmacy N/A ()

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Anafranil Guidelines: Drug Coverage (clomipramine) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Analpram Advanced Guidelines: Drug Coverage Kit (hydrocortisone Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetate/pramoxine) Equivalent Medications  Prior Authorization/Medical Androderm Gel J3490 PBM Necessity Guidelines: Pharmacy N/A () Androderm  Prior Authorization/Medical Necessity Guidelines: Androgel Androgel Gel J3490 PBM  Therapeutic Equivalent Pharmacy N/A (testosterone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Android, Oreton, Methyl, Virilon and Tablet J8499 N/A N/A Pharmacy N/A Methitest (methyl- testosterone) *Precertification Notes: HCPCS code S0132 () requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Notes: Coverage is S0132* and through Optum Pharmacy/ Antagon (ganirelix) Injection Infertility Diagnosis and limited to members with J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Antara  Therapeutic Equivalent (fenofibrate) - Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A 30mg and 90mg Criteria - New and Therapeutic strengths only Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Antara 43mg, Guidelines: Drug Coverage 130mg Capsule J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (fenofibrate) Equivalent Medications Anusol HC  Therapeutic Equivalent Suppository Guidelines: Drug Coverage Suppository J8499 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic (hydrocortisone) Equivalent Medications Anzemet Injection J1260 N/A N/A Medical N/A (dolasetron) Tablet Q0180 N/A N/A Pharmacy N/A  Prior Authorization/Medical Aplenzin Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A () Brand Medications Apligraf Patch Q4101 N/A N/A Medical N/A Apop 10% gel Topical Gel J3490 N/A N/A Pharmacy N/A (sulfacetamide) Apriso Capsule J8499 N/A N/A Pharmacy N/A (mesalamine)  Prior Authorization/ Notification Guidelines: Aptensio XR Aptensio XR Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Aptiom  Prior Authorization/Medical (eslicarbazepine Tablet J8499 PBM Necessity Guidelines: Aptiom Pharmacy N/A acetate) (eslicarbazepine acetate)  Therapeutic Equivalent Aqua Glycolic HC Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (hydrocortisone) Criteria - New and Therapeutic Equivalent Medications Aralast NP Oxford’s  Precertification Guidelines: Intravenous [Alpha1-Proteinase J0256 Medical Alpha -Proteinase Inhibitors Medical N/A injection 1 Inhibitor (Human)] Management J0882-  Precertification Guidelines: Oxford’s *Precertification is required if Aranesp Injection, ESRD OR Anemia Drugs: Darbepoetin Alfa, Medical Medical provided in a hospital or MD's (darbepoetin) SQ Injection J0881-Non- Epoetin Alfa and Methoxy Management* office. ESRD Polyethylene Glycol-Epoetin Beta  Prior Authorization/ Arcalyst Injection, J2793 PBM Notification Guidelines: Pharmacy N/A (rilonacept) SQ Injection Rilonacept (Arcalyst)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Aricept 23mg Guidelines: Drug Coverage (donepezil Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Therapeutic Equivalent Arimidex (brand Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A only) () Criteria - New and Therapeutic Equivalent Medications *No precertification is required if Arixtra Injection, J1652 N/A* N/A Pharmacy dispensed by a retail pharmacy (fondaparinux) SQ Injection or mail order through PBM.  Prior Authorization/ Armodafinil Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (generic Nuvigil) Nuvigil (armodafinil) ArmonAir  Therapeutic Equivalent RespiClick Inhalation Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (fluticasone powder Criteria - New and Therapeutic propionate) Equivalent Medications Arnuity Ellipta Inhalation (fluticasone J3490 N/A N/A Pharmacy N/A Powder furoate)  Prior Authorization/Medical Arymo ER Tablet J8499 PBM Necessity Guidelines: Arymo Pharmacy N/A (morphine sulfate) ER  Therapeutic Equivalent Asacol HD Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (mesalamine) Criteria - New and Therapeutic Equivalent Medications AsmalPred and AsmalPred Plus Tablet J8499 N/A N/A Pharmacy N/A (Prednisolone) Asmanex HFA Inhaler J3490 N/A N/A Pharmacy N/A ()  Therapeutic Equivalent Astagraf XL Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (tacrolimus) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Astelin (brand) Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (azelastine) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Astepro Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A (azelastine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Atelvia Guidelines: Drug Coverage (risedronate Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Ativan (brand Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A only) (lorazepam) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Atorvastatin Notification Guidelines: - *Applies to New York Lines of (generic Lipitor) Tablet J8499 PBM* Pharmacy Cardiovascular Disease Business only. 10mg, 20mg Prevention Zero Cost Share* **Precertification Notes:  Prior Authorization/ Precertification for NJ Small LOBs Notification Guidelines: is based on the member's Atralin (tretinoin) benefit. Atralin (tretinoin) Varies S0117 PBM**  Therapeutic Equivalent Pharmacy* *Benefit Note: Not all groups Guidelines: Drug Coverage have selected the standard Criteria - New and Therapeutic pharmacy benefit. Refer to Equivalent Medications member's pharmacy plan, if applicable.  Prior Authorization/ Aubagio Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (teriflunomide) Aubagio Augmentin  Therapeutic Equivalent (amoxicillin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A clavulanate) Criteria - New and Therapeutic (brand) Equivalent Medications Augmentin ED-600  Therapeutic Equivalent (amoxicillin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A clavulanate) Criteria - New and Therapeutic (brand) Equivalent Medications Augmentin XR/ Amoxicillin-  Therapeutic Equivalent Clavulanate ER Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (amoxicillin and Criteria - New and Therapeutic clavulanate Equivalent Medications potassium)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Auralgan 5.5%/1.4% Drops, J3490 N/A N/A Pharmacy N/A (antipyrine, Solution benzocaine) Auryxia (ferric Tablet J8499 N/A N/A Pharmacy N/A citrate) Austedo  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (deutetrabenazine) Necessity Guidelines: Austedo  Therapeutic Equivalent Auvi-Q Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A (epinephrine) Criteria - New and Therapeutic Equivalent Medications Avar Foam (9.5%-  Therapeutic Equivalent 5%), Avar, Avar LS Guidelines: Drug Coverage (sodium Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfacetamide/ Equivalent Medications sulfur) Avastin IV Infusion,  Medical Management *Non-Oncology Indications: J9035 N/A* Medical () Injection Guidelines: Maximum Dosage No precertification required.  Therapeutic Equivalent Avelox tablet Guidelines: Drug Coverage (Brand Only) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (moxifloxacin hcl) Equivalent Medications  Prior Authorization/Medical Avinza (morphine Necessity Guidelines: Avinza sulfate controlled  Therapeutic Equivalent Capsule J8499 PBM Pharmacy N/A release) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Avita (tretinoin) Avita (tretinoin) Varies S0117 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Avodart Guidelines: Drug Coverage () Capsule J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications J1826,  Prior Authorization/ Avonex (Interferon IM Injection Q3025 and PBM Notification Guidelines: Pharmacy N/A Beta 1a) or Injection Q3026 Avonex

Drug Coverage Guidelines Page 15 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Supply Limit Guidelines:  Ceiling Limit. Triptans Supply Limits NJ Plans do not require Axert (almotriptan)  Therapeutic Equivalent Tablet J8499 PBM** Pharmacy* precertification. (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic *Benefit Note: For New York Equivalent Medications plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Prior Authorization/Medical Necessity Guidelines: Axiron Axiron  Therapeutic Equivalent Gel J3490 PBM Pharmacy N/A (testosterone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Azilect (Brand Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Only) (rasagiline) Criteria - New and Therapeutic Equivalent Medications Azor (amlodipine  Therapeutic Equivalent besylate and Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A olmesartan Criteria - New and Therapeutic medoxomil) Equivalent Medications  Prior Authorization/ Banzel Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Rufinamide) Banzel (Rufinamide)  Therapeutic Equivalent Baraclude Tablets Guidelines: Drug Coverage (Brand Only) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (entecavir) Equivalent Medications Baxdela Tablet J8499 N/A N/A Pharmacy N/A (delafloxacin) Beconase AQ  Therapeutic Equivalent (beclomethasone Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A dipropionate, Criteria - New and Therapeutic monohydrate) Equivalent Medications Belbuca  Prior Authorization/Medical Buccal film J3490 PBM Pharmacy N/A (buprenorphine) Necessity Guidelines: Belbuca

Drug Coverage Guidelines Page 16 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Belsomra  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (suvorexant) Belsomra Benicar  Therapeutic Equivalent (olmesartan) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Benicar HCT (olmesartan  Therapeutic Equivalent medoxomil- Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloro- Criteria - New and Therapeutic thiazide)(brand Equivalent Medications only) *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do  Prior Authorization/ not request one, a medical Notification Guidelines: Benlysta Pharmacy/ necessity review will be Injection J0490 PBM Benlysta (belimumab) Medical* conducted post-service to  Precertification Guidelines: determine coverage. It is the Enzyme Replacement Therapy* referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required. Benzaclin Jar  Therapeutic Equivalent (brand only) Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (benzoyl peroxide Criteria - New and Therapeutic and clindamycin) Equivalent Medications  Therapeutic Equivalent Benzaclin Pump Guidelines: Drug Coverage (benzoyl peroxide Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic and clindamycin) Equivalent Medications Benzaclin Kit (1%-  Therapeutic Equivalent 5%) (Clindamycin Guidelines: Drug Coverage Gel J3490 PBM Pharmacy N/A Phosphate-Benzoyl Criteria - New and Therapeutic Peroxide) Equivalent Medications  Therapeutic Equivalent Benzefoam Aerosol/ Guidelines: Drug Coverage J3490 PBM Pharmacy N/A BenzeFoam Ultra Foam Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 17 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Benznidazole Tablets J8499 PBM Notification Guidelines: Pharmacy N/A Benznidazole  Therapeutic Equivalent Bepreve Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (bepotastine) Drops Criteria - New and Therapeutic Equivalent Medications Berinert (C1  Prior Authorization/ esterase inhibitor Injection J0597 PBM Notification Guidelines: Pharmacy N/A human) Berinert  Therapeutic Equivalent Betamethasone Guidelines: Drug Coverage valerate foam Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (generic Luxiq) Equivalent Medications  Therapeutic Equivalent Betapace (sotalol) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic Equivalent Medications Betaseron  Prior Authorization/ J1830 or (Interferon Beta Injection PBM Notification Guidelines: Pharmacy N/A J3490 1b) Betaseron  Prior Authorization/ Bethkis Inhalation J3490 PBM Notification Guidelines: Pharmacy N/A (tobramycin) Solution Bethkis Bevespi Aerosphere Inhalation (glycopyrrolate/ J3490 N/A N/A Pharmacy N/A Aerosol formoterol fumarate)  Therapeutic Equivalent Bevyxxa Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (betrixaban) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Bexarotene caps Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (generic Targretin) Criteria - New and Therapeutic Equivalent Medications Bexxar Injection J3490 N/A N/A Medical N/A (tositumomab) Beyaz  Therapeutic Equivalent (/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A ethinyl estradiol/ Criteria - New and Therapeutic levomefolate) Equivalent Medications

Drug Coverage Guidelines Page 18 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Biktarvy  Therapeutic Equivalent (bictegravir/ Guidelines: Drug Coverage emtricitabine/ Tablets J8499 PBM Pharmacy N/A Criteria - New and Therapeutic tenofovir Equivalent Medications alafenamide)  Therapeutic Equivalent bimatoprost 0.03% Guidelines: Drug Coverage Eye Drops J3490 PBM Pharmacy N/A (generic Lumigan) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Binosto Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (alendronate) Criteria - New and Therapeutic Equivalent Medications Boniva (ibandronate Injection J1740 Medical sodium) N/A N/A N/A Boniva Tablet (ibandronate Tablet J8499 Pharmacy sodium)  Therapeutic Equivalent Bonjesta Guidelines: Drug Coverage (doxylamine / Tablets J8499 PBM Pharmacy N/A Criteria - New and Therapeutic pyridoxine) Equivalent Medications  Prior Authorization/ Notification Guidelines: Bosulif () Tablet J8999 PBM Bosutinib (bosulif) Pharmacy N/A  Step Therapy Guidelines: Bosutinib (bosulif) Botox, Botulinum Oxford’s Toxin Type Medical  Precertification Guidelines: Injection J0585 Medical N/A (onabotulinumtoxin Management Botulinum Toxins A and B A) Department *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members without a Pharmacy Benefit. Precertification  Precertification Guidelines: Bravelle IM or SQ *NY Plans: Pharmacy Benefit.* J3355 through Follicle Stimulating See Notes* () Injection Optum* (FSH) *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Brilinta (Ticagrelor) Tablet J8499 N/A N/A Pharmacy N/A

Drug Coverage Guidelines Page 19 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Oxford’s Brineura C9014 and  Precertification Guidelines: Injection Medical Medical N/A (cerliponase alfa) J3590 Brineura (cerliponase alfa) Management  Therapeutic Equivalent Brisdelle Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (paroxetine) Criteria - New and Therapeutic Equivalent Medications Briviact  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (brivaracetam) Necessity Guidelines: Briviact Bromday Ophthalmic J3490 N/A N/A Pharmacy N/A (bromfenac) Drops  Therapeutic Equivalent Topical Bromsite Guidelines: Drug Coverage Ophthalmic J3490 PBM Pharmacy N/A (bromfenac) Criteria - New and Therapeutic Solution Equivalent Medications  Therapeutic Equivalent Budesonide nasal Guidelines: Drug Coverage spray (generic Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Rhinocort Aqua) Equivalent Medications  Prior Authorization/Medical Bunavail Film Necessity Guidelines: (buprenorphine Buccal Film J3490 PBM Pharmacy N/A Buprenorphine/ and naloxone) Products Sublingual Buprenorphine HCl J3490 N/A N/A Pharmacy N/A Tablet Buprenorphine Tablet J3490 N/A N/A Pharmacy N/A (generic Subutex)  Prior Authorization/Medical Buprenorphine/ Necessity Guidelines: naloxone (generic Tablet J8499 PBM Pharmacy N/A Buprenorphine/Naloxone Suboxone) Products  Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Benefits for Smoking Cessation Bupropion (SR) Reform for Health Care Reform apply to Tablet J8499 PBM Pharmacy (generic Zyban)  Supply Limit Guidelines: HCR all plans subject to health care Tobacco Cessation - Supply reform. Limits Override - NJ Fully Insured

Drug Coverage Guidelines Page 20 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Butalbital/ acetaminophen/  Therapeutic Equivalent caffeine/codeine Guidelines: Drug Coverage 50mg/300mg/ Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic 40mg/30mg Equivalent Medications (generic Fioricet with Codeine) Butrans  Prior Authorization/Medical Coverage Criteria does not apply Patch J3490 PBM Pharmacy (buprenorphine) Necessity Guidelines: Butrans to CT of business.  Therapeutic Equivalent Byvalson (nebivolol Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A and valsartan) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Cabometyx Capsule J8999 PBM Notification Guidelines: Pharmacy N/A () Cabometyx Caduet and generic  Therapeutic Equivalent Caduet Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (amlodipine and Criteria - New and Therapeutic atorvastatin) Equivalent Medications *Injectable prescription vitamins administered under the direction Calcijex (Calcitriol) Injection J0636 N/A N/A Medical* of a physician as medically necessary are reimbursed under the Medical Benefit. Calderol Capsule J8499 N/A N/A Pharmacy N/A (calcifediol)  Prior Authorization/ Calquence Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (acalabrutinib) Calquence  Therapeutic Equivalent Powder, Cambia (diclofenac Guidelines: Drug Coverage Tablet, J8499 PBM Pharmacy N/A potassium) Criteria - New and Therapeutic Capsule Equivalent Medications  Therapeutic Equivalent Capecitabine Guidelines: Drug Coverage Tablet J8999 PBM Pharmacy N/A (generic Xeloda) Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 21 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the member is age 19  Prior Authorization/ Caprelsa years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** () chemotherapy drugs do not Caprelsa require precertification. Benefit Note: **NJ Small members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Carbaglu Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (carglumic acid) Carbaglu Cardizem Tablet J8499 PBM Pharmacy N/A (diltiazem) (brand)  Therapeutic Equivalent Cardizem CD Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (diltiazem) (brand) Criteria - New and Therapeutic Cardizem LA Equivalent Medications Tablet J8499 PBM Pharmacy N/A (diltiazem) (brand) Coverage is limited to Members with coverage for vitamins/ supplements through their prescription drug plan. If the member does not have vitamin/ Tablet or supplement coverage through J8499 N/A N/A Pharmacy* Carnitor Solution their prescription drug plan, then (levocarnitine/ this is not covered. Members L-Carnitine) should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Medical Management *Benefit is State Specific. Medical Injection J1955 N/A Guidelines: Formula & Medical* Benefit/Pharmacy Benefit. Specialized Food Carospir Oral  Prior Authorization/Medical Suspension J8499 PBM Pharmacy N/A suspension Necessity Guidelines: Carospir ()

Drug Coverage Guidelines Page 22 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Chimeric Antigen Receptor (CAR)-T Cell Therapy may be eligible for coverage as an [CAR-T (Chimeric autologous stem cell therapy Antigen Receptor) J3490,  eviCore Guidelines: Injectable under a member’s Chemotherapy Drugs: Transplantation Services benefit. Cell Therapy] J9999, Precertification Application of NCCN Clinical Transplant-  Kymriah M0075, Coverage determinations are Injection through Practice Guidelines ation (tisagenlecleucel) Q2040, based on the Optum Transplant Optum*  Optum Transplant Review Services Review Guidelines:  Yescarta Q2041, Guidelines: Hematopoietic Hematopoietic Stem Cell (axicabtagene S2107 Stem Cell Transplantation ciloleucel) Transplantation criteria for covered transplants.

Precertification through Optum is required in all sites of service.  Prior Authorization/ Caverject Vial J0270 PBM Notification Guidelines: Pharmacy N/A (alprostadil) Erectile Dysfunction Agents Cayston  Prior Authorization/ *NJ Small members should refer (Aztreonam for Inhalation J3490 PBM* Notification Guidelines: Pharmacy* to their Certificate of Coverage Inhalation Solution Cayston for precertification guidelines. Solution)  Therapeutic Equivalent Celebrex (brand Guidelines: Drug Coverage Capsule J3490 PBM Pharmacy N/A only) (celecoxib) Criteria - New and Therapeutic Equivalent Medications Celexa  Prior Authorization/Medical (citalopram) Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A (brand only) Brand Medications Cellcept  Therapeutic Equivalent (mycophenolate Tablet/ Guidelines: Drug Coverage J8499 PBM Pharmacy N/A mofetil) (brand Capsule Criteria - New and Therapeutic only) Equivalent Medications Cenestin  Therapeutic Equivalent (conjugated Guidelines: Drug Coverage tablet J8499 PBM Pharmacy N/A ) (brand Criteria - New and Therapeutic only) Equivalent Medications  Therapeutic Equivalent Centany AT Kit Guidelines: Drug Coverage Ointment J3490 PBM Pharmacy N/A (mupirocin) Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 23 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Cerdelga Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (eliglustat) Cerdelga Ceredase® IV Infusion, J0205 N/A N/A Medical N/A (algucerase) Injection  Medical Management Oxford’s Cerezyme® IV Infusion, Guidelines: Intravenous J1786 Medical Medical N/A (imiglucerase) Injection Enzyme Replacement Therapy Management (ERT) for Gaucher Disease Cesamet (nabilone) Capsule J8650 N/A N/A Pharmacy N/A Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Solution Oral J8499 N/A N/A N/A equivalent are excluded from (generic Zyrtec) Solution coverage. Refer to the member specific benefit plan document as applicable. *Benefit Note: Coverage is limited to Members with coverage for fertility drugs Precertification through their prescription drug  Precertification Guidelines: Cetrotide through Optum Pharmacy/ plan. If the Member does not Injection J3490 Infertility Diagnosis and ( acetate) may be Medical* have fertility drug coverage Treatment required through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Cetylev Tablet J8499 N/A N/A Pharmacy N/A (acetylcysteine)  Prior Authorization/Medical Necessity Guidelines: Tobacco Cessation for Health Care Benefits for Smoking Cessation Chantix Reform for Health Care Reform apply to (varenicline Tablet J3490 PBM Pharmacy*  Supply Limit Guidelines: HCR all plans subject to health care tartrate) Tobacco Cessation - Supply reform. Limits Override - NJ Fully Insured J3490 Oxford’s  Precertification Guidelines: Chelation Therapy IV Infusion M0300 and Medical Chelation Therapy for Non- Medical N/A S9355 Management* Overload Conditions

Drug Coverage Guidelines Page 24 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type J0640- J0641 J9000-  eviCore Guidelines: Injectable Chemotherapy J9999 Chemotherapy Drugs: *Precertification is required Injection eviCore* Medical (Injectable) Drugs Q2017 Application of NCCN Clinical through eviCore. Q2043 Practice Guidelines Q2049 and Q2050  Therapeutic Equivalent Chlorzoxazone 250 Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A mg Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Cholbam (cholic Capsule J8499 PBM Notification Guidelines: Pharmacy N/A acid) Cholbam  Therapeutic Equivalent Choline Fenofibrate Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Trilipix) Criteria - New and Therapeutic Equivalent Medications *Precertification Note: HCPCS code J0725 (chorionic gonadatropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with Gonadatropin J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines.  Prior Authorization/ Cialis () Tablet J3490 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents Ciclodan  Therapeutic Equivalent Combination Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Package Criteria - New and Therapeutic () Equivalent Medications

Drug Coverage Guidelines Page 25 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Ciclodan Kit Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (ciclopirox) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Cimduo Guidelines: Drug Coverage (lamivudine / Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic tenofovir DF) Equivalent Medications Cimzia  Prior Authorization/ (certolizumab SQ Injection J3490 PBM Notification Guidelines: Pharmacy N/A pegol) Cimzia (certolizumab pegol)  Precertification Guidelines: J3490, Oxford’s Cinqair Intravenous Respiratory J3590, and Medical Medical N/A (reslizumab) infusion (Cinqair®, Fasenra®, and J2786 Management Nucala®) Cinryze (C1  Prior Authorization/Medical esterase inhibitor Injection J0598 PBM Pharmacy N/A Necessity Guidelines: Cinryze (human)) Cipro Tablet J8499 Pharmacy N/A N/A N/A () Injection J0744 Medical Cipro suspension Oral (Brand Only) J8499 N/A N/A Pharmacy N/A Suspension (ciprofloxacin) Cipro XR (ciprofloxacin Tablet J8499 N/A N/A Pharmacy N/A extended-release) Ciprodex (ciprofloxacin HCL/ Tablet J8499 N/A N/A Pharmacy N/A ) *Precertification is only required Claforan Oxford’s only when used in the treatment  Precertification Guidelines: (cefotaxime IV Infusion J0698 Medical Medical of Lyme disease. Exception: Lyme Disease sodium) Management* Precertification is not required for Connecticut Members.  Prior Authorization/ Claravis Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (isotretinoin) Claravis  Therapeutic Equivalent Clarifoam EF Topical Guidelines: Drug Coverage (sulfacetamide/ J3490 PBM Pharmacy N/A Foam Criteria - New and Therapeutic sulfur) (brand) Equivalent Medications

Drug Coverage Guidelines Page 26 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Clarinex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (desloratadine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Clarinex D Guidelines: Drug Coverage (desloratadine and Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic pseudoephedrine) Equivalent Medications Clarinex Reditab (desloratadine orally Tablet J8499 N/A N/A Pharmacy N/A disintegrating tablet)  Therapeutic Equivalent Clenpiq (sodium Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A picosulfate) Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Clindacin Pack Guidelines: Drug Coverage (clindamycin Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic phosphate) Equivalent Medications  Therapeutic Equivalent Clindagel Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (clindamycin) Criteria - New and Therapeutic Equivalent Medications Clindamycin  Therapeutic Equivalent 1%/benzoyl Guidelines: Drug Coverage peroxide 5% Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (generic Equivalent Medications BenzaClin) gel Clindamycin1.2%/ benzoyl peroxide Topical J3490 N/A N/A Pharmacy N/A 5% gel (Generic Duac)  Therapeutic Equivalent Clobeta J3490 and Guidelines: Drug Coverage Ointment PBM Pharmacy N/A (Clobetasol) J8499 Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Clobetasol Guidelines: Drug Coverage shampoo (generic Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Clobex shampoo) Equivalent Medications

Drug Coverage Guidelines Page 27 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Clobex Lotion Guidelines: Drug Coverage (clobetasol Lotion J3490 PBM Pharmacy N/A Criteria - New and Therapeutic propionate) Equivalent Medications  Therapeutic Equivalent Clobex Shampoo Guidelines: Drug Coverage (clobetasol Shampoo J3490 PBM Pharmacy N/A Criteria - New and Therapeutic propionate) Equivalent Medications  Therapeutic Equivalent Clodan 0.05% Guidelines: Drug Coverage (clobetasol Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic proprionate) Equivalent Medications  Therapeutic Equivalent Clodan 0.05% Guidelines: Drug Coverage (clobetasol Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic proprionate) Equivalent Medications Cloderm 0.1%  Step Therapy Guidelines: cream Cream J3490 PBM Pharmacy N/A Cloderm (clocortolone) Cloderm cream (Brand Only Cream J3490 N/A N/A Pharmacy N/A (clocortolone) Cocet Plus  Therapeutic Equivalent (acetaminophen J3490 and Guidelines: Drug Coverage Tablet PBM Pharmacy N/A and codeine J8499 Criteria - New and Therapeutic phosphate) Equivalent Medications  Therapeutic Equivalent Colazal Guidelines: Drug Coverage (balsalazide) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Colchicine Capsule Guidelines: Drug Coverage (manufacturer: Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic West-Ward) Equivalent Medications  Prior Authorization/ Notification Guidelines: Colchicine Tablet Colchicine Tablet (manufacturer: Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A Prasco Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 28 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Colcrys Colcrys (colchicine) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications *Precertification Note: Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Cometriq years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (cabozantinib) chemotherapy drugs do not Cometriq require precertification. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Comfort Pac w/ Guidelines: Drug Coverage Tizanidine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (tizanidine) Equivalent Medications Compounds and  Prior Authorization/ *NJ Small members should refer Bulk Powders: Various J7999 PBM Notification Guidelines: Pharmacy to their Certificate of Coverage various drugs Compounds and Bulk Powders for precertification guidelines.  Prior Authorization/ Concerta Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (methylphenidate) Concerta  Therapeutic Equivalent Guidelines: Drug Coverage Conzip (tramadol) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications Copaxone  Prior Authorization/ Injection, (glatiramer J1595 PBM Notification Guidelines: Pharmacy N/A SQ Injection acetate) Copaxone Copaxone  Prior Authorization/ (glatiramer Injection J3490 PBM Notification Guidelines: Pharmacy N/A acetate) 40mg Copaxone J3490 and Copegus (ribarivin) Tablet N/A N/A Pharmacy N/A J3590

Drug Coverage Guidelines Page 29 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Step Therapy Guidelines: Cordran Cordran 0.05 %  Therapeutic Equivalent cream Cream J3490 PBM Pharmacy N/A Guidelines: Drug Coverage (clurandrenolide) Criteria - New and Therapeutic Equivalent Medications  Step Therapy Guidelines: Cordran Cordran 0.05%  Therapeutic Equivalent lotion Lotion J3490 PBM Pharmacy N/A Guidelines: Drug Coverage (flurandrenolide) Criteria - New and Therapeutic Equivalent Medications Cordran Ointment Topical  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (flurandrenolide) Ointment Cordran Ointment  Therapeutic Equivalent Coreg CR J3490 and Guidelines: Drug Coverage (carvedilol Capsule PBM Pharmacy N/A J8499 Criteria - New and Therapeutic phosphate) Equivalent Medications Corgard (nadolol) Tablet J3490 N/A N/A Pharmacy N/A  Prior Authorization/ Corlanor Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (ivabradine) Corlanor  Prior Authorization/ Notification Guidelines: Cosentyx Injection J3490 PBM Cosentyx Pharmacy N/A (secukinumab)  Step Therapy Guidelines: Cosentyx  Therapeutic Equivalent Cosopt PF Ophthalmic Guidelines: Drug Coverage (dorzolamide hcl/ J3490 PBM Pharmacy N/A solution Criteria - New and Therapeutic timolol maleate Equivalent Medications  Prior Authorization/ Cotellic Tablet J8999 PBM Notification Guidelines: Pharmacy N/A () Cotellic  Prior Authorization/ Notification Guidelines: Oral Cotempla XR-ODT Cotempla XR-ODT disintegratin J8499 PBM  Therapeutic Equivalent Pharmacy N/A (methylphenidate) g tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cresemba ( Capsule J8499 N/A N/A Pharmacy N/A sulfate)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Crestor Guidelines: Drug Coverage (rosuvastatin Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic ) Equivalent Medications *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility Crinone Gel J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progesterone gel) Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Benefit Note: Coverage is limited to Members with coverage for fertility drugs Precertification through their prescription drug  Precertification Guidelines: Crinone 8% through Optum Pharmacy/ plan. If the Member does not Injection J3490 Infertility Diagnosis and (progesterone) may be Medical* have fertility drug coverage Treatment required through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Crofab (crotalidae polyvalent immune Injection J0840 N/A N/A Medical N/A fab (ovine)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do  Precertification Guidelines: not request one, a medical Crysvita o Crysvita (-Twza) Injection J3590 N/A* Medical necessity review will be (Burosumab-Twza) o Review at Launch for New to conducted post-service to Market Medications* determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 10/01/2018, precertification will be required. Cultivate  Step Therapy Guidelines: (fluticasone Lotion J3490 PBM Pharmacy N/A Cultivate propionate 0.05%)  Therapeutic Equivalent Cuprimine Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (penicillamine) Criteria - New and Therapeutic Equivalent Medications  Precertification Guidelines: o Immune Globulin (IVIG & Cuvitru [immune Oxford’s SCIG) globulin Injection J1555 Medical o Immune Globulin Site of Medical N/A subcutaneous Management Care Review Guidelines for (human)] Medical Necessity of Hospital Outpatient Facility Infusion Cyclophosphamide Oral J8530 N/A N/A Pharmacy N/A (Cytoxan) Cyclophosph Capsule Capsule J8999 N/A N/A Pharmacy N/A (cyclophosphamide)  Therapeutic Equivalent Cymbalta Guidelines: Drug Coverage (duloxetine) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Prior Authorization/ Cystaran Ophthalmic J3490 PBM Notification Guidelines: Pharmacy N/A (cysteamine) Solution Cystaran (cysteamine)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Cytogam (cytomegalovirus 90291 or immune globulin Injection N/A N/A Medical N/A J0850 intravenous (human)  Prior Authorization/Medical Daklinza Tablet J3490 PBM Necessity Guidelines: Pharmacy N/A (daclatasvir) Daklinza  Prior Authorization/ *NJ Small members should refer Daliresp Tablet J3490 PBM* Notification Guidelines: Pharmacy* to their Certificate of Coverage (Roflumilast) Daliresp for precertification guidelines.  Prior Authorization/Medical Daraprim Tablet J3490 PBM Necessity Guidelines: Pharmacy N/A (pyrimethamine) Daraprim *No precertification is required if J0882-  Benefit Guidelines: Anemia dispensed by a retail pharmacy Oxford’s Darbepoetin Alfa Injgection, ESRD OR Drugs: Darbepoetin Alfa, through the PBM. Medical Pharmacy (Aranesp) SQ Injection J0881-Non- Epoetin Alfa and Methoxy *Precertification is required if Management* ESRD Polyethylene Glycol-Epoetin Beta provided in a hospital or MD's office.  Therapeutic Equivalent Daxbia Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (cephalexin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Daytrana Daytrana Patch J3490 PBM  Therapeutic Equivalent Pharmacy N/A (methylphenidate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Decadron Guidelines: Drug Coverage Tablets J8499 PBM Pharmacy N/A (dexamethasone) Criteria - New and Therapeutic Equivalent Medications Deca-Durabolin Injection J2320 N/A N/A Medical N/A (nandrolone) Delatestryl (testosterone Injection J3490 N/A N/A Medical N/A enanthate)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Delos Guidelines: Drug Coverage lotion/cleanser Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (benzoyl peroxide) Equivalent Medications Delzicol  Therapeutic Equivalent (mesalamine Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A delayed release Criteria - New and Therapeutic Capsule) Equivalent Medications  Therapeutic Equivalent Denavir Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (penciclovir) Criteria - New and Therapeutic Equivalent Medications Depakote  Prior Authorization/Medical (divalproex Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A sodium) Depakote Depakote ER  Prior Authorization/Medical (divalproex sodium Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A extended release) Depakote ER *Coverage is limited to Members with coverage for contraceptives through their prescription drug Depo Provera plan. If the Member does not 150mg, Depo- have contraceptive coverage  Benefit Guidelines: subQ provera 104 Injection J3490 N/A Pharmacy* through their prescription drug Contraceptives (medroxy- plan, then this is not covered. progesterone) Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Depo Provera 400mg (medroxy- Injection J3490* N/A N/A Medical Only administered in MD's office. progesterone) Depo Testosterone (testosterone Injection J3490 N/A N/A Medical N/A cypionate)  Therapeutic Equivalent Dermasorb AF 3- Guidelines: Drug Coverage 0.5% kit Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (hydrocortisone) Equivalent Medications  Therapeutic Equivalent Dermasorb XM Guidelines: Drug Coverage 39% kit Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (hydrocortisone) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Descovy (emtricitabine/ Tablet J8499 N/A N/A Pharmacy N/A tenofovir alafenamide)  Therapeutic Equivalent Desloratadine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Clarinex) Criteria - New and Therapeutic Equivalent Medications Desonate 0.05%  Step Therapy Guidelines: Gel J3490 PBM Pharmacy N/A gel (desonide) Desonate  Therapeutic Equivalent Desonil Guidelines: Drug Coverage cream/ointment Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (Kit) (desonide) Equivalent Medications  Prior Authorization/ Desoxyn (meth- Tablet J3490 N/A Notification Guidelines: Pharmacy N/A amphetamine) Desoxyn Desvenlafaxine Tablet J8499 N/A N/A Pharmacy N/A (desvenlafaxine)  Therapeutic Equivalent Desvenlafaxine ER Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (desvenlafaxine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Detrol (tolterodine) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Detrol LA J3490 and Guidelines: Drug Coverage (tolterodine Capsule PBM Pharmacy N/A J8499 Criteria - New and Therapeutic tartrate) Equivalent Medications  Prior Authorization/ Dexedrine (dextro- Tablet or S0160 PBM Notification Guidelines: Pharmacy N/A amphetamine) Capsule Dexedrine Dexilant (brand) Capsule J8499 N/A N/A Pharmacy N/A (dexlansoprazole)  Therapeutic Equivalent Dexmethylphen- Guidelines: Drug Coverage idate extended- Criteria - New and Therapeutic release capsule Capsule J8499 PBM Equivalent Medications Pharmacy N/A (generic Focalin  Prior Authorization/ XR) Notification Guidelines: Focalin

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Dextrostat (dextro- Tablet S0160 PBM Notification Guidelines: Pharmacy N/A amphetamine) Dextrostat D.H.E. 45  Therapeutic Equivalent (dihydro- Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A ergotamine) Criteria - New and Therapeutic (brand) Equivalent Medications A4206, A4210, A4233- A4236, A4244- A4245, A4250, A4253, A4256, A4258- A4259,  Precertification Guidelines: A9275, Diabetes Supply Coverage for Diabetic Supplies Varies E0607, N/A N/A N/A Commercial Plans (Including E2100- New Jersey Small Group Plans) E2101, E0784, K0601- K0605, A4230- A4232, A6257, J1610, J1815, J1817 and J3490  Therapeutic Equivalent Dibenzyline Guidelines: Drug Coverage (phenoxyl- Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic benzamine) (brand) Equivalent Medications Diclegis (doxylamine  Prior Authorization/Medical succinate and Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Diclegis pyridoxine hydrochloride)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Diclofenac 1% Guidelines: Drug Coverage topical gel (generic Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Voltaren) Equivalent Medications Dicloxacillin Sodium (Dycil, Capsule J8499 N/A N/A Pharmacy N/A Dynapen) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Differin 0.1% Varies J3490 N/A N/A N/A equivalent are excluded from (adapalene) coverage. Refer to the member specific benefit plan document as applicable. Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Differin 0.3% Gel Topical Gel J3490 N/A N/A N/A equivalent are excluded from (adapalene) coverage. Refer to the member specific benefit plan document as applicable. Diflucan Tablet J8499 N/A N/A Pharmacy N/A ()  Therapeutic Equivalent Diovan (valsartan) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Diovan HCT Guidelines: Drug Coverage (valsartan) (brand Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic only) Equivalent Medications  Therapeutic Equivalent Tablet and Guidelines: Drug Coverage Disalcid (salsalate) J8499 PBM Pharmacy N/A Capsule Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Dolophine Tablets S0109 PBM Necessity Guidelines: Pharmacy N/A (methadone) Dolophine Donepezil 5 or Oral Dis- 10mg (generic intergrating J8499 N/A N/A N/A N/A Aricept) Tablet

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Donepezil 23mg Guidelines: Drug Coverage (generic Aricept Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic 23mg) Equivalent Medications Doribax IV Infusion J1267 N/A N/A Medical N/A (doripenem)  Therapeutic Equivalent Doryx (doxycycline Guidelines: Drug Coverage hyclate) delayed Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic release tablet Equivalent Medications  Prior Authorization/ Topical Doxepin Cream J3490 PBM Notification Guidelines: Pharmacy N/A Cream Doxepin Cream Doxorubicin Q2049 and Hydrochloride Injection N/A N/A Medical N/A Q2050 Liposomal  Therapeutic Equivalent Doxycycline 75mg Guidelines: Drug Coverage capsule (generic Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Monodox) Equivalent Medications  Therapeutic Equivalent Doxycycline Guidelines: Drug Coverage 150mg capsule Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (generic Monodox) Equivalent Medications  Therapeutic Equivalent Doxycycline Guidelines: Drug Coverage Delayed-Release Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Capsule 40mg Equivalent Medications *Oral chelation agents do not D-Pennicillamine Oral Agent J3490 N/A* N/A Pharmacy require precertification. Drisdol Capsule, J3490, and N/A N/A Pharmacy N/A (ergocalciferol) Liquid J8499 Duac (Clindamycin and Benzoyl Topical J3490  Therapeutic Equivalent Peroxide) Guidelines: Drug Coverage PBM Pharmacy N/A Duac CS Criteria - New and Therapeutic (Clindamycin and Topical J3490 Equivalent Medications Benzoyl Peroxide)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Duexis (famotidine Tablet J8499 N/A N/A Pharmacy equivalent are excluded from and ibuprofen) coverage. Refer to the member specific benefit plan document as applicable. Dulera (mometasone  Step Therapy Guidelines: furoate/formoterol Inhaler J3490 PBM Pharmacy N/A Dulera fumarate dihydrate) Duopa (carbidopa/ Enteral  Prior Authorization/Medical J3490 PBM Pharmacy N/A levodopa) Suspension Necessity Guidelines: Duopa  Prior Authorization/Medical Dupixent Injection J3590 PBM Necessity Guidelines: Pharmacy N/A (dupilumab) Dupixent  Prior Authorization/Medical Necessity Guidelines: Duragesic Duragesic (Brand Transdermal J3490 PBM  Therapeutic Equivalent Pharmacy N/A Only) (fentanyl) Patch Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Durlaza (aspirin) Capsule J8499 N/A N/A N/A equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable.  Therapeutic Equivalent Guidelines: Drug Coverage Dutoprol Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Gout Duzallo (lesinurad  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A /allopurinol) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Dyanavel XR Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (amphetamine) Suspension Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Dymista Guidelines: Drug Coverage (fluticasone Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (Flonase) Equivalent Medications Dynavel XR  Prior Authorization/ Oral (amphetamine J8499 PBM Notification Guidelines: Pharmacy N/A Suspension extended release) Dynavel XR Dysport Oxford’s  Precertification Guidelines: (abobotulinumtoxi Injection J0586 Medical Medical N/A Botulinum Toxins A and B n A) Management  Therapeutic Equivalent Ecoza ( Guidelines: Drug Coverage nitrate topical Topical J3490 PBM Pharmacy* N/A Criteria - New and Therapeutic foam 1%) Equivalent Medications  Prior Authorization/ Edex (alprostadil) Vial J0270 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents  Therapeutic Equivalent Guidelines: Drug Coverage Edluar (zolpidem) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications E.E.S. 400  Therapeutic Equivalent (erythromycin Guidelines: Drug Coverage Oral Liquid J8499 PBM Pharmacy N/A ethylsuccinate) Criteria - New and Therapeutic (brand) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Select Effexor XR Brand Medications (venlafaxine) Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Egrifta Injection J8999 PBM Notification Guidelines: Pharmacy N/A (tesamorelin) Egrifta (tesamorelin)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Elaprase IV Infusion,  Precertification Guidelines: necessity review will be J1743 N/A* Medical (idursulfase) Injection Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required.  Medical Management Oxford’s Elelyso Guidelines: Intravenous Injection J3060 Medical Medical N/A (taliglucerase alfa) Enzyme Replacement Therapy Management (ERT) for Gaucher Disease  Therapeutic Equivalent Elestat (epinastine Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A HCL) Solution Criteria - New and Therapeutic Equivalent Medications Elidel Topical J3490 PBM  Step Therapy: Elidel Pharmacy N/A (pimecrolimus) J1950,  Prior Authorization/ Eligard (leuprolide J9217, SQ Injection PBM Notification Guidelines: Pharmacy N/A acetate) J9218 and Eligard (leuprolide acetate) J9219  Therapeutic Equivalent Emadine Ophthalmic Guidelines: Drug Coverage (emedastine J3490 PBM Pharmacy N/A Solution Criteria - New and Therapeutic difumarate) Equivalent Medications Embeda (morphine  Prior Authorization/Medical sulphate and Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Embeda hcl) Emend Capsule or J8501 Pharmacy (aprepitant) Trifold Pack N/A N/A N/A Emend IV Infusion J1453 Medical (fosaprepitant)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Necessity Guidelines: Emflaza Emflaza Oral  Therapeutic Equivalent J8499 PBM Pharmacy N/A (deflazacort) suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Empagliflozin/ Tablet J3490 N/A N/A Pharmacy N/A Metformin Emverm Chewable  Prior Authorization/Medical J8499 PBM Pharmacy N/A (mebendazole) Tablet Necessity Guidelines: Emverm  Therapeutic Equivalent Enablex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (darifenacin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Enbrel Notification Guidelines: Injection J1438 PBM Pharmacy N/A (etanercept) Enbrel (etanercept)  Step Therapy: Enbrel Endari (L- Oral Powder  Prior Authorization/Medical J8499 PBM Pharmacy N/A ) for Solution Necessity Guidelines: Endari *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility Endometrin Vaginal J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progesterone) Insert Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Enstilar foam Topical (calcipotriene/ J3490 N/A N/A Pharmacy N/A Foam betamethasone)  Therapeutic Equivalent Entocort EC Guidelines: Drug Coverage (budesonide) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Entresto  Prior Authorization/Medical (valsartan – Tablet J8499 PBM Necessity Guidelines: Entestro Pharmacy N/A sacubitril) (valsartan-sacubitril)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Hospital Outpatient Facility: Administration of Entyvio in a  Medical Management hospital outpatient facility Guidelines: Maximum Dosage (including any ambulatory Oxford’s  Precertification Guidelines: infusion suite associated with the Entyvio J3380 and Injection Medical - Entyvio (vedolizumab) Medical hospital) requires precertification (vedolizumab) J3490 Management - Specialty Medication with review by a Medical Director Administration – Site of Care or their designee. Refer to: Review Guidelines Specialty Medication Administration – Site of Care Review Guidelines.  Therapeutic Equivalent Envarsus XR Guidelines: Drug Coverage Tablet J7508 PBM Pharmacy N/A (tacrolimus) Criteria - New and Therapeutic Equivalent Medications Powder for  Prior Authorization/Medical Epaned (enalapril) Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Solution Solid Oral Dosage Forms  Prior Authorization/ Epanova (omega- Capsule J8499 PBM Notification Guidelines: Pharmacy N/A 3-carboxylic acids) Epanova Epclusa  Prior Authorization/Medical (sofosbuvir/ Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Epclusa velpatasfir) *Benefit Notes: Not covered for cosmetic conditions. Not all Epi Quinn Micro groups have selected the Varies J3490 N/A N/A Pharmacy* (hydroquinone) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Therapeutic Equivalent Epiduo (adapalene Guidelines: Drug Coverage and benzoyl Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic peroxide) Equivalent Medications  Therapeutic Equivalent Epiduo Forte Guidelines: Drug Coverage (adapalene and Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic benzoyl peroxide) Equivalent Medications Epinephrine Pen  Therapeutic Equivalent Injection, 0.15mg Pen Guidelines: Drug Coverage and 0.3mg J0171 PBM Pharmacy N/A Injection Criteria - New and Therapeutic (generic Equivalent Medications Adrenaclick)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent EpiPen/EpiPen Jr. J0171, Guidelines: Drug Coverage (epinephrine) Injection PBM Pharmacy N/A J3490 Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Epzicom (abacavir/ Guidelines: Drug Coverage lamivudine) (brand Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic only) Equivalent Medications Ergomar  Prior Authorization/Medical (ergotamine Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A tartrate) Ergomar Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Erivedge years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (vismodegib) chemotherapy drugs do not Erivedge require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Ertaczo Guidelines: Drug Coverage ( Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic nitrate) Equivalent Medications *No precertification is required if dispensed by a retail pharmacy Oxford’s through the PBM. Q4081- Medical  Precertification Guidelines: Erythropoetin *Precertification is required if Injection, ESRD OR Management* Anemia Drugs: Darbepoetin Alfa, Medical/ (EPO, Epoetin Alfa, provided in a hospital or MD's SQ Injection J0885-non- Epoetin Alfa and Methoxy Pharmacy Epogen, Procrit) office. ESRD Polyethylene Glycol-Epoetin Beta *No precertification is required if N/A* dispensed by a retail pharmacy through the PBM.  Prior Authorization/Medical Esbriet Capsule J8499 PBM Necessity Guidelines: Esbriet Pharmacy N/A (pirfenidone) (pirfenidone)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Esomeprazole Capsule J8499 N/A* N/A N/A* equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable.  Therapeutic Equivalent Estradiol (generic Guidelines: Drug Coverage Estrace cream Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic 0.01%) Equivalent Medications Estradiol TD twice  Therapeutic Equivalent weekly patch Transdermal Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (generic Vivelle- Patch Criteria - New and Therapeutic Dot) Equivalent Medications Estradiol vaginal tablet [Yuvafem Vaginal J3490 N/A N/A Pharmacy N/A (generic for Tablet Vagifem)] *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Estrostep FE have contraceptive coverage  Benefit Guidelines: (ethinyl estradiol Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives and norethindrone) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Eucrisa Topical  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (crisaborole) Ointment Eucrisa *Precertification is not required in Intra- Oxford’s Euflexxa (sodium  Precertification Guidelines: the office for Oxford's preferred Articular J7323 Medical Medical hyaluronate) Sodium Hyaluronate products of Euflexxa, Synvisc or Injection Management* Synvisc-One (J7323 and J7325).  Prior Authorization/ Notification Guidelines: Evekeo Evekeo (amphetamine Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A sulfate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 45 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Evista Evista (raloxifene)  Therapeutic Equivalent Oral J8999 PBM Pharmacy N/A (Brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Evotaz (atazanavir/ Tablet J8499 N/A N/A Pharmacy N/A cobicistat) Evzio (nalozone Auto-  Prior Authorization/Medical J3490 PBM Pharmacy N/A HCL injection) Injector Necessity Guidelines: Evzio Exalgo  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (hydromorphone) Necessity Guidelines: Exalgo  Therapeutic Equivalent Excelon Patch Transdermal Guidelines: Drug Coverage (rivastigmine) J3490 PBM Pharmacy N/A patch Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Exforge J3490 and Guidelines: Drug Coverage (amlodipine Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic valsartan) Equivalent Medications Exforge HCT  Therapeutic Equivalent (amlodipine, J3490 and Guidelines: Drug Coverage Tablet PBM Pharmacy N/A hydrochlorothiazide J8499 Criteria - New and Therapeutic and valsartan) Equivalent Medications  Prior Authorization/ Exjade Tablet J3490 PBM Notification Guidelines: Pharmacy N/A (Deferasirox) Exjade  Precertification Guidelines: Hospital Outpatient Facility: o Exondys 51 Administration of Exondys 51 in a o Specialty Medication hospital outpatient facility Administration – Site of Care (including any ambulatory Oxford’s Review Guidelines infusion suite associated with the Exondys 51 Intravenous J1428 Medical Medical hospital) requires precertification (eteplirsen) Management with review by a Medical Director or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Extavia (interferon J1830 or Injection PBM Extavia Pharmacy N/A B-1b) J3490  Step Therapy Guidelines: Extavia (interferon B-1b) Eylea (afibercept) Injection J0178 N/A N/A Medical N/A  Prior Authorization/ Notification Guidelines: Fabior (tazarotene) Fabior (tazarotene) Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Fabrazyme® IV Infusion,  Precertification Guidelines: necessity review will be J0180 N/A* Medical (agalsidase beta) Injection Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required. Falessa Kit (birth  Therapeutic Equivalent control plus Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A vitamin Criteria - New and Therapeutic supplement) Equivalent Medications Famvir Tablet J8499 N/A N/A Pharmacy N/A (famciclovir) Fanapt Oral J8499 N/A N/A Pharmacy N/A (iloperidone)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications SGLT2 Farxiga to New York and Connecticut Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy (depagliflozin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.  Prior Authorization/ Farydak Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (panobinostat) Farydak  Precertification Guidelines: Oxford’s Fasenra Subcutaneo J3490, Respiratory Interleukins Medical Medical N/A (benralizumab) us Injection J3590 (Cinqair®, Fasenra®, and Management Nucala®) Tablet and Felbatol  Prior Authorization/Medical Oral J8499 PBM Pharmacy N/A (felbamate) Necessity Guidelines: Felbatol Suspension  Therapeutic Equivalent Femara (letrozole) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Fenofibrate 43mg, Guidelines: Drug Coverage 130mg (generic Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Antara) capsule Equivalent Medications  Therapeutic Equivalent Fenofibrate 48mg, Guidelines: Drug Coverage 145mg (generic Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Tricor) Equivalent Medications  Therapeutic Equivalent Fenofibrate 50mg, Guidelines: Drug Coverage 150mg (generic Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Lipofen) capsule Equivalent Medications  Therapeutic Equivalent Fenoglide Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (fenofibrate) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Fentanyl Citrate Lozenge J8499 PBM Notification Guidelines: Actiq Pharmacy N/A (generic Actiq) (fentanyl citrate)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Fentanyl Citrate Oral Powder J8499 PBM Necessity Guidelines: Fentora Pharmacy N/A bulk powder (fentanyl) Fentanyl  Therapeutic Equivalent transdermal patch Topical Guidelines: Drug Coverage (37.5, 62.5 and J3490 PBM Pharmacy N/A Patch Criteria - New and Therapeutic 87.5 mcg/hr Equivalent Medications strengths only)  Prior Authorization/Medical Necessity Guidelines: Fentora (fentanyl) Fentora (fentanyl Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A buccal) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Ferriprox Tablet J3490 PBM Notification Guidelines: Pharmacy N/A (Deferiprone) Ferriprox *Precertification Note: HCPCS code J3355 (urofollitropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification **Benefit Note: Coverage is  Precertification Guidelines: Fertinex J3355* and through Optum Pharmacy/ limited to Members with Injection Infertility Diagnosis and (urofollitropin) J3490 may be Medical** coverage for fertility drugs Treatment required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Fetzima  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (Levomilnacipran) Fetzima  Therapeutic Equivalent Fibricor 35mg, Guidelines: Drug Coverage 105mg (fenofibric Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic acid) Equivalent Medications Finacea 15% Foam Foam J3490 N/A N/A Pharmacy N/A ()

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Fioricet with  Therapeutic Equivalent Codeine capsule Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A 50mg/300mg/ Criteria - New and Therapeutic 40mg/30mg Equivalent Medications Fioricet with  Therapeutic Equivalent Codeine Guidelines: Drug Coverage 50mg/325mg/ Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic 40mg/30mg Equivalent Medications (Brand Only)  Prior Authorization/ Firazyr (icatibant) Injection J1744 PBM Notification Guidelines: Pharmacy N/A Firazyr *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Precertification Guidelines: Firmagon Injection J9155 Medical Releasing Medical Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. *Benefit Note for Infertility Use: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility First Progesterone Varies J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progestin) Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Firvanq Oral Guidelines: Drug Coverage (vancomycin J8499 PBM Pharmacy N/A solution Criteria - New and Therapeutic hydrochloride) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Precertification Guidelines: o Immune Globulin (IVIG) and Flebogamma Oxford’s SCIG (immune globulin Injection J1572 Medical o Immune Globulin Site of Medical N/A Non-Lyophilized) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion  Therapeutic Equivalent J3490, Guidelines: Drug Coverage Flector (diclofenac) Patch PBM Pharmacy N/A J8499 Criteria - New and Therapeutic Equivalent Medications Flolipid Oral  Prior Authorization/Medical ( J8499 PBM Pharmacy N/A Suspension Necessity Guidelines: Flolipid suspension)  Therapeutic Equivalent Flomax Guidelines: Drug Coverage (tamsulosin) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Flo-Pred J3490 and Guidelines: Drug Coverage Suspension PBM Pharmacy N/A (prednisolone) J8499 Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Floxin 0.3% Otic Otic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A () Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent FlowTuss Oral Guidelines: Drug Coverage (hydrocodone/ J8499 PBM Pharmacy N/A Solution Criteria - New and Therapeutic guaifenesin) Equivalent Medications Flublok (Influenza  Medical Management Vaccine, Intra- Guidelines: Recombinant muscular Q2033 N/A Medical N/A o Preventive Care Services Hemagglutinin Injection o Vaccines Antigens) FluMist (influenza virus vaccine Nasal Spray 90660 N/A N/A Medical N/A (nasal))  Therapeutic Equivalent Fluocinonide 0.1% Guidelines: Drug Coverage cream (generic Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Vanos) Equivalent Medications Fluorouracil 0.5% Topical J3490 N/A N/A Pharmacy N/A Cream

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent 60mg Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A tablet Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Fluoxetine tablets Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Sarafem) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Fluticasone/ Guidelines: Drug Coverage Inhaler J3490 PBM Pharmacy N/A Salmeterol Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Fluticasone Topical J3490 PBM Notification Guidelines: Pharmacy N/A (topical) Compounds and Bulk Powders Focalin  Prior Authorization/ (dexmethylphenida Capsule J8499 PBM Notification Guidelines: Pharmacy N/A te HCl) Focalin  Prior Authorization/ Notification Guidelines: Focalin XR Focalin XR (dexmethylphenida Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A te HCl [extended Guidelines: Drug Coverage release]) Criteria - New and Therapeutic Equivalent Medications *Coverage is limited to Members with coverage for vitamins/ supplements through their prescription drug plan. If the Member does not have vitamin/ supplement coverage through Folic Acid Tablet J8499 N/A N/A Pharmacy* their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members Precertification  Precertification Guidelines: without a Pharmacy Benefit. Follistim AQ Injection S0128 through Follicle Stimulating Hormone See Notes* *NY Plans: Pharmacy Benefit. (follitropin beta) Optum* (FSH) Gonadotropins *Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.  Prior Authorization/Medical Forfivo XL Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A (bupropion HCL) Brand Medications  Prior Authorization/Medical Fortamet Necessity Guidelines: (metformin Tablet J8499 PBM Pharmacy N/A Fortamet (metformin extended- extended-release) release)  Prior Authorization/ Forteo Injection, J3110 PBM Notification Guidelines: Pharmacy N/A (teriparatide) SQ Injection Teriparatide (Forteo)  Prior Authorization/Medical Necessity Guidelines: Fortesta  Therapeutic Equivalent Gel J3490 PBM Pharmacy N/A Fortesta Guidelines: Drug Coverage (testosterone) Criteria - New and Therapeutic Equivalent Medications Injection J1950 N/A N/A Medical N/A *No precertification is required if Fragmin Injection, J1645 N/A* N/A Pharmacy dispensed by a retail pharmacy (dalteparin) SQ Injection or Mail Order through PBM. **Precertification Note: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not Frova  Supply Limit Guidelines: require precertification. Tablet J8499 PBM** Pharmacy* (frovatriptan) Triptans Supply Limits *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Fuzeon Injection J3490 N/A N/A Medical N/A (enfuvirtide)  Prior Authorization/Medical Fycompa Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A (perampanel) Fycompa Gammagard® Liquid J1569 (immunoglobulin,  Precertification Guidelines: Non-Lyophilized) o Immune Globulin (IVIG) and Gammaplex Oxford’s SCIG (immunoglobulin, Injection J1557 Medical o Immune Globulin Site of Medical N/A Non-Lyophilized) Management Care Review Guidelines for Gamunex-C, Medical Necessity of Hospital Gammaked Outpatient Facility Infusion J1561 (immune globulin, Non-Lyophilized) Gattex  Prior Authorization/ Injection, (teduglutide [rDNA J3490 PBM Notification Guidelines: Pharmacy N/A SQ Injection origin]) Gattex  Therapeutic Equivalent Gelnique Guidelines: Drug Coverage Topical gel J3490 PBM Pharmacy N/A (oxybutynin) Criteria - New and Therapeutic Equivalent Medications *Precertification with review by a Intra- Oxford’s Medical Director or their Gel-One  Precertification Guidelines: Articular J7324 Medical Medical Designee is required in all sites of (Hyaluronan) Sodium Hyaluronate Injection Management* service for J7321, J7324 and J7326. Intra- Oxford’s Gel-Syn (sodium  Precertification Guidelines: Articular J7328 Medical Medical N/A hyaluronate) Sodium Hyaluronate Injection Management  Therapeutic Equivalent Guidelines: Drug Coverage Genadur Kit Nail Laquer J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Generess FE Guidelines: Drug Coverage (norethindrone/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic ethinyl estradiol) Equivalent Medications Generic Tablet J8499 N/A N/A Pharmacy N/A Levetiracetam XR

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Necessity Guidelines: Genotropin (somatropin) Genotropin Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Genotropin Guidelines: Drug Coverage MiniQuick Injection J2941 PBM Pharmacy N/A Criteria - New and Therapeutic (somatropin) Equivalent Medications Genvisc 850 Intra- Oxford’s  Precertification Guidelines: (sodium Articular J7320 Medical Medical N/A Sodium Hyaluronate hyaluronate) Injection Management Genvoya (elvitegravir/ cobicistat/  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A emtricitabine/ Genvoya tenofovir alafenamide)  Therapeutic Equivalent Geodon Guidelines: Drug Coverage (ziprasisdone) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Gialax Kit Orol Guidelines: Drug Coverage (polyethylene J8499 PBM Pharmacy N/A solution Criteria - New and Therapeutic glycol) Equivalent Medications  Therapeutic Equivalent Giazo (balsalazide Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A disodium) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Gilenya Injection J3490 PBM Notification Guidelines: Pharmacy N/A (fingolimod) Gilenya

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Gilotrif () Tablet J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Gilotrif (Afatinib) require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Glassia [Alpha1- Oxford’s  Precertification Guidelines: Intravenous Proteinase J0257 Medical Alpha -Proteinase Inhibitors Medical N/A injection 1 Inhibitor (Human)] Management  Prior Authorization/ Notification Guidelines: Glatopa Glatopa (Glatiramer 20mg Injection J3490 PBM  Therapeutic Equivalent Pharmacy N/A [generic Guidelines: Drug Coverage Copaxone]) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed  Prior Authorization/ in a Coverage Criteria/Guideline Notification Guidelines: when the Member is age 19 Gleevec Gleevec ( years or older. All other oral Oral, Varies S0088 PBM*  Therapeutic Equivalent Pharmacy** mesylate) chemotherapy drugs do not Guidelines: Drug Coverage require precertification. Criteria - New and Therapeutic Benefit Note: **NJ Small Equivalent Medications Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Glucophage XR  Prior Authorization/Medical (metformin Necessity Guidelines: Tablet J8499 PBM Pharmacy N/A extended-release Glucophage XR (metformin [brand only]) extended-release [brand only])

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Glumetza Necessity Guidelines: (metformin Tablet J8499 PBM Pharmacy N/A Glumetza (metformin extended- extended-release) release) The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Glyxambi Diabetes Medications SGLT2 to New York and Connecticut (empagliflozin/ Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy plans and products. linagliptin)  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.  Therapeutic Equivalent Extended Gocovri Guidelines: Drug Coverage release J8499 PBM Pharmacy N/A (amantadine) Criteria - New and Therapeutic capsules Equivalent Medications *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit. Medical Benefit for Members Gonal-F /Gonal-f Precertification  Precertification Guidelines: without a Pharmacy Benefit. IM or SQ RFF (follitropin S0126 through Follicle Stimulating Hormone See Notes* *NY Plans: Pharmacy Benefit.* Injection alfa) Optum* (FSH) Gonadotropins *Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.  Therapeutic Equivalent Gonitro Sublingual Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (nitroglycerin) Powder Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Gralise J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A (gabapentin) J8499 Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Pharmacy Benefit: If dispensed by a retail pharmacy  eviCore Guidelines: White or mail order through PBM. Blood Cell Colony Stimulating Precertification through the PBM Factors** Granix PBM*/ is required. Injection J1447  Therapeutic Equivalent See Notes (tbo-filgrastiim) eviCore** **Medical Benefit: If provided Guidelines: Drug Coverage in a hospital, MD's office, or in Criteria - New and Therapeutic conjunction with home health Equivalent Medications* care. Precertification through eviCore is required.  Prior Authorization/Medical Grastek (Timothy Sublingual Necessity Guidelines: Grastek Grass Pollen J8499 PBM Pharmacy N/A Tablet (Timothy Grass Pollen Allergen Allergen Extract) Extract) Haegarda [C1  Prior Authorization/ Esterase Inhibitor Injection J3490 PBM Notification Guidelines: Pharmacy N/A Subcutaneous Haegarda (Human)] Halog 0.1% cream  Step Therapy Guidelines: Cream J3490 PBM Pharmacy N/A (halcinonide) Halog Halog 0.1%  Step Therapy Guidelines: ointment Ointment J3490 PBM Pharmacy N/A Halog (halcinonide) Halotestin Tablet J3490 N/A N/A Pharmacy N/A () Harvoni™  Prior Authorization/Medical (ledipasvir/ Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Harvoni sofosbuvir)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) J0725 requires precertification through Optum in all sites of service when associated with an infertility Precertification diagnosis code.  Precertification Guidelines: HCG (chorionic J0725* and through Optum Pharmacy/ **Benefit Note: Coverage is Injection Infertility Diagnosis and gonadotropin) J3490 may be Medical** limited to Members with Treatment required* coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines. Hectorol Capsule J8499 N/A N/A Pharmacy N/A (doxercalciferol) Injection J1270 N/A N/A Medical N/A  Therapeutic Equivalent Helidac (bismuth Capsule/ Guidelines: Drug Coverage J8499 PBM Pharmacy N/A subsalicylate) Tablet Criteria - New and Therapeutic Equivalent Medications Hemangeol Oral  Therapeutic Equivalent solution Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (propranolol Solution Criteria - New and Therapeutic hydrochloride) Equivalent Medications Hemlibra  Prior Authorization/ (emicizumab- Injection J3490 PBM Notification Guidelines: Pharmacy N/A kxwh) Hemlibra J7175 See Notes*  Precertification Guidelines: See Notes* Effective 12/01/2013 for NY HEMOPHILIA o Assisted Administration of LOBS (excluding Healthy NY DRUGS J7178 J7179 Clotting Factors and and NY Individual Plans) and Brand Names Coagulant Blood Products J7180 New Jersey Large and Small Adynovate, o Clotting Factors and Groups: J7181 Advate, Coagulant Blood Products *Precertification: J7182 o Eloctate™ (Antihemophilic Afstyla, Is required through Oxford for J7183 Alphanate, Factor (Recombinant), FC self-administered clotting factor Fusion ) for Alphanine SD J7185 drugs (including Eloctate) Connecticut Lines of Business Alprolix J7186 provided by a Hemophilia J7187 (Medical Benefit) Treatment Center including Bebulin, o Home Health Care J7188 (Medical benefit applies): Benefix,  Prior Authorization/Medical  NY Presbyterian Hospital- Coagadex, J7189 Necessity Guidelines: Weill Cornell Center

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Corifact J7190 o Advate  Mount Sinai Medical Eloctate J7192 o Adynovate Center Feiba NF J7193 o Eloctate Medical Necessity  Long Island Jewish o Feiba VH J7194 Helixate FS Medical Center o Ixinity Helixate FS**, J7195 Is required for self- o Recombinate Hemofil-M, J7198 administered Eloctate when o Xyntha covered under the pharmacy Humate-P, J7199  Therapeutic Equivalent benefit, with precertification Idelvion, J7200 Guidelines: Drug Coverage through the PBM. Ixinity** J7201 Criteria - New and Therapeutic Is NOT required for all other Equivalent Medications** Koate-DVI, J7202 self-administered clotting factor Kogenate FS, J7205 drugs (except Eloctate) obtained Kovaltry J7207 through any specialty designated Monoclate-P J7209 pharmacy (Pharmacy benefit Mononine J7210 applies). Novoeight J7211 Is required if assisted administration (provider’s office, Novoseven RT clinic, home, etc). Nuwig Eloctate is covered under the Obizur medical benefit, precertification Profilnine SD obtained through Oxford. Recombinate, For Connecticut LOB RiaSTAP Member’s regardless of date Rixubis of service: Tretten *Self-administered clotting Vonvendi factor drugs (except Eloctate) Wilate do not require precertification and are covered under the Xyntha medical benefit. Xyntha Solofuse Self-administered Eloctate requires precertification through Oxford and is covered under the medical benefit. *If the member requires assisted administration of their clotting factor drugs, precertification is required in all sites of service and is covered under the medical benefit. For assisted administration in the home, please refer to Home Health Care. *HMO Members: If drugs are

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type requested or supplied through a non-par vendor and authorization is not approved, these services will not be reimbursed by Oxford. HepaGam B (hepatitis B J1571 and Injection N/A N/A Medical N/A immune globulin J1573 [human]) *Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM. J1642 or Heparin Injection N/A N/A See Notes* *Medical Benefit: If provided in J1644 a hospital, MD's office, or in conjunction with home health care.  eviCore Guidelines: Injectable Chemotherapy Drugs: Oxford’s *For Oncology and Non- Herceptin Application of NCCN Clinical Injection J9355 Medical Medical Oncology Use: Precertification () Practice Guidelines Management* is required  Precertification Guidelines: Maximum Dosage Hetlioz  Prior Authorization/Medical Capsule J8499 PBM Pharmacy N/A (tasimelteon) Necessity Guidelines: Hetlioz  Precertification Guidelines: o Immune Globulin (IVIG) and Oxford’s SCIG Hizentra (immune Injection J1559 Medical o Immune Globulin Site of Medical N/A globulin) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion  Therapeutic Equivalent Horizant Guidelines: Drug Coverage (gabapentin, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic enacarbil) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Humatrope (somatropin) Humatrope Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Precertification Note: *HCPCS code S0122 () requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: Benefit Note: **Coverage is Humegon S0122* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with (menotropins) J3490 may be Medical** Treatment coverage for fertility drugs required through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines.  Prior Authorization/ Humira Injection, J0135 PBM Notification Guidelines: Pharmacy N/A (adalimumab) SQ Injection Humira (adalimumab) Intra- Oxford’s Hyalgan (sodium  Precertification Guidelines: Articular J7321 Medical Medical N/A hyaluronate) Sodium Hyaluronate Injection Management Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 Hycamtin  Prior Authorization/ years or older. All other oral (topotecan Oral J8705 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not hydrochloride) Hycamtin require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Hycofenix  Therapeutic Equivalent (hydrocodone/ Oral Guidelines: Drug Coverage J3490 PBM Pharmacy N/A pseudoephedrine/ solution Criteria - New and Therapeutic guaifenesin) Equivalent Medications hydrocortisone 1% ointment in Ointment J3490 N/A N/A Pharmacy N/A absorbase

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Hydromorphone ER Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A Hydromorphone ER Oxford’s  Precertification Guidelines: Hydroxyproges- Injection J1729 Medical 17-Alpha-Hydroxyprogesterone Medical N/A terone caproate Management Caproate (Makena and 17P) Hysingla ER  Prior Authorization/Medical (hydrocodone Tablet J8499 PBM Necessity Guidelines: Hysingla Pharmacy N/A bitartrate) ER Hytakerol Capsule J8499 N/A N/A Pharmacy N/A (dihydrotachysterol)  Prior Authorization/ Ibrance Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (palbociclib) Ibrance Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Iclusig () Oral J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Iclusig require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Idhifa () Tablet J8999 PBM Pharmacy N/A Notification Guidelines: Idhifa Hospital Outpatient Facility: Administration of Actemra in a hospital outpatient facility  Precertification Guidelines: (including any ambulatory Oxford’s o Ilaris® (Canakinumab) infusion suite associated with the Ilaris Injection J0638 Medical o Specialty Medication Medical hospital) requires precertification (canakinumab) Management Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Ophthalmic Guidelines: Drug Coverage Ilevro (nepafenac) J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic Equivalent Medications Precertification Note: Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 Imatinib (generic S0088 and years or older. All other oral Oral N/A N/A Pharmacy Gleevec) J8999 chemotherapy drugs do not require precertification. Benefit Note: NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Imbruvica Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (ibrutinib) Imbruvica **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. J3490, *NJ Plans do not require Imitrex  Supply Limit Guidelines: Nasal Spray J8499 and PBM** Pharmacy* precertification. (sumatriptan) Triptans Supply Limits J3030 *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Therapeutic Equivalent Imitrex Guidelines: Drug Coverage (sumatriptan) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Supply Limit Guidelines: Triptans Supply Limits Imitrex  Therapeutic Equivalent (sumatriptan) Injection J3030 PBM Pharmacy N/A Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications Immune Globulin (IVIG and SCIG)

IVIg: Bivigam Carimune NF ® Gammaplex J1459 ® Flebogamma J1556 Flebogamma® DIF J1557 Gammagard®  Precertification Guidelines: J1559 Liquid o Immune Globulin (IVIG and Gammagard® S/D J1561 Oxford’s SCIG) Gammaked™ IV Infusion J1566 Medical o Immune Globulin Site of Medical N/A ®- Management Care Review Guidelines for Gamunex C J1568 Medical Necessity of Hospital Octogam® J1569 Outpatient Facility Infusion Privigen® J1572 J1575 SCIG: J1599 Gammagard® Liquid Gammaked™ Gamunex®-C Hizentra® HyQvia  Prior Authorization/ Impavido Tablet J8499 PBM Notification Guidelines: Pharmacy N/A () Impavido  Therapeutic Equivalent Impoyz (clobetasol Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A propionate) cream Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Imuran J7500, Guidelines: Drug Coverage (azathioprine) Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic (brand only) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Increlex SQ Injection J2170 PBM Necessity Guidelines: Increlex Pharmacy N/A () (mecasermin) Incruse Ellipta Inhalation J3490 N/A N/A Pharmacy N/A (umeclidinium) Powder  Therapeutic Equivalent Inderal LA (Brand Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A only) (propranolol) Criteria - New and Therapeutic Equivalent Medications *Precertification is required in all sites of service. Hospital Outpatient Facility:  Precertification Guidelines: Administration of Inflectra in a o Infliximab (Remicade®, hospital outpatient facility Oxford’s Inflectra™, Renflexis™) (including any ambulatory Inflectra Intravenous Q5103 Medical o Maximum Dosage Medical infusion suite associated with the (infliximab) Management* o Specialty Medication hospital) requires precertification Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines. Ingrezza  Prior Authorization/Medical Capsules J8499 PBM Pharmacy N/A (valbenazine) Necessity Guidelines: Ingrezza Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Inlyta () Oral J8999 PBM* Pharmacy** Notification Guidelines: Inlyta chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. *No precertification is required if Innohep Injection, J1655 N/A* N/A Pharmacy dispensed by a retail pharmacy (tinzaparin) SQ Injection or mail order through PBM

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type (Novolin 70/30, Novolog *The Prior Authorization/ pens and vials,  Prior Authorization/ Notification Guidelines: Insulin Novolog Mix 70/30 Notification Guidelines: policy applies to New York and pens and vials, Injection J1815 PBM Insulin* Pharmacy Connecticut plans and products. Apidra, Apidra  Step Therapy Guidelines: The Step Therapy: Insulin policy Solostar, Fiasp, Insulin applies to New Jersey plans and Novolin N, Novolin products. R)  Therapeutic Equivalent Intermezzo Sublingual Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (zolpidem tartrate) Tablet Criteria - New and Therapeutic Equivalent Medications Intrarosa Vaginal J3490 N/A N/A Pharmacy N/A () Inserts  eviCore Guidelines: Injectable Chemotherapy Drugs: Intron-A Application of NCCN Clinical *For Oncology and Non- (interferon Alfa- Injection J9212 PBM* Practice Guidelines Pharmacy Oncology use: Precertification 2b)  Prior Authorization/ is required. Notification Guidelines: Intron-A (interferon alpha-2b)  Therapeutic Equivalent Intuniv Guidelines: Drug Coverage (guanfacine) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Invega Injection J3490 N/A N/A Medical N/A (paliperidone)  Therapeutic Equivalent Invega Guidelines: Drug Coverage (paliperidone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications SGLT2 Invokana to New York and Connecticut Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy (canagliflozin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Guidelines: Drug Coverage Irenka (duloxetine) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Iressa () Tablet J8999 PBM Pharmacy NA Notification Guidelines: Iressa  Prior Authorization/ Jadenu Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (defirasirox) Jadenu Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Jakafi (ruxolitinib) Oral J8999 PBM* Pharmacy** Notification Guidelines: Jakafi chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Jalyn (dutasteride J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A and tamsulosin) J8499 Criteria - New and Therapeutic Equivalent Medications The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications DPP4 Notification Guidelines: Janumet Inhibitors (CT/NY) policy applies Diabetes Medications DPP4 (sitagliptin and to New York and Connecticut Tablet J3490 PBM Inhibitors (CT/NY) Pharmacy metformin plans and products.  Step Therapy Guidelines: hydrochloride) The Step Therapy Guidelines: Diabetes Medications DPP4 Diabetes Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications DPP4 Janumet XR Notification Guidelines: Inhibitors (CT/NY) policy applies (sitagliptin and Diabetes Medications DPP4 to New York and Connecticut metformin Tablet J3490 PBM Inhibitors (CT/NY) Pharmacy plans and products. hydrochloride,  Step Therapy Guidelines: The Step Therapy Guidelines: extended release) Diabetes Medications DPP4 Diabetes Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications DPP4 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications DPP4 Januvia to New York and Connecticut Tablet J3490 PBM Inhibitors (CT/NY) Pharmacy (sitagliptin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications DPP4 Diabetes Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Diabetes Medications SGLT2 Jardiance to New York and Connecticut Tablet J8499 PBM Inhibitors (CT/NY) Pharmacy (empagliflozin) plans and products.  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Jentadueto XR Extended (linagliptin/ release J8499 N/A N/A Pharmacy N/A metformin) tablet Jublia  Prior Authorization/Medical Topical J3490 PBM Pharmacy N/A () Necessity Guidelines: Jublia  Therapeutic Equivalent Juluca Guidelines: Drug Coverage (dolutegravir / Tablets J8499 PBM Pharmacy N/A Criteria - New and Therapeutic rilpivirine) Equivalent Medications Juxtapid  Prior Authorization/Medical Capsule J8499 PBM Pharmacy N/A (lomitapide) Necessity Guidelines: Juxtapid

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Kadian (morphine  Prior Authorization/Medical sulfate extended Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Kadian release) Kalbitor IV Infusion J1290 N/A N/A Medical N/A (ecallantide)  Prior Authorization/Medical Kalydeco Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A (ivacaftor) Kalydeco *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Kanuma  Precertification Guidelines: necessity review will be Injection J2840 N/A* Medical (sebelipase alfa) Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required.  Therapeutic Equivalent Kapvay (clonidine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Karbinal ER Oral Guidelines: Drug Coverage (carbinoxamine J8499 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic maleate) Equivalent Medications  Therapeutic Equivalent Kenalog Spray Topical Guidelines: Drug Coverage (triamcinolone) J3490 PBM Pharmacy N/A Spray Criteria - New and Therapeutic (brand) Equivalent Medications Keppra Injection J1953 N/A N/A Medical N/A (levatiricetam) Keppra  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (levetiracetam) Necessity Guidelines: Keppra

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Keppra XR  Prior Authorization/Medical (levetiracetam Tablet J8499 PBM Necessity Guidelines: Keppra Pharmacy N/A extended XR release[XR])  Therapeutic Equivalent Keralac 47% Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A cream (urea) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Keralyt Scalp Kit Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A () Criteria - New and Therapeutic Equivalent Medications Kerydin  Prior Authorization/Medical Topical J3490 PBM Pharmacy N/A () Necessity Guidelines: Kerydin  Therapeutic Equivalent Ketocon J3490 and Guidelines: Drug Coverage Ointment PBM Pharmacy N/A () J8499 Criteria - New and Therapeutic Equivalent Medications Ketodan  Therapeutic Equivalent Combination Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Package Criteria - New and Therapeutic (ketoconazole) Equivalent Medications Keveyis  Prior Authorization/ (dichlorphena- Tablet J8499 N/A Notification Guidelines: Pharmacy N/A mide) Keveyis  Prior Authorization/ Notification Guidelines: Kevzara Injection J3490 PBM Kevzara Pharmacy N/A (sarilumab)  Step Therapy Guidelines: Kevzara  Therapeutic Equivalent Khedezla Guidelines: Drug Coverage (desvenlafaxine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic extended release) Equivalent Medications  Prior Authorization/ Injection, Kineret (anakinra) J3490 PBM Notification Guidelines: Pharmacy N/A SQ Injection Kineret (anakinra)  Prior Authorization/ Kisqali (ribociclib) Tablet J8499 PBM Pharmacy N/A Notification Guidelines: Kisqali Kisqali Femara 200 Pak (ribociclib/ Tablet J8499 N/A N/A Pharmacy N/A letrozole)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Kitabis Pak Kitabis Pak Inhalation J3490 PBM  Therapeutic Equivalent Pharmacy N/A (tobramycin) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications *NJ Small Members should refer  Prior Authorization/ Korlym J3490 and to their Certificate of Coverage Oral PBM Notification Guidelines: Pharmacy* () J8499 for precertification and quantity Korlym limit guidelines. Krystexxa Injection J2507 N/A N/A Medical N/A (pegloticase)  Prior Authorization/ Kuvan (sapropterin Tablet J8499 PBM Notification Guidelines: Kuvan Pharmacy N/A dihydrochloride) (sapropterin dihydrochloride) Kynamro  Prior Authorization/Medical (Mipomersen SQ Injection J3490 PBM Necessity Guidelines: Pharmacy N/A Sodium) Kynamro™ IV Injection J1626 N/A N/A Medical N/A Kytril (granisetron Tablet, Oral Q0166 and hydrochloride) N/A N/A Pharmacy N/A Solution J8499 Lamictal  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (lamotrigine) Necessity Guidelines: Lamictal Lamictal ODT  Prior Authorization/Medical (lamotrigine orally Tablet J8499 PBM Necessity Guidelines: Lamictal Pharmacy N/A disintegrating ODT Tablet) Lamictal XR  Prior Authorization/Medical (lamotrigine Tablet J8499 PBM Necessity Guidelines: Lamictal Pharmacy N/A extended release) XR Lamisil ( Tablet J8499 N/A N/A N/A N/A hydrochloride)  Prior Authorization/Medical Lamotrigine XR Tablet J3490 PBM Necessity Guidelines: Pharmacy N/A Lamotrigine XR  Therapeutic Equivalent Lantus (insulin Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A glargine) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Lantus Solostar Guidelines: Drug Coverage Pen J3490 PBM Pharmacy N/A (insulin glargine) Criteria - New and Therapeutic Equivalent Medications Lazanda (fentanyl  Prior Authorization/Medical Nasal Spray J3490 PBM Pharmacy N/A nasal spray) Necessity Guidelines: Lazanda Latuda Tablet J8499 N/A N/A Pharmacy N/A ()  eviCore Guidelines: Injectable Chemotherapy Drugs: Oxford’s Application of NCCN Clinical *For Oncology and Non- Lemtrada J0202 and Infusion Medical Practice Guidelines Medical Oncology Use: Precertification is (alemtuzumab) J9999 Management*  Precertification Guidelines: required. Lemtrada (Alemtuzumab) (for non-oncology indications)  Prior Authorization/ Lenvima Capsule J8999 PBM Notification Guidelines: Pharmacy N/A () Lenvima  Step Therapy Guidelines: Lescol XL Lescol (fluvastatin)  Therapeutic Equivalent Capsule J8499 PBM Pharmacy N/A (brand and Guidelines: Drug Coverage generic) Criteria - New and Therapeutic Equivalent Medications Letairis  Prior Authorization/Medical Tablet J3490 PBM Pharmacy N/A (ambrisentan) Necessity Guidelines: Letairis Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM.  eviCore Guidelines: White Precertification is not required. Leukine Injection, J2820 eviCore* Blood Cell Colony Stimulating See Notes *Medical Benefit: If provided in () SQ Injection Factors* a hospital, MD's office, or in conjunction with home health care. Precertification through eviCore is required.

Leuprolide Acetate  Prior Authorization/ *For Oncology and Non- (subcutaneous) Injection J9218 PBM* Notification Guidelines: Pharmacy Oncology Use: Precertification (Eligard), Leuprolide Acetate is required. 1mg/0.2mL

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Levalbuterol nebs Guidelines: Drug Coverage (generic Xopenex Inhalation J8499 PBM Pharmacy N/A Criteria - New and Therapeutic nebs) Equivalent Medications  Prior Authorization/ Levitra ( Tablet J3490 PBM Notification Guidelines: Pharmacy N/A HCI) Erectile Dysfunction Agents  Therapeutic Equivalent Lexapro Guidelines: Drug Coverage (escitalopram) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Lexiscan IV Infusion J2785 N/A N/A Medical N/A (regadenoson)  Therapeutic Equivalent Librax Guidelines: Drug Coverage (chlordiazepoxide / Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic clidinium) (brand) Equivalent Medications  Prior Authorization/ Topical Lidocaine Patch J3490 PBM Notification Guidelines: Pharmacy N/A Patch Lidocaine Patch  Therapeutic Equivalent Lidoderm Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (lidocaine) Criteria - New and Therapeutic Equivalent Medications Lidorx (lidocaine Topical Gel J3490 N/A N/A Pharmacy N/A hydrochloride) Lidovin 3.95% Topical J3490 N/A N/A Pharmacy N/A (lidocaine) Cream  Prior Authorization/ Linzess Capsule J3490 PBM Notification Guidelines: Pharmacy N/A (linaclotide) Linzess (Linaclotide)

 Therapeutic Equivalent Lipitor (brand only) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (atorvastatin) Criteria - New and Therapeutic Equivalent Medications

 Therapeutic Equivalent Lipofen Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (fenofibrate) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Liptruzet (ezetimibe and Tablet J8499 N/A N/A Pharmacy N/A atorvastatin) Livalo  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (pitavastatin) Livalo  Therapeutic Equivalent Lo Minastrin FE Guidelines: Drug Coverage (ethinyl estradiol / Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic norethindrone) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives Lo/Ovral (ethinyl through their prescription drug estradiol and plan. If the Member does not ) have contraceptive coverage  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives plan, then these are not covered. Loestrin/FE Members should refer to their Certificate of Coverage or (ethinyl estradiol and norethindrone) Prescription Drug Rider language for coverage guidelines. Locoid Lipocream &  Therapeutic Equivalent Locoid Lotion Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (hydrocortisone Criteria - New and Therapeutic butyrate) Equivalent Medications  Therapeutic Equivalent LoCort Guidelines: Drug Coverage Tablets J3490 PBM Pharmacy N/A (dexamethasone) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Lodosyn Guidelines: Drug Coverage (carbidopa) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Lofibra 54mg, Guidelines: Drug Coverage 160mg (Brand Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic only) (fenofibrate) Equivalent Medications  Therapeutic Equivalent Lofibra 67, 134, Guidelines: Drug Coverage 200mg Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (fenofibrate) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Lonhala Magnair Inhalation Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (glycopyrrolate) solution Criteria - New and Therapeutic Equivalent Medications Lonsurf  Prior Authorization/ (trifluridine/ Tablet J8999 PBM Notification Guidelines: Pharmacy N/A tipiracil) Lonsurf  Therapeutic Equivalent Loprox Shampoo Guidelines: Drug Coverage Shampoo J3490 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Loprox Suspension Topical Guidelines: Drug Coverage 95251 PBM Pharmacy N/A (ciclopirox) Suspension Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Loprox 0.77% Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A cream (ciclopirox) Cream Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Lorzone Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (chlorzoxazone) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Lotemax Gel Ophthalmic Guidelines: Drug Coverage (loteprednol J3490 PBM Pharmacy N/A Gel Criteria - New and Therapeutic etabonate) Equivalent Medications  Prior Authorization/ Notification Guidelines: Lotronex (Alosteron) Lotronex FDA approved only for use in Tablet J8499 N/A  Therapeutic Equivalent Pharmacy (alosetron) (brand) women. Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Lovaza (Brand Lovaza Only) (omega-3- Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A acid ethyl esters) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lovaza (Generic)  Prior Authorization/ (omega-3-acid Capsule J8499 PBM Notification Guidelines: Pharmacy N/A ethyl esters) Lovaza

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Lovenox Injection, J1650 N/A N/A Pharmacy N/A (enoxaparin) SQ Injection Lucentis Injection J2778 N/A N/A Medical N/A () *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Lumizyme  Precertification Guidelines: necessity review will be Injection J0221 N/A* Medical (alglucosidase alfa) Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required. *Pharmacy Benefit if dispensed by a retail pharmacy. *Medical Benefit if provided in an MD's office. *Coverage is limited to Members Lunelle with coverage for contraceptives (medroxyprogester  Benefit Guidelines: through their prescription drug one acetate and Injection J3490 N/A See Notes* Contraceptives plan. If the Member does not estradiol have contraceptive coverage cypionate) through their prescription drug plan then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Lunesta Guidelines: Drug Coverage (eszopicione) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Lupron,  eviCore Guidelines: Injectable *Precertification Note: J1950, Oxford’s Lupron-3, Chemotherapy Drugs: For Oncology Use Injection J9217, and Medical Medical** Lupron-4, Application of NCCN Clinical precertification is required. J9219 Management* Lupron Depot, Practice Guidelines For Non-Oncology Use

Drug Coverage Guidelines Page 77 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Lupron Depot  Precertification Guidelines: precertification through Oxford Pediatric Gonadotropin Releasing Medical Management is required Lupron Implant Hormone Analogs for all indications for: (Leuprolide - Lupron Depot Pediatric (all Acetate): dosages) and - Lupron Depot 3.75mg, Lupron Depot 11.25mg 3.75mg, 11.25 (3 month Precertification is required for all supply of 3.75 dosages of Lupron Depot for the dose) diagnosis of gender dysphoria; refer to Precertification Lupron Depot Guidelines: Gonadotropin Releasing Hormone Analogs for 7.5mg applicable Gender Dysphoria 22.5 (3 month ICD-10 diagnosis codes. supply of 7.5mg

dose) Precertification is not required 30mg (4 month for Lupron Depot 7.5mg, dose of 7.5mg) 22.5mg, and 30mg for the diagnosis of Cancer.

Lupron Depot- New Jersey Small Members Pediatric: should refer to their Certificate of 7.5mg, Coverage for precertification 11.25mg, guidelines. 15mg **Benefit Note: For Connecticut Large and Small Plans: Infertility drugs will be covered under the Pharmacy Benefit if the Member has pharmacy coverage. If the Member does not have pharmacy coverage, infertility drugs will be covered under the Medical Benefit.  Therapeutic Equivalent Luxiq foam Guidelines: Drug Coverage (betamethasone Foam J3490 PBM Pharmacy N/A Criteria - New and Therapeutic valerate) Equivalent Medications Luxturna J3490, Oxford’s  Precertification Guidelines: (voretigene Injection J3590, Medical Luxturna™ (Voretigene Medical N/A neparvovecrzyl) C9399 Management Neparvovecrzyl)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Guidelines: Drug Coverage Luzu () Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Lynparza Capsule J8999 PBM Notification Guidelines: Pharmacy N/A () Lynparza  Step Therapy Guidelines: Lyrica (pregabalin) Tablet J8499 PBM Pharmacy N/A Lyrica Lyrica CR  Step Therapy Guidelines: Tablets J8499 PBM Pharmacy N/A (pregabalin) Lyrica CR Macugen (pegaptanib Injection J2503 N/A N/A Medical N/A sodium) Makena (17-alpha- Oxford’s  Precertification Guidelines: hydroxy- Injection J1726 Medical 17-Alpha-Hydroxyprogesterone Medical N/A progesterone Management Caproate (Makena and 17P) caproate or 17P) *Coverage is limited to Members with coverage for prenatal vitamins through their Materna, prescription drug plan. If the Natalcare, Natalins Member does not have prenatal Rx, Niferex-PN, vitamin coverage through their Prenate 90, Tablet S0197 N/A N/A Pharmacy* prescription drug plan then these Prenatal Plus, are not covered. Members should Prenatal Rx, and refer to their Certificate of Stuartnatal Plus Coverage or Prescription Drug Rider language for coverage guidelines. Mavyret  Prior Authorization/Medical (glecaprevir and Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Mavyret pibrentasvir)  Supply Limit Guidelines: Triptans Supply Limits Maxalt and Maxalt-  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A MLT (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Mekinist Tablet J8499 PBM Notification Guidelines: Pharmacy N/A () Mekinist (Trametinib) Precertification  Precertification Guidelines: Menopur Injection S0122* and Pharmacy/ *Precertification Note: HCPCS through Human Menopausal

Drug Coverage Guidelines Page 79 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type (Menotropins) J3490 Optum* Gonadotropins (hMG) Medical** code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Mepron  Therapeutic Equivalent suspension (Brand Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A Only) Suspension Criteria - New and Therapeutic () Equivalent Medications *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Mepsevii  Precertification Guidelines: necessity review will be (vestronidase alfa- Injection J3590 N/A* Medical Enzyme Replacement Therapy* conducted post-service to vjbk) determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required.  Therapeutic Equivalent Mesalamine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Lialda) Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 80 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Metadate CD Notification Guidelines: (methylphenidate Metadate CD hydrochloride) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A ([controlled Guidelines: Drug Coverage release brand only) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Metadate ER Tablet J8499 PBM Notification Guidelines: Pharmacy N/A Metadate ER Methitest (methyl- Tablet J8499 N/A N/A Pharmacy N/A testosterone) Methylin and  Prior Authorization/ Methylin ER Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (methylphenidate) Methylin and Methylin ER Methylphenidate  Prior Authorization/ extended-release Capsule J8499 PBM Notification Guidelines: Pharmacy N/A capsule (generic Metadate CD Metadate CD)  Prior Authorization/ Notification Guidelines: Methylphenidate Concerta extended-release Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A tablet (generic Guidelines: Drug Coverage Concerta) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Metoprolol Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A 37.5mg, 75mg Criteria - New and Therapeutic Equivalent Medications metoprolol extended release/  Therapeutic Equivalent hydrochloro- Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A thiazide (Dutoprol Criteria - New and Therapeutic Authorized Equivalent Medications Generic)  Therapeutic Equivalent Metozolv ODT Guidelines: Drug Coverage ( Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications Precertification  Precertification Guidelines: *Precertification Note: HCPCS Metrodin J3355* and through Optum Pharmacy/ Injection Infertility Diagnosis and code J3355 (urofollitropin) (urofollitropin) J3490 may be Medical** Treatment requires precertification through required*

Drug Coverage Guidelines Page 81 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Metrogel 0.75%  Therapeutic Equivalent Vaginal Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Metrogel 1% Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Metronidazole 1% Guidelines: Drug Coverage gel (generic Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Metrogel 1%) Equivalent Medications Metvixia (Methyl Topical J7309 N/A N/A Medical N/A aminolevulinate)  Therapeutic Equivalent Micardis (Brand Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A Only) (telmisartan) Criteria - New and Therapeutic Equivalent Medications Micardis HCT (Brand  Therapeutic Equivalent Only) (telmisartan/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochlorothiazide Criteria - New and Therapeutic ) Equivalent Medications Micort-HC 2.5%  Therapeutic Equivalent cream Topical Guidelines: Drug Coverage PBM Pharmacy N/A (hydrocortisone Cream Criteria - New and Therapeutic acetate) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage Micronor  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug (norethidrone) Contraceptives plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Certain groups may exclude these services from coverage if such coverage would be contrary Oxford’s to the Group's bona fide religious Mifeprex  Precertification Guidelines: Oral S0190 Medical Medical* tenets. Please refer to the (mifepristone) Mifeprex® (Mifepristone) Management Member's Certificate of Coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit.  Prior Authorization/Medical Necessity Guidelines: Migranal Migranal (dihydro-  Therapeutic Equivalent ergotamine) Nasal Spray J3490 PBM Pharmacy N/A Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Migranal (dihydro-  Prior Authorization/Medical ergotamine) Nasal Spray J3490 PBM Pharmacy N/A Necessity Guidelines: Migranal (generic) Minastrin 24 FE  Therapeutic Equivalent (norethindrone Guidelines: Drug Coverage acetate and ethinyl Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic estradiol/ferrous Equivalent Medications fumarate) Minocin Injection J2265 N/A N/A Medical N/A (minocycline)  Therapeutic Equivalent Minocin 50mg, Guidelines: Drug Coverage 75mg and 100mg Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (minocycline hcl) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Minocycline Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Dynacin) Criteria - New and Therapeutic Equivalent Medications Minocycline  Prior Authorization/Medical extended-release Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Solodyn (generic Solodyn)  Therapeutic Equivalent Mirapex ER Guidelines: Drug Coverage (pramipexole Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic dihydrochloride) Equivalent Medications Mircera (methoxy  Precertification Guidelines: Oxford’s polyethylene Anemia Drugs: Darbepoetin Alfa, Injection J3490 Medical Medical N/A glycol-epoetin Epoetin Alfa and Methoxy Management* beta) Polyethylene Glycol-Epoetin Beta Certain groups may exclude these services from coverage if such coverage would be contrary Oxford’s  Precertification Guidelines: to the Group's bona fide religious Misoprostol Tablet S0191 Medical Abortions (Therapeutic and Medical* tenets. Please refer to the Management Elective) Member's Certificate of Coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit. Mitigare Capsule J8499 N/A N/A Pharmacy N/A (colchicine)  Therapeutic Equivalent Moderiba Tablet Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (ribavirin) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Moderiba Pak Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (ribavirin) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Modicon (ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives norethindrone) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Molindone Tablet J8499 N/A N/A Pharmacy N/A Momexin Combo Package Cream J3490 N/A N/A Pharmacy N/A (mometasone furoate)  Therapeutic Equivalent Monodox Guidelines: Drug Coverage (doxycycline) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Morgidox Capsule J8499 N/A N/A Pharmacy N/A (doxycycline) Morgidox Kit/  Therapeutic Equivalent Combo Pkg Capsule/ Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (doxycycline plus Topical Criteria - New and Therapeutic cleanser) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Extended- MorphaBond ER MorphaBond ER release J8499 PBM  Therapeutic Equivalent Pharmacy N/A (morphine sulfate) tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Morphine Sulfate  Prior Authorization/Medical Controlled-Release Necessity Guidelines: Tablets J8499 PBM Pharmacy N/A (generic MS Morphine Sulfate Contin) Morphine Sulfate Extended Release Tablet J8499 N/A N/A Pharmacy N/A Pellets (generic Kadian)

Drug Coverage Guidelines Page 85 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Motofen Guidelines: Drug Coverage (difenoxin/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic atropine) Equivalent Medications  Prior Authorization/ Movantik Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (naloxegol) Movantik Mozobil (plerixafor) Injection J2562 N/A N/A Medical N/A  Prior Authorization/Medical MS Contin Tablet J8499 PBM Necessity Guidelines: MS Pharmacy N/A Contin  Prior Authorization/ Multaq Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (dronedarone) Multaq  Prior Authorization/ Muse (alprostadil) Pellet J0275 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents  Prior Authorization/Medical Myalept Injection J3490 PBM Necessity Guidelines: Myalept Pharmacy N/A (metreleptin) (metreleptin)  Prior Authorization/ Mydayis (mixed Notification Guidelines: salts of a single Mydayis entity Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A amphetamine Guidelines: Drug Coverage product) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Myfortic J7518, Guidelines: Drug Coverage (mycophenolic Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic acid) (brand only) Equivalent Medications Myobloc Oxford’s  Precertification Guidelines: (rimabotulinum- Injection J0587 Medical Medical N/A Botulinum Toxins A and B toxin B) Management  Prior Authorization/ Myorisan Capsule J8499 PBM Notification Guidelines: Pharmacy N/A (isotretinoin) Myorisan Myozyme IV Infusion, J0220 N/A N/A Medical N/A (alglucosidase alfa) Injection  Therapeutic Equivalent Myrbetriq Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (mirabegron) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Mysoline  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (primidone) Necessity Guidelines: Mysoline Mytesi  Prior Authorization/ Oral J8999 PBM Pharmacy N/A (crofelemer) Notification Guidelines: Mytesi  Therapeutic Equivalent Naftin 1% Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A ( hcl) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Naftin 2% gel Guidelines: Drug Coverage (naftifine Topical Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Naglazyme  Precertification Guidelines: necessity review will be Injection J1458 N/A* Medical (galsulfase) Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required.  Therapeutic Equivalent Namenda XR Guidelines: Drug Coverage (Memantine Capsule J8499 PBM N/A N/A Criteria - New and Therapeutic Hydrochloride) Equivalent Medications  Therapeutic Equivalent Namzaric Guidelines: Drug Coverage (memantine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Therapeutic Equivalent Naprelan J3490 and Guidelines: Drug Coverage (Naproxen Tablet PBM Pharmacy N/A J8499 Criteria - New and Therapeutic Sodium) Equivalent Medications Naprelan CR (Dose J3490 and Card) (Naproxen Tablet N/A N/A Pharmacy N/A J8499 Sodium)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Narcan Nasal Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A Spray (naloxone) Criteria - New and Therapeutic Equivalent Medications Nasonex  Therapeutic Equivalent (mometasone Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A furoate Criteria - New and Therapeutic monohydrate) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Natesto Natesto  Therapeutic Equivalent (testosterone nasal Nasal Gel J3490 PBM Pharmacy N/A Guidelines: Drug Coverage gel) Criteria - New and Therapeutic Equivalent Medications Natpara  Prior Authorization/Medical (parathyroid Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Natpara hormone) Natrecor Injection J2325 N/A N/A Medical N/A (nesiritide)  Therapeutic Equivalent Natroba (spinosad) Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (brand only) Suspension Criteria - New and Therapeutic Equivalent Medications *Benefit Notes: Not covered for cosmetic conditions. Not all Nava-SC groups have selected the Varies J3490 PBM N/A Pharmacy* (hydroquinone) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. NeoBenz Micro Liquid J3490 PBM N/A Pharmacy N/A (benzoyl peroxide)  Therapeutic Equivalent Neoral J7515, Guidelines: Drug Coverage (cyclosporine) Capsule J7502, PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) J8499 Equivalent Medications  Therapeutic Equivalent Neo-Synalar Guidelines: Drug Coverage (neomycin sulfate Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic and fluocinolone) Equivalent Medications  Therapeutic Equivalent Neo-Synalar kit Guidelines: Drug Coverage (neomycin sulfate Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic and fluocinolone) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Nerlynx () Tablet J8499 PBM Notification Guidelines: Pharmacy N/A Nerlynx Neuac 1.2%-5% (clindamycin Topical J3490 N/A N/A Pharmacy N/A phosphate and benzoyl peroxide) Neuac 1.2%-5% kit (clindamycin Topical J3490 N/A N/A Pharmacy N/A phosphate and benzoyl peroxide) Pharmacy Benefit: If dispensed by a retail pharmacy or mail  Benefit Guidelines: Maximum order through PBM. Dosage* Precertification is not required. Neulasta Injection, J2505 eviCore*  eviCore Guidelines: White See Notes *Medical Benefit: If provided in () SQ Injection Blood Cell Colony Stimulating a hospital, MD's office, or in Factors* conjunction with home health care. Precertification through eviCore is required. *Pharmacy Benefit: If  eviCore Guidelines: White dispensed by a retail pharmacy Blood Cell Colony Stimulating or mail order through PBM. Factors** Precertification is required. Neupogen Injection, PBM*/ J1442  Therapeutic Equivalent See Notes **Medical Benefit: If provided () SQ Injection eviCore** Guidelines: Drug Coverage in a hospital, MD's office, or in Criteria - New and Therapeutic conjunction with home health Equivalent Medications* care. Precertification through eviCore is required. Capsule,  Prior Authorization/Medical Neurontin Tablet or J8499 PBM Necessity Guidelines: Pharmacy N/A (gabapentin) Oral Neurontin Solution Nevirapine  Therapeutic Equivalent extended release Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (nevirapine) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM  Prior Authorization/ Nexavar ( is only required for those Oral Tablet J8999 PBM* Notification Guidelines: Pharmacy** tosylate) Oncology Drugs specifically listed Nexavar in a Coverage Criteria/Guideline when the Member is age 19

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type years or older. All other oral chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Nexavir Injection J3490 N/A N/A Medical N/A (kutapressin) Nexiclon XR Tablet, (clonidine J8499 N/A N/A Pharmacy N/A Suspension extended release) Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Nexium Capsule J8499 N/A N/A N/A equivalent are excluded from (esomeprazole) coverage. Refer to the member specific benefit plan document as applicable. Nexium  Prior Authorization/Medical Suspension Suspension J8499 PBM Necessity Guidelines: Non- Pharmacy N/A (esomeprazole) Solid Oral Dosage Forms  Therapeutic Equivalent Nicazeldoxy 30 kit Guidelines: Drug Coverage (Doxycycline plus Oral J8499 PBM Pharmacy N/A Criteria - New and Therapeutic MVI) Equivalent Medications Nicotine OTC Benefits for Tobacco Cessation products: for Health Care Reform apply to nicotine gum (e.g., all plans subject to health care Nicorette, Thrive),  Prior Authorization/Medical reform nicotine lozenge Necessity Guidelines: Tobacco (e.g., Commit, Cessation for Health Care Transdermal Nicorette), nicotine Reform Patch/Gum/ A9150 PBM Pharmacy patch (e.g.,  Supply Limit Guidelines: HCR Lozenge Nicoderm CQ), Tobacco Cessation - Supply Nicotrol Inhaler Limits Override - NJ Fully (nicotine inhalation Insured system), Nicotrol NS (nicotine nasal spray)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Benefits for Tobacco Cessation Nicotrol Inhaler Inhalation Necessity Guidelines: Tobacco for Health Care Reform apply to J3490 PBM Pharmacy* (nicotine) System Cessation for Health Care all plans subject to health care Reform reform  Prior Authorization/Medical Benefits for Tobacco Cessation Nicotrol NS Necessity Guidelines: Tobacco for Health Care Reform apply to Varies J3490 PBM Pharmacy* (nicotine) Cessation for Health Care all plans subject to health care Reform reform *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have Niferex (iron A9152 and vitamin/supplement coverage polysaccharide) or Capsule N/A N/A Pharmacy* A9153 through their prescription drug Niferex 150 Forte plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Prior Authorization/ Ninlaro (ixazomib) Capsule J8999 PBM Notification Guidelines: Pharmacy N/A Ninlaro  Therapeutic Equivalent Nitroglycerin spray Guidelines: Drug Coverage (generic Spray J8499 PBM Pharmacy N/A Criteria - New and Therapeutic nitrolingual) Equivalent Medications  Therapeutic Equivalent Nitrolingual Pump Guidelines: Drug Coverage Spray Spray J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (nitroglycerin) Equivalent Medications  Prior Authorization/ Nityr (nitisinone) Tablet J8499 PBM Pharmacy N/A Notification Guidelines: Nityr  Therapeutic Equivalent Noctiva Guidelines: Drug Coverage (desmopressin Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetate) Equivalent Medications  Prior Authorization/Medical Norditropin AQ Injection J2941 PBM Necessity Guidelines: Pharmacy N/A (Somatropin) Norditropin (somatropin)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Necessity Guidelines: Norditropin (somatropin) Norditropin Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (Somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Norditropin FlexPro Pen Guidelines: Drug Coverage J2941 PBM Pharmacy N/A (somatropin) Injection Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Norditropin NordiFlex (somatropin) Pen NordiFlex J2941 PBM  Therapeutic Equivalent Pharmacy N/A Injection (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Noritate Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (metronidazolel) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Northera Capsule J8499 PBM Necessity Guidelines: Pharmacy N/A (droxidopa) Northera *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Novarel (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with gonadotropin) J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Noxafil Tablet J8499 N/A N/A Pharmacy N/A (posaconazole)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Precertification Guidelines: Sub- J3490, Oxford’s Nucala Respiratory Interleukins cutaneous J3590, and Medical Medical N/A (mepolizumab) (Cinqair®, Fasenra®, and Injection J2182 Management Nucala®) Nucynta ER  Prior Authorization/Medical (tapentadol Tablet J8499 PBM Necessity Guidelines: Nucynta Pharmacy N/A extended release) ER Nuedexta  Prior Authorization/ (dextromethorpha Capsules J8499 PBM Notification Guidelines: Pharmacy N/A n / quinidine) Nuedexta Nuplazid  Prior Authorization/ (pimavanserin Tablet J8499 N/A Notification Guidelines: Pharmacy N/A tartrate) Nuplazid Nutritonal Therapy, Formula and IV Infusion, Oxford’s  Medical Management *Benefit is State Specific. Specialized Foods, Oral Tube Varies Medical Guidelines: Formula & See Notes* Medical Benefit/Pharmacy Benefit Parenteral Feed Management Specialized Food Nutrition Therapy  Prior Authorization/Medical NuSpin Injection J2941 PBM Necessity Guidelines: NuSpin Pharmacy N/A (somatropin) (somatropin) Nutropin and  Prior Authorization/Medical Nutropin AQ Injection J2941 PBM Necessity Guidelines: Nutropin Pharmacy N/A (somatropin) and Nutropin AQ (somatropin) *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Nuvaring have contraceptive coverage  Benefit Guidelines: (/ Vaginal Ring J7303 N/A Pharmacy* through their prescription drug Contraceptives ethinyl estradiol) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Therapeutic Equivalent Nuvessa Guidelines: Drug Coverage Vaginal Gel J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Nuvigil Nuvigil (armodafinil) (armodafinil) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nymalize Oral J3490 N/A N/A Pharmacy N/A (nimodipine) Solution  Therapeutic Equivalent /triamcinol Guidelines: Drug Coverage one (generic Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Mycolog II) cream Equivalent Medications Nystatin/triamcinol  Therapeutic Equivalent one (generic Guidelines: Drug Coverage Ointment J3490 PBM Pharmacy N/A Mycolog II) Criteria - New and Therapeutic ointment Equivalent Medications Obredon solution Oral  Step Therapy Guidelines: (hydrocodone/ J8499 PBM Pharmacy N/A Solution Obredon guaifenesin) Ocaliva (obeticholic  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A acid) Necessity Guidelines: Ocaliva Hospital Outpatient Facility: Administration of Actemra in a hospital outpatient facility  Precertification Guidelines: (including any ambulatory Oxford’s o Ocrevus (Ocrelizumab) infusion suite associated with the Ocrevus Injection J2350 Medical o Specialty Medication Medical hospital) requires precertification (Ocrelizumab) Management Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines.  Precertification Guidelines: o Immune Globulin (IVIG) and Octagam (immune Oxford’s SCIG globulin, Non- IV Infusion J1568 Medical o Immune Globulin Site of Medical N/A lyophilized) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion Odactra (house Sublingual  Prior Authorization/Medical dust mite allergen J8499 PBM Pharmacy N/A Tablet Necessity Guidelines: Odactra extract)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Odefsey (emtricitabine/ Tablet J8499 N/A N/A Pharmacy N/A rilpivirine/ tenofovir)  Prior Authorization/ Odomzo Capsule J8999 PBM Notification Guidelines: Pharmacy N/A (sonidegib) Odomzo  Prior Authorization/Medical Ofev () Capsule J8499 PBM Necessity Guidelines: Ofev Pharmacy N/A (nintedanib) Oforta (fludarabine Oral J8562 N/A N/A Pharmacy N/A phosphate)  Therapeutic Equivalent Oleptro ( Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride) Criteria - New and Therapeutic Equivalent Medications Oleptro ER (trazodone Tablet J8499 N/A N/A Pharmacy N/A hydrochloride ER) Olmesartan Tablet J8499 N/A N/A Pharmacy N/A (generic Benicar) Omesartan/ hydrochloro- Tablet J8499 N/A N/A Pharmacy N/A thiazide (generic Benicar HCT)  Therapeutic Equivalent Olux (clobetasol Guidelines: Drug Coverage Foam J3490 PBM Pharmacy N/A propionate) Criteria - New and Therapeutic Equivalent Medications Olux-CP (clobetasol Foam J3490 N/A N/A Pharmacy N/A propionate)  Therapeutic Equivalent Olux-E (clobetasol Guidelines: Drug Coverage Foam J3490 PBM Pharmacy N/A propionate) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Olysio (simeprevir) Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Olysio Omeclamox-Pak  Therapeutic Equivalent (omeprazole, Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A clarithromycin, Criteria - New and Therapeutic amoxicillin) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Omeprazole Capsule J8499 N/A N/A Pharmacy N/A (generic) Note: Prescription drugs for which there is a therapeutic Omeprazole/ over-the-counter (OTC) sodium Capsule J8499 N/A N/A N/A equivalent are excluded from bicarbonate coverage. Refer to the member (generic) specific benefit plan document as applicable.  Therapeutic Equivalent Omnaris Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A (ciclesonide) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Omnitrope (somatropin) Omnitrope Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Omtryg (omega-3- Notification Guidelines: Capsule J8499 PBM Pharmacy N/A acid ethyl esters A) Omtryg

Onexton 1.2-  Therapeutic Equivalent 3.75% Guidelines: Drug Coverage (clindamycin Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic phosphate and Equivalent Medications benzoyl peroxide)  Prior Authorization/ Onfi (clobazam) Oral J8999 PBM Pharmacy N/A Notification Guidelines: Onfi  Therapeutic Equivalent Onmel Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A () Criteria - New and Therapeutic Equivalent Medications Onsolis (fentanyl Film J8499 N/A N/A Pharmacy N/A buccal soluble film)  Supply Limit Guidelines: Triptans Supply Limits Onzetra Xsail Nasal  Therapeutic Equivalent J3490 PBM Pharmacy N/A (sumatriptan) Powder Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Necessity Guidelines: Opana Opana ER ER (oxymorphone Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A extended release) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Opsumit  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (macitentan) Necessity Guidelines: Opsumit  Therapeutic Equivalent Optivar (brand Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A only) (azelastine) Drops Criteria - New and Therapeutic Equivalent Medications Oralair (Sweet Vernal, Orchard,  Prior Authorization/Medical Perennial Rye, Necessity Guidelines: Oralair Timothy and Sublingual (Sweet Vernal, Orchard, J8499 PBM Pharmacy N/A Kentucky Blue Tablet Perennial Rye, Timothy and Grass, Mixed Kentucky Blue Grass Mixed Pollens Allergen Pollens Allergen Extract) Extract) Oramorph Oral J8499 N/A N/A Pharmacy N/A (morphine) Solution Orbivan (butalbital, acetaminophen, Oral J8499 N/A N/A Pharmacy N/A and caffeine) Hospital Outpatient Facility: Administration of Orencia in a  Precertification Guidelines: hospital outpatient facility o Orencia® (Abatacept) (including any ambulatory Oxford’s Injection for Intravenous infusion suite associated with the Orencia Intravenous J0129 Medical Infusion Medical hospital) requires precertification (abatacept) Management o Specialty Medication with review by a Medical Director Administration – Site of Care or their designee. Refer to: Review Guidelines Specialty Medication Administration – Site of Care Review Guidelines  Prior Authorization/ Orencia Notification Guidelines: SQ Injection J3590 PBM Pharmacy N/A (abatacept) Orencia  Step Therapy: Orencia

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Orenitram N/A Tablet J8499 PBM Necessity Guidelines: Pharmacy (treprostinil) Orenitram  Prior Authorization/ Orfadin (nitisinone) Capsule J8499 PBM Pharmacy N/A Notification Guideline: Orfadin Orkambi™  Prior Authorization/Medical (lumacaftor/ Capsule J8499 PBM Pharmacy N/A Necessity Guidelines: Orkambi ivacaftor) Orkambi 100-125  Therapeutic Equivalent mg tablet only Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (lumacaftor/ivacaft Criteria - New and Therapeutic or) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Ortho Cept (ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives ) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Ortho Cyclen have contraceptive coverage  Benefit Guidelines: (ethinyl estradiol Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives and ) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Ortho Novum have contraceptive coverage  Benefit Guidelines: (ethinyl estradiol Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives and norethindrone) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug Ortho-Evra plan. If the Member does not (Generic) (Ethinyl have contraceptive coverage  Benefit Guidelines: estradiol and Patch J7304 N/A Pharmacy* through their prescription drug Contraceptives plan, then these are not covered. transdermal) Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug  Benefit Guidelines: Ortho-Evra (Brand plan. If the Member does not Contraceptives Only) (Ethinyl have contraceptive coverage  Therapeutic Equivalent estradiol and Patch J7304 PBM Pharmacy* through their prescription drug Guidelines: Drug Coverage norelgestromin plan, then these are not covered. Criteria - New and Therapeutic transdermal) Members should refer to their Equivalent Medications Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug  Benefit Guidelines: plan. If the Member does not Ortho Tri- Contraceptives have contraceptive coverage Cyclen/Lo (ethinyl  Therapeutic Equivalent Pill S4993 N/A Pharmacy* through their prescription drug estradiol and Guidelines: Drug Coverage plan, then these are not covered. norgestimate) Criteria - New and Therapeutic Members should refer to their Equivalent Medications Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification with review by a Intra- Oxford’s Medical Director or their Orthovisc (sodium  Precertification Guidelines: Articular J7324 Medical Medical Designee is required in all sites of hyaluronate) Sodium Hyaluronate Injection Management* service for J7321, J7324 and J7326. Otezla (apremilast) Tablet J8499 N/A N/A Pharmacy N/A Otic Care Ophthalmic (neomycin/ J3490 N/A N/A Pharmacy N/A Drops polymyxin-B HC) Otovel  Therapeutic Equivalent (ciprofloxacin and Otic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A fluocinolone Solution Criteria - New and Therapeutic acetonide) Equivalent Medications  Step Therapy Guidelines: Otrexup Otrexup  Therapeutic Equivalent (methotrexate Injection J3490 PBM Pharmacy N/A Guidelines: Drug Coverage injection) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Ovace Plus 9.8% Guidelines: Drug Coverage lotion (sodium Lotion J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfacetamide) Equivalent Medications  Therapeutic Equivalent Ovace Plus foam Topical Guidelines: Drug Coverage (sodium J3490 PBM Pharmacy N/A Foam Criteria - New and Therapeutic sulfacetamide) Equivalent Medications *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility Precertification diagnosis code.  Precertification Guidelines: Ovidrel (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and **Benefit Note: Coverage is gonadotropin) J3490 may be Medical** Treatment limited to Members with required* coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type guidelines. *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage Ovrette  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug (Norgestrel) Contraceptives plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Oxandrin Tablet J8499 N/A N/A Pharmacy N/A ()  Therapeutic Equivalent Oxaydo Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (oxycodone hcl) Criteria - New and Therapeutic Equivalent Medications Oxistat  Prior Authorization/Medical ( Cream J3490 PBM Pharmacy N/A Necessity Guidelines: Oxistat nitrate)  Therapeutic Equivalent Oxistat Guidelines: Drug Coverage (oxiconazole Lotion J3490 PBM Pharmacy N/A Criteria - New and Therapeutic nitrate) Equivalent Medications Oxtellar XR  Prior Authorization/Medical (oxcarbazepine Tablet J8499 PBM Necessity Guidelines: Oxteller Pharmacy N/A extended release) XR Oxycontin  Prior Authorization/Medical (oxycodone Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A extended release) Oxycontin  Prior Authorization/Medical Oxycodone ER Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A 12HR Tablet Oxycodone ER  Prior Authorization/Medical Oxymorphone Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A extended release Oxymorphone

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Oxytrol Tablet J8499 N/A N/A N/A equivalent are excluded from (oxybutynin) coverage. Refer to the member specific benefit plan document as applicable.  Therapeutic Equivalent Ozempic Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A (semaglutide) Criteria - New and Therapeutic Equivalent Medications Ozurdex Intravitreal J7312 N/A N/A Medical N/A (dexamethasone) Implant Pacnex HP and Pacnex LP (benzoyl Topical J3490 N/A N/A Pharmacy N/A peroxide) Pancreaze  Step Therapy Guidelines: Capsule J3490, PBM Pharmacy N/A (pancrelipase) Pancreaze Pantoprazole Tablet J8499 N/A N/A Pharmacy N/A (generic)  Therapeutic Equivalent Parlodel Guidelines: Drug Coverage (bromocriptine Tablet J3490 PBM Pharmacy N/A Criteria - New and Therapeutic mesylate) Equivalent Medications  Therapeutic Equivalent Pataday Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (olopatadine) Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Patanol Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (olopatadine HCL) Solution Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Pazeo (olopatadine Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A hydrochloride) Solution Criteria - New and Therapeutic Equivalent Medications Pcp 100 Kit (magesium citrate,  Therapeutic Equivalent bisacodyl, Guidelines: Drug Coverage petrolatum, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic polyethylene glycol Equivalent Medications 3350, metoclopramide)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Pediaderm AF  Therapeutic Equivalent (nystatin) and Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A Pediaderm TA Criteria - New and Therapeutic (triamcinolone) Equivalent Medications  Therapeutic Equivalent Pediprox-4 Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (benzalkonium) Criteria - New and Therapeutic Equivalent Medications Pegasys  Prior Authorization/ (peginterferon Injection J3490 PBM Notification Guidelines: Pharmacy N/A Alfa-2a) Pegasys (peginterferon alfa-2a) Peg-Intron  Prior Authorization/ (peginterferon Injection J3490 PBM Notification Guidelines: PEG- Pharmacy N/A Alfa-2b) Intron (peginterferon alfa-2b) g *Precertification Note: J2540 potassium Precertification is only required Oxford’s  Precertification Guidelines: only when used in the treatment IV Infusion Medical Medical Penicillin g Lyme Disease of Lyme disease. J2510 Management* procaine, Aqueous Exception: Precertification is not required for CT Members.  Therapeutic Equivalent Penlac Nail Lacquer Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (ciclopirox) (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Pennsaid 1.5% Guidelines: Drug Coverage Drops (diclofenac Drops J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Pennsaid 2% Topical Guidelines: Drug Coverage (diclofenac J3490 PBM Pharmacy N/A Solution Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Pentasa Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (mesalamine) Criteria - New and Therapeutic Equivalent Medications Percocet  Therapeutic Equivalent (acetaminophen Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A and oxycodone) Criteria - New and Therapeutic (brand only) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Note: HCPCS code S0122 (menotropins) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification **Benefit Note: Coverage is  Precertification Guidelines: Pergonal S0122* and through Optum Pharmacy/ limited to Members with Injection Infertility Diagnosis and (menotropins) J3490 may be Medical** coverage for fertility drugs Treatment required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Pertzye  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (pancrelipase) Pertzye  Prior Authorization/Medical Pexeva (paroxetine Tablet J8499 PBM Necessity Guidelines: Select Pharmacy N/A mesylate) Brand Medications *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have Phoslo (calcium vitamin/supplement coverage Capsule J8499 N/A N/A Pharmacy* acetate) through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Planzapine, long Injection J2358 N/A N/A Medical N/A acting  Therapeutic Equivalent Plavix (clopidogrel) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Plegridy Pen &  Prior Authorization/ Prefilled Syringe Injection J3490 PBM Notification Guidelines: Pharmacy N/A (peginterferon Plegridy beta-1a)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Plexion 9.8-4.8%  Therapeutic Equivalent cream, liquid, Guidelines: Drug Coverage lotion Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic (sulfacetamide/ Equivalent Medications sulfur) Plexion Cloth  Therapeutic Equivalent 9.8%-4.8% pads Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (sulfacetamide/ Criteria - New and Therapeutic sulfur) Equivalent Medications *Coverage is limited to Members with coverage for fluoride vitamins through their Poly-Vi-Flor/Iron, prescription drug plan. If the Polyvitamin Member does not have fluoride w/Fluoride, Tri-Vi- Tablet, Oral vitamin coverage through their Flor/Iron, J3490 N/A N/A Pharmacy* Solution prescription drug plan, then Trivitamin these are not covered. Members w/Fluoride, and Vi- should refer to their Certificate of Daylin Coverage or Prescription Drug Rider language for coverage guidelines. Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Pomalyst years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (pomalidomide) chemotherapy drugs do not Pomalyst require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Potiga (Ezogabine) Tablet J8499 PBM N/A Pharmacy N/A

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Coverage is limited to Members with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have Potaba Capsule, vitamin/supplement coverage (aminobenzoate Tablet or J8499 N/A N/A Pharmacy* through their prescription drug potassium) Powder plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.  Prior Authorization/Medical Praluent Injection J3490 PBM Necessity Guidelines: Praluent Pharmacy N/A (alirocumab) (alirocumab)  Therapeutic Equivalent Pramosone E Guidelines: Drug Coverage (hydrocortisone Topical J3490 PBM* Pharmacy N/A Criteria - New and Therapeutic and pramoxine) Equivalent Medications *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Pregnyl (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with gonadotropin) J3490 may be Medical** Treatment coverage for fertility drugs required* through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines.  Therapeutic Equivalent Prescription Guidelines: Drug Coverage Emollients/ Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Mosturizers Equivalent Medications  Therapeutic Equivalent Prestalia Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (perindopril) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Prevacid (lansoprazole)  Prior Authorization/Medical Solutab Tablet J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Lansoprazole Solid Oral Dosage Forms generic Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Prevacid Capsule J3490 N/A N/A N/A equivalent are excluded from (lansoprazole) coverage. Refer to the member specific benefit plan document as applicable. Prevpac ((lansoprazole 30-  Therapeutic Equivalent mg) (amoxicillin Capsule/ Guidelines: Drug Coverage J8499 PBM* Pharmacy N/A 500-mg) , Tablet Criteria - New and Therapeutic (clarithromycin Equivalent Medications 500-mg)  Therapeutic Equivalent Prevymis Guidelines: Drug Coverage Tablets J8499 PBM Pharmacy N/A (letermovir) Criteria - New and Therapeutic Equivalent Medications Prezcobix (darunavir/ Tablet J8499 N/A N/A Pharmacy N/A cobicistat) Prilosec Capsule J8499 PBM N/A Pharmacy N/A (omeprazole)  Therapeutic Equivalent Prilosec Guidelines: Drug Coverage Suspension Suspension J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (omeprazole) Equivalent Medications  Therapeutic Equivalent Pristiq Guidelines: Drug Coverage (desvenlafaxine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic succinate) Equivalent Medications  Precertification Guidelines: o Immune Globulin (IVIG) and Oxford’s SCIG Privigen (immune IV Infusion J1459 Medical o Immune Globulin Site of Medical N/A globulin) Management Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type

ProAir Respimat Inhaler J3490 N/A N/A Pharmacy N/A (albuterol)

G0516, G0517, Oxford’s  Precertification Guidelines: Probuphine Subdermal G0518, Medical Buprenorphine (Probuphine® & Medical N/A (buprenorphine) Implant J3490, Management Sublocade™) J0570, and 11981  Prior Authorization/ Procentra (dextro- Oral J8499 PBM Notification Guidelines: Pharmacy N/A amphetamine) Solution Procentra Benefit Note for Infertility Use *Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the  Precertification Guidelines: Member does not have fertility Prochieve Gel J3490 N/A Infertility Diagnosis and Pharmacy* drug coverage through their (progesterone gel) Treatment prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Procort  Therapeutic Equivalent (hydrocortisone Guidelines: Drug Coverage Topical J3490 PBM* Pharmacy N/A acetate and Criteria - New and Therapeutic pramoxine HCl) Equivalent Medications  Therapeutic Equivalent Proctocort Rectal Guidelines: Drug Coverage (hydrocortisone) J3490 PBM Pharmacy N/A Cream Criteria - New and Therapeutic (brand) Equivalent Medications Capsule,  Prior Authorization/ Procysbi Delayed Notification Guidelines: (cysteamine J8499 PBM Pharmacy N/A Release Procysbi (cysteamine bitartrate) bitartrate) Pellet  Step Therapy: Procysbi Prodrin  Therapeutic Equivalent (acetaminophen/ Guidelines: Drug Coverage Caplet J8499 PBM* Pharmacy N/A caffeine/ Criteria - New and Therapeutic isometheptene) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Note: HCPCS code J0725 (chorionic gonadotropin) requires precertification through Optum in all sites of service when associated with an infertility diagnosis code. Precertification  Precertification Guidelines: **Benefit Note: Coverage is Profasi (chorionic J0725* and through Optum Pharmacy/ Injection Infertility Diagnosis and limited to Members with gonadotropin) J3490 may be Medical** Treatment coverage for fertility drugs required** through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Progesterone Injection J3490 N/A N/A Medical N/A  Therapeutic Equivalent Prograf J7503, Guidelines: Drug Coverage (tacrolimus) Capsule J7507, PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) J8499 Equivalent Medications

Prolastin-C Oxford’s Intravenous  Precertification Guidelines: [Alpha -Proteinase Medical Medical N/A 1 injection J0256 Alpha -Proteinase Inhibitors Inhibitor [Human)] Management 1

 Therapeutic Equivalent Prolensa Opthalmic Guidelines: Drug Coverage (Bromfenac J3490 PBM* Pharmacy N/A Solution Criteria - New and Therapeutic Ophthalmic) Equivalent Medications *Precertification is required  eviCore Guidelines: Injectable through Oxford for all requests Oxford’s Chemotherapy Drugs: for NON-oncology indications. Prolia, Xgeva Medical Application of NCCN Clinical Injection J0897 Medical **Precertification is required (denosumab) Management*/ Practice Guidelines** through eviCore healthcare for all eviCore**  Precertification Guidelines: requests for oncology Denosumab (Prolia® & Xgeva®)* indications.  Prior Authorization/ Promacta Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Eltrombopag) Promacta

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Promiseb Complete Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Kit (Promiseb) Criteria - New and Therapeutic Equivalent Medications *Benefit Notes: Not covered for cosmetic conditions. Not all Propecia, groups have selected the Varies J3490 PBM N/A Pharmacy* ) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Proscar J8499 and Tablet N/A N/A Pharmacy N/A (finasteride) S0138 Protein C [human] IV Infusion J2724 N/A N/A Medical N/A concentrate  Therapeutic Equivalent Protonix Guidelines: Drug Coverage (Pantoprazole) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Protonix Granules Guidelines: Drug Coverage for Suspension Oral J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (pantoprazole) Equivalent Medications  Step Therapy Guidelines: Protopic Protopic Topical  Therapeutic Equivalent J8499 PBM Pharmacy N/A (tacrolimus) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Provigil (modafanil) Provigil (modafinil) Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Provigil (modafinil) Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (generic) Provigil (modafanil)  Therapeutic Equivalent Prozac (fluoxetine) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Prozac Weekly Guidelines: Drug Coverage (brand only) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (fluoxetine) Equivalent Medications Prozena 4% patch Topical J3490 N/A N/A Pharmacy N/A (lidocaine) Patch  Prior Authorization/ Topical Prudoxin (doxepin) J3490 PBM Notification Guidelines: Pharmacy N/A Cream Prudoxin Pulmicort Flexhaler Inhalation  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (budesonide) Powder Pulmicort  Prior Authorization/ Pulmozyme® Inhalation 7639 PBM Notification Guidelines: Pharmacy N/A (Dornase Alfa) Solution Pulmozyme (dornase alfa) *CT Plans: Medical Benefit. *NJ Plans: Pharmacy Benefit Medical Benefit for Members Oxford’s  Precertification Guidelines: without a Pharmacy Benefit. Puregon (follitropin IM or SQ S0128 Medical Infertility Diagnosis and See Notes* *NY Plans: Pharmacy Benefit.* beta) Injection Management Treatment *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.  Prior Authorization/Medical Purixan 20mg/ml Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A (mercaptopurine) Suspension Solid Oral Dosage Forms  Prior Authorization/Medical Oral Qbrelis (lisinopril) J8499 PBM Necessity Guidelines: Non- Pharmacy N/A Solution Solid Oral Dosage Forms  Therapeutic Equivalent Qnasl Guidelines: Drug Coverage (beclomethasone Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic dipropionate) Equivalent Medications  Therapeutic Equivalent Qtern Guidelines: Drug Coverage (dapagliflozin/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic saxagliptin) Equivalent Medications  Therapeutic Equivalent Quartette (ethinyl Guidelines: Drug Coverage estradiol/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic levonorgestrel) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Qudexy XR Capsule J8499 PBM Necessity Guidelines: Qudexy Pharmacy N/A () XR  Prior Authorization/ Notification Guidelines: Quillichew ER Quillichew ER (methylphenidate Chewable J8499 PBM  Therapeutic Equivalent Pharmacy N/A hcl) extended Tablet Guidelines: Drug Coverage release Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Quillivant XR Quillivant XR (methylphenidate Liquid J8499 PBM  Therapeutic Equivalent Pharmacy N/A HCL) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Qutenza (capsaicin Patch J3490 N/A N/A Pharmacy N/A 8% patch) QVAR Redihaler (beclomethasone Inhaler J3490 N/A N/A Pharmacy N/A diproprionate HFA) Rabeprazole Tablet J8499 N/A N/A Pharmacy N/A (generic) Hospital Outpatient Facility: Administration of Radicava in a hospital outpatient facility  Precertification Guidelines: (including any ambulatory Oxford’s o RadicavaTM (Edaravone) infusion suite associated with the Radicava Intravenous J3490 Medical o Specialty Medication Medical hospital) requires precertification (edaravone) injection Management Administration - Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines.  Prior Authorization/Medical Ragwitek (Short Sublingual Necessity Guidelines: Ragweed Pollen J8499 PBM Pharmacy N/A Tablet Ragwitek (Short Ragweed Pollen Allergen Extract) Allergen Extract)  Prior Authorization/ Raloxifene Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (generic) Raloxifene

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Tablet  Therapeutic Equivalent Rapamune J7520, Guidelines: Drug Coverage (sirolimus) (brand PBM Pharmacy N/A J8499 Criteria - New and Therapeutic only) Equivalent Medications Rasuvo Auto-  Step Therapy Guidelines: (methotrexate J3490 PBM Pharmacy N/A Injector Rasuvo injection) Ravicti (Glycerol  Prior Authorization/ Phenylbutyrate Oral Liquid J3490 PBM Notification Guidelines: Pharmacy N/A. Oral Liquid) Ravicti  Therapeutic Equivalent Rayaldee Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (calcifediol) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Rayos (delayed- Guidelines: Drug Coverage release Tablet J3490 PBM Pharmacy N/A Criteria - New and Therapeutic prednisone) Equivalent Medications J3490 and Rebetol (ribavirin) Tablet N/A N/A Pharmacy N/A J3590 J1826,  Prior Authorization/ Rebif (interferon Injection, Q3025 and PBM Notification Guidelines: Rebif Pharmacy N/A beta-1a) SQ Injection Q3026  Step therapy: Rebif Rebinyn  Therapeutic Equivalent (Coagulation Intravenous Guidelines: Drug Coverage Factor IX J7195 PBM Pharmacy N/A injection Criteria - New and Therapeutic (Recombinant), Equivalent Medications GlycoPEGylated) Reclast (zoledronic  Medical Management IV Infusion J3489 N/A Medical N/A acid) Guidelines: Maximum Dosage Rectiv (nitroglycerin Ointment J3490 N/A N/A Pharmacy N/A ointment)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM.  Precertification Guidelines: PBM* Precertification through the PBM Platelet Derived Growth Factors Oxford’s is required. Regranex for Treatment of Wounds** Pharmacy* Gel S0157 Medical **Medical Benefit: If provided ( gel)  Prior Authorization/ Medical** Manage- in a hospital, MD's office, or in Notification Guidelines: ment** conjunction with Home Health Regranex (becaplermin) Care. Precertification through Oxford’s Medical Management is required. Relenza Oral Inhaler J3490 N/A N/A Pharmacy N/A (zanamivir) Relistor  Prior Authorization/Medical (methylnatrexone Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Relistor ) Relistor  Prior Authorization/Medical (methylnaltrexone Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Relistor bromide) **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require  Supply Limit Guidelines: Relpax (eletriptan) Tablet J3490 PBM** Pharmacy* precertification. Triptans Supply Limits *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Note: No precertification required in office. Precertification is required for outpatient and home setting.  Medical Management Hospital Outpatient Facility: Guidelines: Maximum Dosage Administration of Remicade in a  Precertification Guidelines: Oxford’s hospital outpatient facility Remicade o Infliximab (Remicade®, Intravenous J1745 Medical Medical (including any ambulatory (infliximab) Inflectra™, Renflexis™) Management* infusion suite associated with the o Specialty Medication hospital) requires precertification Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines *Precertification Note: Precertification is required in all sites of service.  Medical Management Hospital Outpatient Facility: Guidelines: Maximum Dosage Administration of Renflexis in a  Precertification Guidelines: hospital outpatient facility Oxford’s Renflexis o Infliximab (Remicade®, (including any ambulatory Injection Q5104 Medical Medical (infliximab) Inflectra™, Renflexis™) infusion suite associated with the Management* o Specialty Medication hospital) requires precertification Administration – Site of Care with review by a Medical Director Review Guidelines or their designee. Refer to: Specialty Medication Administration – Site of Care Review Guidelines **Precertification Note: Precertification is not required for Members under 30 years of age.  Prior Authorization/ *Benefit Notes: Not covered for Renova (tretinoin) Varies S0117 PBM** Notification Guidelines: Retin- Pharmacy* cosmetic conditions. Not all A and Retin-A Micro (tretinoin) groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Repatha  Prior Authorization/Medical Injection J3490 PBM Pharmacy N/A (evolocumab) Necessity Guidelines: Repatha Repository Injection J3490 and  Prior Authorization/Medical Corticotropin self- PBM Pharmacy N/A J0800 Necessity Guidelines: Acthar Injection administered

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type (H.P.Acthar Gel) Injection by Oxford’s  Precertification Guidelines: a medical Medical Repository Corticotropin Medical N/A professional Management Injection (H.P. Acthar Gel)  Therapeutic Equivalent Requip XL J8499 and Guidelines: Drug Coverage (ropinirole Tablet PBM Pharmacy N/A J3490 Criteria - New and Therapeutic extended release) Equivalent Medications Rescula Ophthalmic  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (unoprostone) Solution Rescula Restasis  Prior Authorization/Medical (cyclosporine Ophthalmic Necessity Guidelines: Restasis ophthalmic J3490 PBM Pharmacy N/A Solution (cyclosporine ophthalmic emulsion) single- emulsion) use vials Restasis  Prior Authorization/Medical (cyclosporine Necessity Guidelines: Restasis ophthalmic (cyclosporine ophthalmic emulsion) (multi- Ophthalmic emulsion) J3490 PBM Pharmacy N/A use) Solution  Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Retin- A and Retin-A Micro (tretinoin) Retin-A (tretinoin) Topical S0117, PBM  Therapeutic Equivalent Pharmacy N/A (brand only) Cream J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Retin- Retin-A (tretinoin) A and Retin-A Micro (tretinoin) S0117, (brand and Topical Gel PBM  Therapeutic Equivalent Pharmacy N/A J3490 generic) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Retin- A and Retin-A Micro (tretinoin) Retin-A Micro Topical S0117 PBM  Therapeutic Equivalent Pharmacy N/A (tretinoin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Retin- Retin-A Micro A and Retin-A Micro (tretinoin) Pump (tretinoin) Topical S0117 PBM  Therapeutic Equivalent Pharmacy N/A (brand and Guidelines: Drug Coverage generic) Criteria - New and Therapeutic Equivalent Medications Revatio ( Tablet J3490 N/A N/A Pharmacy N/A citrate)  Prior Authorization/Medical Necessity Guidelines: Revatio (sildenafil citrate) Revatio (sildenafil Oral J3490 PBM  Therapeutic Equivalent Pharmacy N/A citrate) 10mg/ml Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Revlimid years or older. All other oral Oral J8999 PBM Notification Guidelines: Pharmacy** (lenalidomide) chemotherapy drugs do not Revlimid require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Rexaphenac 1% Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A cream (diclofenac) Criteria - New and Therapeutic Equivalent Medications Rexulti  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (brexpiprazole) Necessity Guidelines: Rexulti  Therapeutic Equivalent Rhinocort Aqua Guidelines: Drug Coverage Nasal Spray J3490 PBM Pharmacy N/A (budesonide) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Rho(D) (immune globulin) BayRHo- J2788, D, Gamulin Rh, J2790, HypRho-D Mini-  Precertification Guidelines: IV Infusion, J2791, Dose, MICRhoGAM, N/A Immune Globulin (IVIG) and Medical N/A IM Injection J2792, and Mini-Gamulin Rh, SCIG 90384- RhoGAM, 90386 Rhophylac, WinRho SDF Rhofade Topical  Prior Authorization/Medical (oxymetazoline J3490 PBM Pharmacy N/A Cream Necessity Guidelines: Rhofade hydrochloride)  Therapeutic Equivalent Rhopressa Ophthalmic Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (netarsudil) solution Criteria - New and Therapeutic Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Riax (benzoyl Topical J3490 N/A N/A Pharmacy equivalent are excluded from peroxide) Foam coverage. Refer to the member specific benefit plan document as applicable.  Therapeutic Equivalent Guidelines: Drug Coverage Ribapak (ribavirin) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications J3490, Ribasphere Capsule J3590 and N/A N/A Pharmacy N/A (ribavirin) J8499  Therapeutic Equivalent Risperdal Guidelines: Drug Coverage () Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Ritalin  Prior Authorization/ Tablet J8499 PBM Pharmacy N/A (methylphenidate) Notification Guidelines: Ritalin  Prior Authorization/ Ritalin LA Notification Guidelines: Ritalin (methylphenidate LA hydrochloride Capsule J8499 PBM  Therapeutic Equivalent Pharmacy N/A [extended Guidelines: Drug Coverage release]) (brand Criteria - New and Therapeutic and generic) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Ritalin SR  Prior Authorization/ (methylphenidate Tablet J8499 PBM Notification Guidelines: Ritalin Pharmacy N/A [controlled- SR release])  eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Oxford’s *For Oncology and Non- Rituxan Practice Guidelines Infusion J9310 Medical Medical Oncology Use: Precertification (rituximab)  Medical Management Management* is required. Guidelines: Maximum Dosage  Precertification Guidelines: Rituxan® (Rituximab) **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require  Supply Limit Guidelines: Rizatriptan Tablet J8499 PBM** Pharmacy* precertification. Triptans Supply Limits *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Rocaltrol Capsule, S0169 N/A N/A Pharmacy N/A (calcitriol) Liquid *Benefit Notes: Not covered for cosmetic conditions. Not all Rogaine J3490 and groups have selected the Varies PBM N/A Pharmacy* (minoxidil) S0139 standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Therapeutic Equivalent Rosadan kit Guidelines: Drug Coverage Cream/Gel J3490 PBM Pharmacy N/A (metronidazole) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Rosula (sodium Topical Guidelines: Drug Coverage sulfacetamide J3490 PBM Pharmacy N/A Wash Criteria - New and Therapeutic 10%/sulfur 4%) Equivalent Medications Rosuvastatin Tablet J8499 N/A N/A Pharmacy N/A (generic Crestor)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Rozerem  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (ramelteon) Rozerem (ramelteon) J8999 PBM  Prior Authorization/ Rubraca Pharmacy N/A Tablet Notification Guidelines: (rucaparib) Rubraca Ruconest (C1  Prior Authorization/ J0596 and esterase inhibitor Injection PBM Notification Guidelines: Pharmacy N/A J3490 [Recombinant]) Ruconest Rybix ODT (tramadol Tablet J8499 N/A N/A Pharmacy N/A hydrochloride)  Prior Authorization/ Rydapt Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (midostaurin) Rydapt  Therapeutic Equivalent Rytary (carbidopa Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A and levodopa) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Ryvent Guidelines: Drug Coverage (carbinoxamine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic maleate) Equivalent Medications Ryzolt (tramadol hydrochloride Tablet J8499 N/A N/A Pharmacy N/A Extended release) Oral  Prior Authorization/ Sabril (vigabatrin) J8499 PBM Pharmacy N/A Solution Notification Guidelines: Sabril Safyral  Therapeutic Equivalent (drospirenone/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A ethinyl estradiol/ Criteria - New and Therapeutic levomefolate) Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Saizen (somatropin) Saizen Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sancuso  Therapeutic Equivalent (granisetron Guidelines: Drug Coverage Patch J3490 PBM Pharmacy N/A transdermal Criteria - New and Therapeutic system) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Sanctura (trospium) (brand  Therapeutic Equivalent and generic) and Guidelines: Drug Coverage Sanctura XR Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (trospium chloride) Equivalent Medications (brand and generic)  Therapeutic Equivalent Sandimmune J7502, Guidelines: Drug Coverage (cyclosporine) Capsule J7515, PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) J8499 Equivalent Medications Sandostatin  Prior Authorization/ SQ or IV (octreotide J2354 PBM Notification Guidelines: Pharmacy N/A Injection acetate) Sandostatin  Prior Authorization/ Notification Guidelines: Sandostatin (Brand Sandostatin SQ or IV only) (octreotide J2354 PBM  Therapeutic Equivalent Pharmacy N/A Injection acetate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications **Precertification is required through eviCore for oncology Oxford’s Sandostatin LAR  Precertification Guidelines: indications. Medical Depot (octreotide IM Injection J2353 Sandostatin, Sandostatin LAR Medical *Precertification is required Management*/ acetate) DEPOT (octreotide acetate) through Oxford’s Medical eviCore** Management for all other indications. Saphris Oral J8499 N/A N/A Pharmacy N/A (asenapine)  Therapeutic Equivalent Sarafem Tablets Guidelines: Drug Coverage Tablets J8499 PBM Pharmacy N/A (fluoxetine) Criteria - New and Therapeutic Equivalent Medications Savaysa Tablet J8499 N/A N/A Pharmacy N/A (edoxaban) Savella Tablet J8499 N/A N/A Pharmacy N/A (milnacipran) Seebri Neohaler Inhalation J3490 N/A N/A Pharmacy N/A (glycopyrrolate) Powder

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Segluromet Guidelines: Drug Coverage (ertugliflozin/ Tablets J8499 PBM Pharmacy N/A Criteria - New and Therapeutic metformin hcl) Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Selrx (selenium Shampoo J3490 N/A N/A N/A equivalent are excluded from sulfide) coverage. Refer to the member specific benefit plan document as applicable.  Prior Authorization/ Selzentry Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (Maraviroc) Selzentry Sensipar  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (cinacalcet) Necessity Guidelines: Sensipar  Therapeutic Equivalent Sernivo spray Topical Guidelines: Drug Coverage (betamethasone J3490 PBM Pharmacy N/A Spray Criteria - New and Therapeutic dipropionate) Equivalent Medications Seroquel  Therapeutic Equivalent (quetiapine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A fumarate) (brand Criteria - New and Therapeutic only) Equivalent Medications *Step Therapy coverage criteria  Therapeutic Equivalent is for groups on the Essential PDL Seroquel XR Guidelines: Drug Coverage only. More information about if (Brand Only) Tablet J8499 PBM Pharmacy Criteria - New and Therapeutic this program applies can be (quetiapine) Equivalent Medications found on myuhc.com or by calling customer service.  Prior Authorization/Medical Serostim Injection, J2941 PBM Necessity Guidelines: Pharmacy N/A (somatropin) SQ Injection Serostim (somatropin) Signifor  Prior Authorization/ (pasireotide SQ Injection J3490 PBM Notification Guidelines: Pharmacy N/A diaspartate) Signifor Sildenafil citrate Tablet J8499 N/A N/A Pharmacy N/A (generic Revatio)  Therapeutic Equivalent Silenor (doxepin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Medical Siliq (brodalumab) Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Siliq  Therapeutic Equivalent Simbrinza 1-0.2% Opthalmic Guidelines: Drug Coverage (Brimonidine and J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic Brinzolamide) Equivalent Medications  Prior Authorization/ Simponi SQ Injection J3490 PBM Notification Guidelines: Pharmacy N/A (golimumab) Simponi (golimumab) *Hospital Outpatient Facility: Administration of Simponi Aria in  Precertification Guidelines: a hospital outpatient facility o Simponi Aria® (Golimumab) (including any ambulatory Oxford’s Injection for Intravenous infusion suite associated with the Simponi Aria Infusion J1602 Medical Infusion Medical hospital) requires precertification (golimumab) Management* o Specialty Medication with review by a Medical Director Administration – Site of Care or their designee. Refer to: Review Guidelines Specialty Medication Administration – Site of Care Review Guidelines. Simvastatin  Prior Authorization/ (generic Zocor) Notification Guidelines: - *Applies to New York Lines of Tablet J8499 PBM* Pharmacy 5mg, 10mg, 20mg, Cardiovascular Disease Business only 40mg Prevention Zero Cost Share* Singulair  Therapeutic Equivalent (montelukast Tablet, Guidelines: Drug Coverage J3490 PBM Pharmacy N/A sodium) (Brand Granule Criteria - New and Therapeutic only) Equivalent Medications Singulair Chewable  Therapeutic Equivalent Tablet (montelukast Chewable Guidelines: Drug Coverage J3490 PBM Pharmacy N/A sodium) (brand Tablet Criteria - New and Therapeutic only) Equivalent Medications Sirturo Tablet J8499 N/A N/A Pharmacy N/A (bedaquiline)  Therapeutic Equivalent Guidelines: Drug Coverage Sitavig (acyclovir) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Skelaxin (Brand Guidelines: Drug Coverage Oral J8999 PBM Pharmacy N/A only) (metaxalone) Criteria - New and Therapeutic Equivalent Medications Skyla Intrauterine Q0090 N/A  Benefit Guidelines: Pharmacy* *Coverage is limited to Members

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type (Levonorgestrel- Device Contraceptives with coverage for contraceptives Releasing through their prescription drug Intrauterine plan. If the Member does not Contraceptive have contraceptive coverage System) 13.5mg through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Sodium  Therapeutic Equivalent Sulfacetamide/ Toplical Guidelines: Drug Coverage Sulfur 9%-4.5% J3490 PBM Pharmacy N/A Lotion Criteria - New and Therapeutic Kit (generic Equivalent Medications Sumadan Kit) *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the Solage (mequinol) Varies J3490 PBM N/A Pharmacy* standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Prior Authorization/ Solaraze Topical Gel J3490 PBM Notification Guidelines: Pharmacy N/A (diclofenac) Solaraze Soliqua (insulin  Prior Authorization/ glargine/ Injection J3490 PBM Notification Guidelines: Pharmacy N/A lixisenatide) Soliqua *Precertification Note: Precertification is required for the drug Soliris in all sites of service. Additional precertification may be required for the site of care of  Medical Management the injection. Guidelines: Maximum Dosage Oxford’s  Precertification Guidelines: When administered in; Soliris Injection J1300 Medical o Soliris (eculizumab) Medical  Hospital Outpatient (eculizumab) Management* o Specialty Medication Facility: Administration Administration - Site of Care of Soliris in a hospital Review Guidelines outpatient facility (including any ambulatory infusion suite associated with the hospital) requires additional precertification

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type with review by a Medical Director or their designee. Refer to: Specialty Medication Administration - Site of Care Review Guidelines.  Home: Administration of Soliris in the home requires additional precertification for the home care services. Refer to: Home Health Care.  Provider’s Office or Freestanding Ambulatory Infusion Suite (not associated with a hospital): Administration of Soliris in a provider’s office or freestanding ambulatory infusion suite not associated with a hospital does not require additional precertification.  Prior Authorization/Medical Necessity Guidelines: Solodyn Solodyn  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A (minocycline HCL) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Solosec Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (secnidazole) granules Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Regulatory Guidelines: Soltamox Soltamox Oral J8999 PBM  Therapeutic Equivalent Pharmacy N/A ( citrate) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Soma 250mg  Therapeutic Equivalent (carisoprodol)/ J3490, Guidelines: Drug Coverage Tablet PBM Pharmacy N/A carisoprodol J8499 Criteria - New and Therapeutic 250mg (generic) Equivalent Medications Somac, Pantoloc, Protium, Pantecta, Tablet J8499 N/A N/A Pharmacy N/A and Pantoheal (Pantoprazole) Somatuline Depot IM Injection J1930 N/A N/A Medical N/A (lanreotide)  Prior Authorization/Medical Somavert Injection, J3590 PBM Necessity Guidelines: Pharmacy N/A (pegvisomant) SQ Injection Somavert Sonata () Tablet J8499 N/A N/A Pharmacy N/A Soolantra  Step Therapy Guidelines: Cream J3490 PBM Pharmacy N/A () Soolantra  Therapeutic Equivalent Sorilux Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (calcipotriene) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Sotylize (sotalol Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A hydrochloride) Solution Solid Oral Dosage Forms

Sovaldi  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (sofosbuvir) Necessity Guidelines: Sovaldi

Oxford’s Spinraza Intrathecal  Precertification Guidelines: J2326 Medical Medical N/A (Nusinersen) Injection Spinraza (Nusinersen) Management Spiriva Respimat Inhaler J3490 N/A N/A Pharmacy N/A (tiotropium) Sporanox Capsule J1835 N/A N/A Pharmacy N/A (itraconazole)  Prior Authorization/Medical Necessity Guidelines: Spritam Spritam  Therapeutic Equivalent Tablet J8499 PBM Pharmacy N/A (levetiracetam) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Sprix Nasal Spray (ketorolac Nasal Spray J3490 N/A N/A Pharmacy N/A tromethamine) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/Medical years or older. All other oral Sprycel () Oral J8999 PBM* Pharmacy** Necessity Guidelines: Sprycel chemotherapy drugs do not require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent SSS 10-4 (sodium Guidelines: Drug Coverage polystyrene Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfonate) Equivalent Medications  Prior Authorization/ Notification Guidelines: Erectile Dysfunction Agents Staxyn (vardenafil) Oral J3490 PBM  Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Steglatro Guidelines: Drug Coverage Tablets J8499 PBM Pharmacy N/A (ertugliflozin) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Steglujan Guidelines: Drug Coverage (ertugliflozin/ Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sitagliptin) Equivalent Medications  Medical Management Guidelines: Maximum Dosage *Precertification through PBM if PBM*  Precertification Guidelines: obtained at a pharmacy. Sub- Oxford’s Stelara Stelara (Ustekinumab) Pharmacy* (Pharmacy Benefit) cutaneous J3357 Medical (ustekinumab)  Prior Authorization/ /Medical** **No precertification if provided Injection Management Notification Guidelines: in an office or outpatient setting. ** Stelara Injection for (Medical Benefit) Subcutaneous Use

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Medical Management Oxford’s Stelara Intravenous Guidelines: Maximum Dosage J3358 Medical Medical N/A (ustekinumab) Infusion  Precertification Guidelines: Management Stelara (Ustekinumab)  Prior Authorization/ Stendra (avanafil) Tablet J3490 PBM Notification Guidelines: Pharmacy N/A Erectile Dysfunction Agents  Therapeutic Equivalent Stiolto Respimat Guidelines: Drug Coverage (olodaterol/ Inhaler J3490 PBM Pharmacy N/A Criteria - New and Therapeutic tiotropium) Equivalent Medications  Prior Authorization/ Stivarga Tablet J8999 PBM Notification Guidelines: Pharmacy N/A () Stivarga  Therapeutic Equivalent Strattera (Brand Guidelines: Drug Coverage only) Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (atomoxetine) Equivalent Medications Strensiq (asfotase  Prior Authorization/Medical Injection J3490 PBM Pharmacy N/A alfa) Necessity Guidelines: Strensiq Striant  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (testosterone) Necessity Guidelines: Striant Stribild® (elvitegravir/ cobicistat/  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A emtricitabine/ Stribild tenofovir disoproxil fumarate) Striverdi Respimat Inhalation J3490 N/A N/A Pharmacy N/A (olodaterol) Spray

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do Sublocade  Precertification Guidelines: not request one, a medical (buprenorphine Injection J3490 N/A* Buprenorphine (Probuphine® and Medical necessity review will be extended-release) Sublocade™) conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 07/01/2018, precertification will be required  Prior Authorization/Medical Suboxone Sublingual Necessity Guidelines: (buprenorphine/ J3490 PBM Pharmacy N/A Film, Tablet Buprenorphine/Naloxone naloxone) Products  Prior Authorization/Medical New Jersey Small Members Necessity Guidelines: Subsys should refer to their Certificate of Subsys (fentanyl  Therapeutic Equivalent Oral Spray J3490 PBM* Pharmacy* Coverage for precertification sublingual spray) Guidelines: Drug Coverage guidelines and quantity limit Criteria - New and Therapeutic guidelines. Equivalent Medications Succimer (DMSA), *Oral chelation agents do not (dimercaptosuccini Oral Agent J3490 N/A* N/A Pharmacy require precertification. c acid)  Therapeutic Equivalent Sumadan (sodium Guidelines: Drug Coverage sulfacetamide and Topical Kit J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfur) Equivalent Medications Sumadan Cleanser (sodium sulfacetamide and  Therapeutic Equivalent sulfur) in a Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A Moisturizing Wash Criteria - New and Therapeutic Novasome® Equivalent Medications Vehicle) (brand only)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Sumadan XLT Kit (sulfacetamide  Therapeutic Equivalent sodium, sulfur, Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A avobenzone, Criteria - New and Therapeutic octinoxate, and Equivalent Medications octisalate) **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. Tablet, J3490, NJ Plans do not require Nasal  Supply Limit Guidelines: Sumatriptan J8499, and PBM** Pharmacy* precertification. Spray, Triptans Supply Limits J3030 Injection *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Supply Limit Guidelines: Triptans Supply Limits Sumavel Dosepro J3490 and  Therapeutic Equivalent Injection PBM** Pharmacy* (Sumatriptan) J8499 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sumaxin TS and  Therapeutic Equivalent Sumaxin CP Guidelines: Drug Coverage (sodium Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic sulfacetamide and Equivalent Medications sulfur) *Precertification with review by a Intra- Oxford’s Medical Director or their Supartz (sodium  Precertification Guidelines: Articular J7321 Medical Medical Designee is required in all sites of hyaluronate) Sodium Hyaluronate Injection Management* service for J7321, J7324 and J7326. *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Supprelin LA Oxford’s  Precertification Guidelines: Precertification Guidelines: ( acetate SC Implant J9226 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone implant) Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Suprax Chewable Tablet J3490 N/A N/A Pharmacy N/A Tablet (cefixime) Sustenna Extended (paliperidone Release J2426 N/A N/A Medical N/A palmitate extended Injection release) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Sutent () Oral PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Sutent require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Sylatron  Prior Authorization/ (peginterferon Injection J3490 PBM Notification Guidelines: Pharmacy N/A alfa-2b) Sylatron Symbicort (budesonide/ formoterol Aerosol J3490 N/A N/A Pharmacy N/A fumarate dehydrate) Symdeko o Prior Authorization/Medical (tezacaftor / Tablets J8499 PBM Necessity Guidelines: Pharmacy N/A ivacaftor) Symdeko Symfi (/  Therapeutic Equivalent lamivudine/ Guidelines: Drug Coverage Tablets J8499 PBM Pharmacy N/A tenofovir disoproxil Criteria - New and Therapeutic fumarate) Equivalent Medications Symfi Lo  Therapeutic Equivalent (efavirenz/ Guidelines: Drug Coverage lamivudine/ Tablets J8499 PBM Pharmacy N/A Criteria - New and Therapeutic tenofovir disoproxil Equivalent Medications fumarate)

Drug Coverage Guidelines Page 131 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Symproic Symproic Tablet J8499 PBM Pharmacy N/A (naldemedine)  Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Oxford’s Synagis  Precertification Guidelines: Injection J3490 Medical Medical N/A (palivizumab) Synagis (palivizumab) Management Synalar 0.01%  Therapeutic Equivalent solution Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (fluocinolone Solution Criteria - New and Therapeutic acetonide) (brand) Equivalent Medications Synalar 0.025%  Therapeutic Equivalent Topical cream/ointment Guidelines: Drug Coverage Cream/ J3490 PBM Pharmacy N/A (fluocinolone Criteria - New and Therapeutic Ointment acetonide) (brand) Equivalent Medications  Therapeutic Equivalent Synalar Kit Guidelines: Drug Coverage (fluocinolone Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetonide) Equivalent Medications  Therapeutic Equivalent Synalar TS Guidelines: Drug Coverage (fluocinolone Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic acetonide) Equivalent Medications Synarel ( Nasal Spray J3490 N/A N/A Pharmacy N/A acetate)  Prior Authorization/Medical Syndros Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A (dronabinol) solution Solid Oral Dosage Forms *Precertification is not required Synvisc and Intra- Oxford’s in the office for Oxford's  Precertification Guidelines: Synvisc-One Articular J7325 Medical Medical preferred products of Euflexxa, Sodium Hyaluronate (Hylan G-F-20) Injection Management* Synvisc or Synvisc-One (J7323 and J7325). Synjardy  Therapeutic Equivalent (empagliflozin/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A metformin Criteria - New and Therapeutic hydrochloride) Equivalent Medications  Prior Authorization/ Syprine (trientine Oral Agent J3490 PBM Notification Guidelines: Pharmacy N/A hydrochloride) Syprine

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Taclonex Ointment  Therapeutic Equivalent (Brand Only) Guidelines: Drug Coverage (calcipotriene/ Ointment J3490 PBM Pharmacy N/A Criteria - New and Therapeutic betamethasone Equivalent Medications dipropionate)  Prior Authorization/ Tafinlar N/A Capsule J8499 PBM Notification Guidelines: Pharmacy () Tafinlar  Prior Authorization/ Tagrisso Tablet J8999 PBM Notification Guidelines: Pharmacy N/A () Tagrisso  Prior Notification/Medical Taltz (ixekizumab) Injection J3490 PBM Pharmacy N/A Necessity Guidelines: Taltz Capsule, Tamiflu Powder or J3490 and (oseltamivir N/A N/A Pharmacy N/A Oral J8499 phosphate) Suspension Tamiflu capsules  Therapeutic Equivalent (Brand only) J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A (oseltamivir J8499 Criteria - New and Therapeutic phosphate) Equivalent Medications  Prior Authorization/ Tamoxifen Oral J8999 PBM Regulatory Guidelines: Pharmacy N/A Tamoxifen  Therapeutic Equivalent Taperdex Pak 6- Guidelines: Drug Coverage day & 12-day Tablets J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (dexamethasone) Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Tarceva () Oral J8999 PBM Notification Guidelines: Pharmacy** chemotherapy drugs do not Tarceva require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Targadox Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (doxycycline) Criteria - New and Therapeutic Equivalent Medications Targretin Gel Topical Gel J3490 N/A N/A Pharmacy N/A (bexarotene) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline  Prior Authorization/ when the Member is age 19 Notification Guidelines: years or older. All other oral Tasigna () Oral J8999 PBM* Tasigna Pharmacy** chemotherapy drugs do not  Step Therapy Guidelines: require precertification. Tasigna Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Tasmar Guidelines: Drug Coverage (tolcapone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications *Coverage is limited to Members with coverage for contraceptives through their prescription drug  Benefit Guidelines: Taytulla plan. If the Member does not Contraceptives (norethindrone have contraceptive coverage  Therapeutic Equivalent acetate and ethinyl Tablet J8499 PBM Pharmacy* through their prescription drug Guidelines: Drug Coverage estradiol, and plan, then these are not covered. Criteria - New and Therapeutic ferrous fumarate) Members should refer to their Equivalent Medications Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type **Precertification Note: Precertification is not required for Members under 30 years of age. Precertification for NJ Small LOBs  Prior Authorization/ is based on the Member's Tazorac Varies J3490 PBM** Notification Guidelines: Pharmacy* benefit. (taxarotene) Tazorac (taxarotene) *Benefit Note: Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Prior Authorization/ Tecfidera (dimethyl Tablet J8499 PBM Notification Guidelines: Pharmacy N/A fumarate) Tecfidera (dimethyl fumarate) Technivie  Prior Authorization/Medical (ombitasvir/ Tablet J8499 PBM Necessity Guidelines: Pharmacy N/A paritaprevir/ Technivie ritonavir) Teflaro (ceftaroline Injection J0712 N/A N/A Medical N/A fosamil)  Therapeutic Equivalent Tekamlo (aliskiren/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A amlodipine) Criteria - New and Therapeutic Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Temodar years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** (temozolomide) chemotherapy drugs do not Temodar require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Tenoretic (atenolol/ Guidelines: Drug Coverage chlorthalidone) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Tenormin Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (atenolol) (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Terbinex Guidelines: Drug Coverage (terbinafine Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride) Equivalent Medications Test Strips and Meters (Diabetic):  Abbott Diabetic Test Strips and A4253 – *The Test Strips policy applies to  Prior Authorization/ Meters Test strips New York and Connecticut plans Notification Guidelines:  Bayer Diabetic Test Strip PBM Pharmacy and products only. o Diabetic Test Strips (NJ) Test Strips and **Contour Next test strips do not E0607 - o Test Strips* Meters** Meter require precertification.  Roche Diabetic Test Strips and Meters Testim  Prior Authorization/Medical Gel J3490 PBM Pharmacy N/A (testosterone gel) Necessity Guidelines: Testim and Injection J3490 N/A N/A Medical N/A estradiol cypionate and Injection J3490 N/A N/A Medical N/A estradiol valerate Testosterone Powder J3490 PBM N/A Pharmacy N/A powder  Prior Authorization/Medical Necessity Guidelines: Topical Testosterone topical gel (generic Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A Testim) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/Medical Necessity Guidelines: Topical Testosterone Androgens topical gel (generic Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A Vogelxo) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Topical Testosterone Androgens topical gel Topical Gel J3490 PBM  Therapeutic Equivalent Pharmacy N/A (manufacturer of Guidelines: Drug Coverage Perrigo Israel) Criteria - New and Therapeutic Equivalent Medications Testred (methyl- Capsule J3490 N/A N/A Pharmacy N/A testosterone) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Thalomid years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** () chemotherapy drugs do not Thalomid require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines. Thyrogen Injection J3490 N/A N/A Medical N/A (thyrotropin alfa)  Therapeutic Equivalent Tirosint Guidelines: Drug Coverage (levothyroxine Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic sodium) Equivalent Medications  Therapeutic Equivalent Tivorbex Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (indomethacin) Criteria - New and Therapeutic Equivalent Medications TNKase J3490 and Intravenous N/A N/A Medical N/A (tenecteplase) J3101

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Tobi™ Nebulizer Solution  Prior Authorization/ (Tobramycin Inhalation Notification Guidelines: TOBI Inhalation Powder or  Therapeutic Equivalent J3490 PBM Pharmacy N/A Solution) and Inhalation Guidelines: Drug Coverage Tobi® Podhaler™ Solution Criteria - New and Therapeutic (Tobramycin Equivalent Medications Inhalation Powder)  Therapeutic Equivalent Tobradex ST Guidelines: Drug Coverage (tobramycin- Ointment J3490 PBM Pharmacy N/A Criteria - New and Therapeutic dexamethasone) Equivalent Medications  Prior Authorization/ Notification Guidelines: Tobramycin Tobramycin nebulized solution Inhalation nebulized solution J3490 PBM  Therapeutic Equivalent Pharmacy N/A Solution (generic Tobi) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Tolak 4% cream Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (fluorouracil) Cream Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Tolterodine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (generic Detrol) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Topamax Tablet or J8499 PBM Necessity Guidelines: Pharmacy N/A (topiramate) Capsule Topamax  Therapeutic Equivalent Topicort Spray Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (Desoximetasone) Spray Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Toujeo Solostar Guidelines: Drug Coverage Injection J3490 PBM Pharmacy N/A (insulin glargine) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Tracleer Tablet J3490 PBM Necessity Guidelines: Tracleer Pharmacy N/A (bosentan) (bosentan)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Tramadol  Therapeutic Equivalent Tramadol Tablet/ extended- Guidelines: Drug Coverage extended-release J8499 Pharmacy N/A Capsule release Criteria - New and Therapeutic (generic ryzolt) (generic ryzolt) Equivalent Medications Travoprost Ophthalmic  Step Therapy Guidelines: J3490 PBM Pharmacy N/A (generic Travatan) Solution Travoprost (generic Travatan) Trelegy Ellipta  Therapeutic Equivalent (fluticasone Guidelines: Drug Coverage furoate/ Inhaler J3490 PBM Pharmacy N/A Criteria - New and Therapeutic umeclidinium/ Equivalent Medications vilanterol) *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Precertification Guidelines: Trelstar Injection J3315 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes.  Prior Authorization/ Tremfya Injection J3490 PBM Notification Guidelines: Pharmacy N/A (guselkumab) Tremfya  Prior Authorization/ Tresiba Flex Touch Injection J3490 PBM Notification Guidelines: Pharmacy N/A (insulin degludec) Tresiba  Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Tretin-X 0.075% 0.075% S0117 and PBM  Therapeutic Equivalent Pharmacy N/A cream (tretinoin) Cream J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Tretin-X 0.0375% 0.0375% J3490 PBM  Therapeutic Equivalent Pharmacy N/A cream (tretinoin) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Tretin-X (tretinoin) Tretin-X Kit Topical J3490 PBM  Therapeutic Equivalent Pharmacy N/A (tretinoin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Tretinoin (generic Topical S0117, PBM Notification Guidelines: Retin- Pharmacy N/A Retin-A) cream) Cream J3490 A and Retin-A Micro (tretinoin)  Prior Authorization/ Notification Guidelines: Retin- A and Retin-A Micro (tretinoin) Tretinoin (generic S0117, Topical Gel PBM  Therapeutic Equivalent Pharmacy N/A Retin-A) gel J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Treximet Guidelines: Drug Coverage (sumatriptan Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic naproxen) Equivalent Medications Trezix  Therapeutic Equivalent (acetaminophen/ Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A caffeine/ Criteria - New and Therapeutic dihydrocodeine) Equivalent Medications Triamcinolone Injection J3300 N/A N/A Medical N/A acetonide  Therapeutic Equivalent Trianex Guidelines: Drug Coverage Ointment J3490 PBM Pharmacy N/A (triamcinolone) Criteria - New and Therapeutic Equivalent Medications Tribenzor (amlodipine,  Therapeutic Equivalent olmesartan, Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A medoxomil, Criteria - New and Therapeutic hydrochlorothiazide Equivalent Medications ) Tricor/Fenofibrate 48mg and 145mg  Therapeutic Equivalent (generic Tricor) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (fenofibrate) and Criteria - New and Therapeutic Trilipix (fenofibrate Equivalent Medications acid)

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Triglide Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (fenofibrate) Criteria - New and Therapeutic Equivalent Medications *Benefit Notes: Not covered for cosmetic conditions. Not all Tri-Luma groups have selected the Varies J3490 N/A N/A Pharmacy* (hydroquinone) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Trileptal  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (oxcarbazepine) Necessity Guidelines: Trileptal  Therapeutic Equivalent Trilipix (fenofibrate Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A acid) Criteria - New and Therapeutic Equivalent Medications Trintellix  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A () Trintellix *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Triphasil have contraceptive coverage (levonorgestrel  Benefit Guidelines: Pill S4993 N/A Pharmacy* through their prescription drug and ethinyl Contraceptives plan, then these are not covered. estradiol) Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. *Precertification is required for the diagnosis of gender dysphoria only; refer to Oxford’s  Precertification Guidelines: Triptodur Precertification Guidelines: Injection J3490 Medical Gonadotropin Releasing Medical () Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable gender dysphoria ICD-10 diagnosis codes. *Precertification is not required  eviCore Guidelines: Injectable for intravenous chemotherapy Trisenox (arsenic Chemotherapy Drugs: drugs however, Oxford will Injection J9017 N/A* Medical trioxide) Application of NCCN Clinical provide a pre-service clinical Practice Guidelines review and coverage determination upon request. In

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type the absence of precertification, Oxford will perform a post- service retrospective review upon claim submission for patients 19 years of age or older. Triumeq (dolutegravir/ Tablet J8499 N/A N/A Pharmacy N/A abacavir/ lamivudine) *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will  Precertification Guidelines: be imposed for failure to request o Trogarzo (Ibalizumab) a pre-service review, if you do o Review at Launch for New to not request one, a medical Trogarzo Injection J3590 N/A* Market Medications Medical necessity review will be (Ibalizumab) o Specialty Medication conducted post-service to Administration – Site of Care determine coverage. It is the Review Guidelines referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 07/01/2018, precertification will be required.  Prior Authorization/Medical Trokendi XR Capsule J8499 PBM Necessity Guidelines: Trokendi Pharmacy N/A (topiramate) XR Troxyca ER  Prior Authorization/Medical (oxycodone hcl Capsules J8499 PBM Necessity Guidelines: Troxyca Pharmacy N/A and naltrexone) ER Trulance  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (plecanatide) Necessity Guidelines: Trulance Trulicity Injection J3490 N/A N/A Pharmacy N/A (dulaglutide) Truvada (emtricitabine and Tablet J8499 N/A N/A Pharmacy N/A tenofovir disoproxil fumarate)  Therapeutic Equivalent Tuzistra XR Oral Guidelines: Drug Coverage (codeine/ J8499 PBM Pharmacy N/A suspension Criteria - New and Therapeutic chlorpheniramine) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Twynsta Guidelines: Drug Coverage (Telmisartan, Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic amlodipine) Equivalent Medications Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Tykerb () Oral J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Tykerb require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Prior Authorization/ Tymlos Injection J3490 PBM Notification Guidelines: Pharmacy N/A (abaloparatide) Tymlos Tysabri Intravenous J2323 N/A N/A Medical N/A (natalizumab)  Prior Authorization/Medical Tyvaso Inhalation J7686 PBM Necessity Guidelines: Tyvaso Pharmacy N/A (treprostinil) Solution (treprostinil) Uceris Tablet J8499 N/A N/A Pharmacy N/A (budesonide) Uceris foam Topical J3490 N/A N/A Pharmacy N/A  Step Therapy Guidelines: Uloric (febuxostat) Tablet J8499 PBM Pharmacy N/A Uloric Note: Prescription drugs for which there is a therapeutic Ultrasal-ER 28.5% over-the-counter (OTC) Topical topical solution J8499 N/A N/A Pharmacy equivalent are excluded from Solution (salicylic acid) coverage. Refer to the member specific benefit plan document as applicable. Ultravate  Prior Authorization/Medical Topical (Halobetasol J3490 PBM Necessity Guidelines: Pharmacy N/A cream Propionate) Ultravate

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Ultravate X  Therapeutic Equivalent Combination Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A Package Criteria - New and Therapeutic (halobetasol) Equivalent Medications Ultresa  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (pancrelipase) Ultresa  Therapeutic Equivalent Umecta emulsion, Foam/ Guidelines: Drug Coverage foam, suspension J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic (urea) Equivalent Medications Umecta Kit (nail  Therapeutic Equivalent film pen/film Nail Film Guidelines: Drug Coverage suspension) (urea Pen/Film J3490 PBM Pharmacy N/A Criteria - New and Therapeutic nail film and Suspension Equivalent Medications hyaluronic acid)  Therapeutic Equivalent Topical Guidelines: Drug Coverage Umecta PD (urea) J3490 PBM Pharmacy N/A Suspension Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Uptravi (selexipag) Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Uptravi Uramaxin GT 45%  Therapeutic Equivalent (urea in Guidelines: Drug Coverage Foam J3490 PBM Pharmacy N/A ammonium Criteria - New and Therapeutic lactate) Equivalent Medications  Therapeutic Equivalent Uramaxin GT Kit Guidelines: Drug Coverage urea plus Cream J3490 PBM Pharmacy N/A Criteria - New and Therapeutic moisturizer) Equivalent Medications  Therapeutic Equivalent Urevaz 44% cream Topical Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (urea) Cream Criteria - New and Therapeutic Equivalent Medications Utibron Neohaler Inhalation (indacaterol/ J3490 N/A N/A Pharmacy N/A Powder glycopyrrolate)  Therapeutic Equivalent Guidelines: Drug Coverage Utopic (urea) 41% Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 144 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Vagifem (estradiol) Vaginal Guidelines: Drug Coverage J3490 PBM Pharmacy N/A (brand only) Insert Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Valchlor Gel Topical J3490 PBM Notification Guidelines: Pharmacy N/A (mechlorethamine) Valchlor Gel  Therapeutic Equivalent Valcyte Guidelines: Drug Coverage (valganciclovir) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications  Therapeutic Equivalent Valium () Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Valsartan (generic Capsule J8499 N/A N/A Pharmacy N/A Diovan)  Therapeutic Equivalent Valtrex Guidelines: Drug Coverage (valacyclovir) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Valturna 150- 160mg, 300mg - Tablet J8499 N/A N/A Pharmacy N/A 320mg (aliskiren and valsartan) Vanatol LQ  Prior Authorization/Medical (butalbital/ Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A acetaminophen/ Solution Solid Oral Dosage Forms caffeine *Benefit Notes: Not covered for cosmetic conditions. Not all Vaniqa groups have selected the Varies J3490 PBM N/A Pharmacy* (eflornithine) standard pharmacy benefit. Refer to Member's pharmacy plan if applicable.  Therapeutic Equivalent Vanos Guidelines: Drug Coverage Topical J3490 PBM Pharmacy N/A (fluocinonide) Criteria - New and Therapeutic Equivalent Medications

Drug Coverage Guidelines Page 145 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Vantas (histrelin Precertification Guidelines: SC Implant J9225 Medical Gonadotropin Releasing Medical implant) Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes. Vantrela ER  Prior Authorization/Medical (hydrocodone Tablets J8499 PBM Necessity Guidelines: Vantrela Pharmacy N/A bitartrate) ER Varubi (rolapitant) Tablet J8670 N/A N/A Pharmacy N/A Vascepa (omega-  Prior Authorization/ 3-acid ethyl Capsule J3490 PBM Notification Guidelines: Pharmacy N/A esters) Vascepa Vascepa 0.5 gram  Prior Authorization/ only (omega-3- Capsule J3490 PBM Notification Guidelines: Pharmacy N/A acid ethyl esters) Vascepa  Therapeutic Equivalent Vaseretic (enalapril/ Guidelines: Drug Coverage hydrochlorothiazide Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic ) (brand) Equivalent Medications  Therapeutic Equivalent Vasotec (enalapril) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Vecamyl Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (mecamylamine) Vecamyl (mecamylamine) Vectical (calcitriol) Topical J3490 N/A N/A Pharmacy N/A Velphoro (sucroferric Tablet J8499 N/A N/A Pharmacy N/A oxyhydroxide) Veltassa Oral  Prior Authorization/Medical J8499 PBM Pharmacy N/A (patiromer) Suspension Necessity Guidelines: Veltassa  Therapeutic Equivalent Veltin (clindamycin Guidelines: Drug Coverage phosphate and Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic tretinoin) Equivalent Medications Vemlidy (tenofovir  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A alafenamide) Vemlidy

Drug Coverage Guidelines Page 146 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Venclexta Tablet J8999 PBM Notification Guidelines: Pharmacy N/A (venetoclax) Venclexta Venlafaxine ER  Therapeutic Equivalent (venlafaxine Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochloride Criteria - New and Therapeutic extended release) Equivalent Medications *The I-neb AAD System (K0730) for administration of Ventavis®  Prior Authorization/Medical Pharmacy (iloprost) requires precertification Inhalation Ventavis (iloprost) Q4074 PBM* Necessity Guidelines: Ventavis and DME through Oxford's Medical Solution (iloprost) (Medical) Management Department and coverage is provide under the Medical benefit.  Therapeutic Equivalent Veramyst Guidelines: Drug Coverage (fluticasone Nasal Spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic furoate) Equivalent Medications  Therapeutic Equivalent Guidelines: Drug Coverage Verdeso (desonide) Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Equivalent Medications Vermox Oral  Prior Authorization/Medical J8499 PBM Pharmacy N/A (mebendazole) Suspension Necessity Guidelines: Vermox  Therapeutic Equivalent Versacloz Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A () suspension Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Verzenio Tablet J8999 PBM Notification Guidelines: Pharmacy N/A (abemaciclib) Verzenio  Therapeutic Equivalent Vesicare Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (solifenacin) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Viagra (sildenafil Tablet J3490 PBM Notification Guidelines: Pharmacy N/A citrate) Erectile Dysfunction Agents Vibativ Injection J3095 N/A N/A Medical N/A (telavancin) Viberzi  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (eluxadoline) Necessity Guidelines: Viberzi

Drug Coverage Guidelines Page 147 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Vicodin 5/300mg Guidelines: Drug Coverage (hydrocodone and Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic acetaminophen) Equivalent Medications Vicodin ES  Therapeutic Equivalent 7.5/300mg Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (hydrocodone and Criteria - New and Therapeutic acetaminophen) Equivalent Medications Vicodin HP  Therapeutic Equivalent 10/300mg Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (hydrocodone and Criteria - New and Therapeutic acetaminophen) Equivalent Medications Viekira Pak Viekira XR  Prior Authorization/Medical (ombitasvir, Oral J8499 PBM Necessity Guidelines: Viekira Pharmacy N/A paritaprevir (ABT- Pak 450) and ritonavir)  Therapeutic Equivalent Vigamox (Brand Ophthalmic Guidelines: Drug Coverage only) J8499 PBM Pharmacy N/A solution Criteria - New and Therapeutic (moxifloxacin) Equivalent Medications *Precertification Notes: We strongly recommend that you request precertification for this medication. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical Vimizim (elosulfase  Precertification Guidelines: necessity review will be Injection J1322 N/A* Medical alfa) Enzyme Replacement Therapy* conducted post-service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of 08/01/2018, precertification will be required.

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Note: Prescription drugs for which there is a therapeutic Vimovo (naproxen over-the-counter (OTC) sodium plus proton Tablet J3490 N/A N/A N/A equivalent are excluded from pump inhibitor) coverage. Refer to the member specific benefit plan document as applicable. C9254 and Injection N/A N/A Medical N/A J3490 Vimpat (Lacosamide)  Prior Authorization/Medical Tablet J8499 PBM Necessity Guidelines: Vimpat Pharmacy N/A (Lacosamide) Viokace  Step Therapy Guidelines: Tablet J3490 PBM Pharmacy N/A (pancrelipase) Viokace  Therapeutic Equivalent Viramune Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (nevirapine) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Viramune XR Guidelines: Drug Coverage 400mg (Brand Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic Only) (nevirapine) Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Virasal (salicylic Topical J3490 N/A N/A Pharmacy equivalent are excluded from acid) (brand only) coverage. Refer to the member specific benefit plan document as applicable. Viread (Brand  Therapeutic Equivalent only) (tenofovir Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A disoproxil Criteria - New and Therapeutic fumarate) Equivalent Medications Visudyne Infusion J3396 N/A N/A Medical N/A () Vitamin B-12 Injection J3420 N/A N/A Medical N/A Vitekta Tablet J8499 N/A N/A Pharmacy N/A (elvitegravir)  Therapeutic Equivalent Vitorin (Brand Guidelines: Drug Coverage only) (ezetimibe Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic and simvastatin) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Vitrasert- Ganciclovir Vitreal Eye Implant J3490 N/A N/A Medical N/A Implant Vituz (hydrocodone  Therapeutic Equivalent bitartrate, and Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A chlorpheniramine Solution Criteria - New and Therapeutic maleate) Equivalent Medications Vivitrol Injection J2315 N/A N/A Medical N/A (Naltrexone)  Therapeutic Equivalent Vivlodex Guidelines: Drug Coverage Capsule J8499 PBM Pharmacy N/A (meloxicam) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Necessity Guidelines: Vogelxo Vogelxo  Therapeutic Equivalent Topical J3490 PBM Pharmacy N/A (testosterone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vosevi (Sofosbuvir/  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A Velpatasvir/ Necessity Guidelines: Vosevi Voxilaprevir) Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Votrient years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** () chemotherapy drugs do not Votrient require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Medical Management VPRIV Guidelines: Intravenous Injection J3385 N/A Medical N/A (velaglucerase) Enzyme Replacement Therapy (ERT) for Gaucher Disease Vraylar  Step Therapy Guidelines: Capsule J8499 PBM Pharmacy N/A (cariprazine) Vraylar

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Vusion Guidelines: Drug Coverage (/ Ointment J3490 PBM Pharmacy N/A Criteria - New and Therapeutic oxide) Equivalent Medications  Therapeutic Equivalent Vytone Guidelines: Drug Coverage (hydrocortisone/ Topical J3490 PBM Pharmacy N/A Criteria - New and Therapeutic lodoquinol) Equivalent Medications  Prior Authorization/ Vyvanse Tablet J3490 N/A Notification Guidelines: Pharmacy N/A (lisdexamfetamine) Vyvanse (lisdexamfetamine)  Step Therapy Guidelines: Vyzulta Vyzulta Ophthalmic  Therapeutic Equivalent (latanoprostene J3490 PBM Pharmacy N/A solution Guidelines: Drug Coverage bunod) Criteria - New and Therapeutic Equivalent Medications *Coverage is limited to Members Weight Loss: with coverage for weight loss Adipex-P , medications through their diethylpropion, prescription drug plan. If the benzphetamine, Member does not have weight Belviq, loss medication coverage through  Prior Authorization/Medical their prescription drug plan, then Belviq XR, Tablet or J8499 PBM Necessity Guidelines: Weight Pharmacy* these are not covered. Members Contrave, Capsule Loss should refer to their Certificate of phendimetrazine, Coverage, or Prescription Drug phentermine, Rider language for coverage Qsymia, guidelines. Saxenda, ** Prior Authorization Guidelines Xenical only apply to New York plans and products

 Therapeutic Equivalent Wellbutrin Guidelines: Drug Coverage (bupropion) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications

 Therapeutic Equivalent Wellbutrin SR Guidelines: Drug Coverage (brand only) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (bupropion) Equivalent Medications

Drug Coverage Guidelines Page 151 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Wellbutrin XL Guidelines: Drug Coverage (bupropion Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic extended release) Equivalent Medications Winstrol Tablet J8499 N/A N/A Pharmacy N/A () Xadago  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A (safinamide) Necessity Guidelines: Xadago Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ years or older. All other oral Xalkori () Oral J8999 PBM* Notification Guidelines: Pharmacy** chemotherapy drugs do not Xalkori require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Xanax Guidelines: Drug Coverage (alprazolam) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Xanax XR Guidelines: Drug Coverage (alprazolam) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Xartemis XR  Therapeutic Equivalent 7.5/325mg Guidelines: Drug Coverage (oxycodone Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic hydrochloride and Equivalent Medications acetaminophen) Xatmep Oral J8610,  Prior Authorization/Medical PBM Pharmacy N/A (methotrexate) Solution J8999 Necessity Guidelines: Xatmep  Prior Authorization/ Notification Guidelines: Xeljanz Tablet J8499 PBM Xeljanz Pharmacy N/A (tofacitinib)  Step Therapy Guidelines: Xeljanz

Drug Coverage Guidelines Page 152 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Prior Authorization/ Notification Guidelines: Xeljanz XR Tablet J8499 PBM Xeljanz XR Pharmacy N/A  Step Therapy Guidelines: Xeljanz XR  Therapeutic Equivalent Xenazine Guidelines: Drug Coverage (tetrabenazine) Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (brand) Equivalent Medications Xeomin Oxford’s  Precertification Guidelines: (incobotulinumtoxin SQ Injection J0588 Medical Medical N/A Botulinum Toxins A and B A) Management  Therapeutic Equivalent Xerese (acyclovir Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A or hydrocortisone) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Xermelo Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (telotristat ethyl) Xermelo  Therapeutic Equivalent Xhance Guidelines: Drug Coverage (fluticasone Nasal spray J3490 PBM Pharmacy N/A Criteria - New and Therapeutic propionate) Equivalent Medications Xiaflex (collagenase Injection J0775 N/A N/A Medical N/A clostridium histolyticum)  Prior Authorization/Medical Xifaxan (rifaximin) Tablet J8499 PBM Pharmacy N/A Necessity Guidelines: Xifaxan The Prior Authorization/ Notification Guidelines:  Prior Authorization/ Diabetes Medications SGLT2 Notification Guidelines: Inhibitors (CT/NY) policy applies Xigduo XR Diabetes Medications SGLT2 to New York and Connecticut (Dapagliflozin and Tablet J3490 PBM* Inhibitors (CT/NY) Pharmacy plans and products. Metformin HCl)  Step Therapy Guidelines: The Step Therapy Guidelines: Diabetes Medications SGLT2 Diabetes Medications SGLT2 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Ophthalmic  Prior Authorization/Medical Xiidra (lifitegrast) J3490 PBM Pharmacy N/A solution Necessity Guidelines: Xiidra

Drug Coverage Guidelines Page 153 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Xodol 10/300  Therapeutic Equivalent (hydrocodone/ Guidelines: Drug Coverage Tablet J8499 PBM* Pharmacy N/A acetaminophen)(br Criteria - New and Therapeutic and and generic) Equivalent Medications Xodol 5/300  Therapeutic Equivalent (hydrocodone / Guidelines: Drug Coverage acetaminophen) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand and Equivalent Medications generic) Xodol 7.5/300  Therapeutic Equivalent (hydrocodone / Guidelines: Drug Coverage acetaminophen) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand and Equivalent Medications generic)  Medical Management Oxford’s Xolair Guidelines: Maximum Dosage SQ Injection J2357 Medical Medical N/A (omalizumab)  Precertification Guidelines: Management Xolair (omalizumab) Xopenex Nebules  Therapeutic Equivalent (levalbuterol Inhalation Guidelines: Drug Coverage hydrochloride) J3490 PBM Pharmacy N/A Solution Criteria - New and Therapeutic Generic Xopenex Equivalent Medications nebules  Prior Authorization/Medical Xtampza ER Capsule J8499 PBM Necessity Guidelines: Xtampza Pharmacy N/A (oxycodone) ER

 Prior Authorization/ Xtandi Notification Guidelines: Xtandi Capsule J8999 PBM Pharmacy N/A (enzalutamide)  Step Therapy Guidelines: Xtandi

 Therapeutic Equivalent Xultophy (insulin Guidelines: Drug Coverage degludec and Injection J3490 PBM Pharmacy N/A Criteria - New and Therapeutic liraglutide) Equivalent Medications  Prior Authorization/ Xuriden (uridine Oral J8499 PBM Notification Guidelines: Pharmacy N/A triacetate) Granules Xuriden  Prior Authorization/Medical Xyrem (Sodium Oral J8499 PBM Necessity Guidelines: Xyrem Pharmacy N/A Oxybate) Solution ()

Drug Coverage Guidelines Page 154 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type *Coverage is limited to Members with coverage for contraceptives through their prescription drug plan. If the Member does not Yasmin 28 have contraceptive coverage  Benefit Guidelines: (drospirenone- Pill S4993 N/A Pharmacy* through their prescription drug Contraceptives ethinyl estradiol) plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Yosprala (aspirin/ Tablet J8499 N/A N/A N/A equivalent are excluded from omeprazole) coverage. Refer to member specific benefit plan document as applicable. Pharmacy Benefit: If dispensed by a retail pharmacy or mail order through PBM.  eviCore Guidelines: White Precertification is not required. Zarxio (filgrastim- Injection Q5101 eviCore* Blood Cell Colony Stimulating See Notes sndz) *Medical Benefit: If provided in Factors* a hospital, MD's office, or in conjunction with home health care. Precertification through eviCore is required. Zavesca® Capsule J8499 N/A N/A Pharmacy N/A (miglustat)  Therapeutic Equivalent Zecuity 6.5mg/4 hr Transdermal Guidelines: Drug Coverage patch (sumatriptan J3490 PBM Pharmacy N/A Patch Criteria - New and Therapeutic iontophoretic) Equivalent Medications Note: Prescription drugs for which there is a therapeutic Zegerid over-the-counter (OTC) (omeprazole/ Capsule J8499 N/A N/A Not covered equivalent are excluded from sodium coverage. Refer to member bicarbonate) specific benefit plan document as applicable.

Drug Coverage Guidelines Page 155 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Zegerid suspension  Prior Authorization/Medical (omeprazole/ Oral J8499 PBM Necessity Guidelines: Non- Pharmacy N/A sodium Suspension Solid Oral Dosage Forms bicarbonate)  Prior Authorization/ Zejula (niraparib) Tablet J3490 PBM Pharmacy N/A Notification Guidelines: Zejula Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19  Prior Authorization/ Zelboraf years or older. All other oral Oral J8999 PBM* Notification Guidelines: Pharmacy** () chemotherapy drugs do not Zelboraf require precertification. Benefit Note: **NJ Small Members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.

Zemaira [Alpha - Oxford’s  Precertification Guidelines: 1 Intravenous Proteinase Medical Alpha -Proteinase Inhibitors Medical N/A injection 1 Inhibitor (Human)] Management J0256  Supply Limit Guidelines: Zembrace Triptans Supply Limits SymTouch  Therapeutic Equivalent Injection J3490 PBM Pharmacy N/A (sumatriptan Guidelines: Drug Coverage succinate) Criteria - New and Therapeutic Equivalent Medications Zemplar Injection J2501 N/A N/A Pharmacy N/A (paricalcitol)  Prior Authorization/ Zenatane Capsule J8499 PBM Notification Guidelines: Pharmacy N/A Zenatane  Prior Authorization/ Notification Guidelines: Zenzedi Zenzedi (dextroamphetami Tablet J8499 PBM  Therapeutic Equivalent Pharmacy N/A ne sulfate) Guidelines: Drug Coverage Criteria - New And Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Zepatier (elbasvir/  Prior Authorization/Medical Tablet J8499 PBM Pharmacy N/A grazoprevir) Necessity Guidelines: Zepatier Zestoretic  Therapeutic Equivalent (lisinopril/ Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A hydrochlorothiazide Criteria - New and Therapeutic ) (brand) Equivalent Medications  Therapeutic Equivalent Zestril (lisinopril) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Zetia (ezetimibe) Guidelines: Drug Coverage Tablet J3490 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Zetonna Inhalation J8499 N/A N/A Pharmacy N/A (ciclesonide) Solution A9542 and Injection N/A N/A Medical N/A Zevalin A9543 (ibritumomab Powder tiuxetan) J3490 N/A N/A Pharmacy N/A Packet  Therapeutic Equivalent Ziana (clindamycin Guidelines: Drug Coverage phosphate and Gel J3490 PBM Pharmacy N/A Criteria - New and Therapeutic Tretinoin Equivalent Medications  Prior Authorization/ Zinbryta Injection J7513 PBM Notification Guidelines: Pharmacy N/A (daclizumab) Zinbryta Zioptan Opthalmic  Step Therapy Guidelines: J8499 PBM Pharmacy N/A (tafluprost) Solution Zioptan (tafluprost)  Therapeutic Equivalent Zipsor 25mg Guidelines: Drug Coverage (diclofenac Capsule J8499 PBM Pharmacy N/A Criteria - New and Therapeutic pottassium) Equivalent Medications Capsule, Zithromax Oral J3490 and N/A N/A Pharmacy N/A (azithromycin) Solution or J8499 Tablet  Therapeutic Equivalent Zodex 6 & 12-Day Guidelines: Drug Coverage pack Tablet J8499 PBM Pharmacy N/A Criteria - New and Therapeutic (dexamethasone) Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Oral Q0179 and Zofran N/A N/A Pharmacy N/A (ondansetron Solution S0181 hydrochloride) IV Injection J2405 N/A N/A Medical N/A Zofran and Zofran Tablet J8499 N/A N/A Pharmacy N/A ODT (ondansetron) Zohydro ER  Prior Authorization/Medical (hydrocodone Tablet J8499 PBM Necessity Guidelines: Zohydro Pharmacy N/A bitartrate extended ER release) *Precertification is required for the diagnosis of Gender Dysphoria only; refer to Oxford’s  Precertification Guidelines: Precertification Guidelines: Zoladex SC Implant J9202 Medical Gonadotropin Releasing Medical Gonadotropin Releasing Hormone Management* Hormone Analogs Analogs for applicable Gender Dysphoria ICD-10 diagnosis codes.  Medical Management Zoledronic acid Injection J3489 N/A Medical N/A Guidelines: Maximum Dosage  Therapeutic Equivalent Zoloft (sertraline) Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (brand only) Criteria - New and Therapeutic Equivalent Medications Zolpidem extended Tablet J8499 N/A N/A Pharmacy N/A release (zolpidem) Zolpimist  Step Therapy Guidelines: Oral Spray J8499 PBM Pharmacy N/A (zolpidem tartrate) Zolpimist (zolpidem tartrate) Zolvit (hydrocodone Liquid J8499 N/A N/A Pharmacy N/A bitartrate and acetaminophen)  Prior Authorization/Medical Necessity Guidelines: Zomacton Zomacton Injection J2941 PBM  Therapeutic Equivalent Pharmacy N/A (somatropin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zometa (zoledronic  Medical Management Injection J3489 N/A Medical N/A acid) Guidelines: Maximum Dosage

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type **Precertification Notes: Precertification through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Zomig and Zomig- Tablet and J8499 and  Supply Limit Guidelines: PBM** Pharmacy* precertification. ZMT (zolmitriptan) Nasal Spray J3590 Triptans Supply Limits *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program.  Therapeutic Equivalent Zonacort Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (dexamethasone) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Topical Zonalon (Doxepin) J3490 PBM Notification Guidelines: Pharmacy N/A Cream Zonalon  Therapeutic Equivalent Zonatuss J3490 and Guidelines: Drug Coverage Capsule PBM Pharmacy N/A (benzonatate) J8499 Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Zonegran Capsule J8499 PBM Necessity Guidelines: Pharmacy N/A (zonisamide) Zonegran Zontivity Tablet J8499 N/A N/A Pharmacy N/A (vorapaxar)  Prior Authorization/Medical Zorbtive Injection J2941 PBM Necessity Guidelines: Zorbtive Pharmacy N/A (somatropin) (somatropin)  Therapeutic Equivalent Zorvolex Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (diclofenac) Criteria - New and Therapeutic Equivalent Medications  Therapeutic Equivalent Zovirax cream Guidelines: Drug Coverage Cream J3490 PBM Pharmacy N/A (acyclovir) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/Medical Zovirax Ointment Topical J3490 PBM Pharmacy N/A Necessity Guidelines: Zovirax

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type Zubsolv (buprenorphine/ Tablet J8499 N/A N/A Pharmacy N/A naloxone)  Therapeutic Equivalent Zuplenz Tablet or Guidelines: Drug Coverage J8499 PBM* Pharmacy N/A (Ondansetron) Film Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Zurampic Tablet J8499 PBM Notification Guidelines: Pharmacy N/A (lesinurad) Zurampic Zutripro (Brand Only) (hydrocodone  Therapeutic Equivalent bitartrate, Oral Guidelines: Drug Coverage chlorpheniramine J8499 PBM* Pharmacy N/A Solution Criteria - New and Therapeutic maleate and Equivalent Medications pseudoephedrine hcl) Tablet,  Prior Authorization/Medical *Benefits for Tobacco Cessation Nasal Necessity Guidelines: Tobacco for Health Care Reform apply to Zyban (bupropion) J3490 PBM Pharmacy Spray, Cessation for Health Care all plans subject to health care Inhaler Reform reform.  Therapeutic Equivalent Zyclara Guidelines: Drug Coverage Cream J3490 PBM* Pharmacy N/A (Imiquimod) Criteria - New and Therapeutic Equivalent Medications  Prior Authorization/ Zydelig (idelalisib) Tablet J8499 PBM Notification Guidelines: Pharmacy N/A Zydelig  Prior Authorization/ Zykadia () Capsule J8999 PBM Notification Guidelines: Pharmacy N/A Zykadia Zylfo and Zylfo CR  Step Therapy Guidelines: Tablet J8499 PBM Pharmacy N/A (zileuton) Zylfo Zymaxid (Gatifloxacin Ophthalmic J3490 N/A N/A Pharmacy N/A ophthalmic Solution solution)  Therapeutic Equivalent Zypitamag Guidelines: Drug Coverage Tablet J8499 PBM Pharmacy N/A (Pitavastatin) Criteria - New and Therapeutic Equivalent Medications

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Dosage CPT/HCPCS Precertification Benefit Medication/Drug Coverage Criteria/Guidelines Notes Form Code(s) Routing Type  Therapeutic Equivalent Zyprexa Guidelines: Drug Coverage () Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications  Therapeutic Equivalent Zyprexa Zydis Guidelines: Drug Coverage (olanzapine) Tablet J8499 PBM* Pharmacy N/A Criteria - New and Therapeutic (brand only) Equivalent Medications Note: Prescription drugs for which there is a therapeutic over-the-counter (OTC) Zyrtec (cetirizine) Oral J8499 N/A N/A N/A equivalent are excluded from solution Solution coverage. Refer to the member specific benefit plan document as applicable. Precertification Note: *Precertification through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 Zytiga (abiraterone  Prior Authorization/ years or older. All other oral Oral J8999 PBM* Pharmacy** acetate) Notification Guidelines: Zytiga chemotherapy drugs do not require precertification. Benefit Note: **NJ Small members should refer to their Certificate of Coverage for precertification guidelines and quantity limit guidelines.  Therapeutic Equivalent Zyvox (linezolid) Tablet/Oral Guidelines: Drug Coverage J8499 PBM Pharmacy N/A (brand) Suspension Criteria - New and Therapeutic Equivalent Medications CPT® is a registered trademark of the American Medical Association

POLICY HISTORY/REVISION INFORMATION

Date Action/Description  Revised conditions of coverage; added instruction to refer to the policy titled Supply Limits: New Jersey Benefit Maximum Limits for details on applicable benefit guidelines for Jersey (NJ) plan members  Revised coverage guidelines for the following medications/drugs: 06/01/2018 Medication/Drug Status Summary of Changes Actemra (Tocilizumab) Updated  Updated step therapy guidelines; refer to Step Therapy Guidelines: Actemra (Tocilizumab) for complete details

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Date Action/Description Actiq (Brand Only) (Fentanyl Citrate) Revised  Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications  Updated medication/drug name to include “Brand Only” Afstyla (Antihemophilic Factor Updated  Updated prior authorization/medical necessity guidelines; refer to [Recombinant] Single Chain) Prior Authorization/Medical Necessity Guidelines: Afstyla for complete details Atorvastatin (Generic Lipitor) 10mg, Updated  Updated prior authorization/notification guidelines; refer to Prior 20mg Authorization/Notification Guidelines: Cardiovascular Disease Prevention Zero Cost Share for complete details Belsomra (Suvorexant) Updated  Updated step therapy guidelines; refer to Step Therapy Guidelines: Belsomra for complete details Benznidazole New  Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)  Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Benznidazole for complete details Bupropion (SR) (Generic Zyban) Revised  Updated medication/drug name to include “SR”  Added supply limit guidelines; refer to Supply Limit Guidelines: HCR Tobacco Cessation - Supply Limits Override - NJ Fully Insured for complete details Carospir Suspension (Spironolactone) Revised  Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Carospir for complete details  Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Chantix (Varenicline Tartrate) Revised  Added supply limit guidelines; refer to Supply Limit Guidelines: HCR Tobacco Cessation - Supply Limits Override - NJ Fully Insured for complete details Cimduo (Lamivudine/Tenofovir DF) New  Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)  Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Cimzia (Certolizumab Pegol) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Cimzia (Certolizumab Pegol) for complete details Cosentyx (Secukinumab) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Cosentyx for complete details Daraprim (Pyrimethamine) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Daraprim for complete details Enbrel (Etanercept) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Enbrel (Etanercept) for

Drug Coverage Guidelines Page 162 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Date Action/Description complete details Ergomar (Ergotamine Tartrate) Updated  Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Migranal for complete details Farydak (Panobinostat) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Farydak for complete details Fentanyl Citrate (Generic Actiq) New  Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)  Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Actiq (Fentanyl Citrate) for complete details Grastek (Timothy Grass Pollen Allergen Updated  Updated prior authorization/medical necessity guidelines; refer to Extract) Prior Authorization/Medical Necessity Guidelines: Grastek (Timothy Grass Pollen Allergen Extract) for complete details Jakafi (Ruxolitinib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Jakafi for complete details Kineret (Anakinra) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Kineret (Anakinra) for complete details Korlym (Mifepristone) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Korlym for complete details Lidocaine Patch Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lidocaine Patch for complete details Lemtrada (Alemtuzumab) Updated  Updated list of applicable HCPCS codes; replaced J9010 with J0202 Linzess (Linaclotide) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Linzess (Linaclotide) for complete details Lynparza (Olaparib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Lynparza for complete details Lyrica CR (Pregabalin) Revised  Added step therapy guidelines; refer to Step Therapy Guidelines: Lyrica CR for complete details  Removed therapeutic equivalent guidelines and corresponding reference link to policy titled Drug Coverage Criteria - New and Therapeutic Equivalent Medications Mekinist (Trametinib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Mekinist (Trametinib) for complete details Migranal (Dihydro-Ergotamine) Updated  Updated prior authorization/medical necessity guidelines; refer to (Brand) Prior Authorization/Medical Necessity Guidelines: Migranal for complete details Migranal (Dihydro-Ergotamine) Updated  Updated prior authorization/medical necessity guidelines; refer to (Generic) Prior Authorization/Medical Necessity Guidelines: Migranal for complete details Movantik (Naloxegol) Updated  Updated prior authorization/notification guidelines; refer to Prior

Drug Coverage Guidelines Page 163 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC

Date Action/Description Authorization/Notification Guidelines: Movantik for complete details Nicotine OTC Products Revised  Added supply limit guidelines; refer to Supply Limit Guidelines: HCR Tobacco Cessation - Supply Limits Override - NJ Fully Insured for complete details Ninlaro (Ixazomib) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Ninlaro for complete details Odactra (House Dust Mite Allergen Updated  Updated prior authorization/medical necessity guidelines; refer to Extract) Prior Authorization/Medical Necessity Guidelines: Odactra for complete details Oralair (Sweet Vernal, Orchard, Updated  Updated prior authorization/medical necessity guidelines; refer to Perennial Rye, Timothy and Kentucky Prior Authorization/Medical Necessity Guidelines: Oralair (Sweet Blue Grass, Mixed Pollens Allergen Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass, Extract) Mixed Pollens Allergen Extract) for complete details Prolia, Xgeva (Denosumab) Revised  Revised coverage guidelines to indicate precertification is required through: o Oxford’s Medical Management for all requests for non-oncology indications o eviCore healthcare for all requests for oncology indications  Added eviCore guidelines; refer to eviCore Guidelines: Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice Guidelines for complete details Radicava (Edaravone) Revised  Added notation to indicate administration of Radicava in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires precertification with review by a Medical Director or their designee; refer to Specialty Medication Administration – Site of Care Review Guidelines Ragwitek (Short Ragweed Pollen Updated  Updated prior authorization/medical necessity guidelines; refer to Allergen Extract) Prior Authorization/Medical Necessity Guidelines: Ragwitek (Short Ragweed Pollen Allergen Extract) for complete details Rexulti (Brexpiprazole) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Rexulti for complete details Rhopressa (Netarsudil) New  Added language to indicate precertification is required through the Pharmacy Benefit Manager (PBM)  Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Rozerem (Ramelteon) Updated  Updated step therapy guidelines; refer to Step Therapy Guidelines: Rozerem (Ramelteon) for complete details Simponi (Golimumab) Updated  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Simponi (Golimumab) for complete details Simponi Aria (Golimumab) Updated  Updated list of related policies: o Modified reference link Precertification Guidelines: Simponi Aria® (Golimumab) Injection for Intravenous Infusion to reflect title

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Date Action/Description change  Added reference link to Precertification Guidelines: Specialty Medication Administration – Site of Care Review Guidelines (previously listed under Notes section only) Simvastatin (Generic Zocor) 5mg, Updated  Updated prior authorization/notification guidelines; refer to Prior 10mg, 20mg, 40mg Authorization/Notification Guidelines: Cardiovascular Disease Prevention Zero Cost Share for complete details Sutent (Sunitinib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Sutent for complete details Symfi (Efavirenz/ New  Added language to indicate precertification is required through the Lamivudine/Tenofovir Disoproxil Pharmacy Benefit Manager (PBM) Fumarate)  Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Smyfi Lo (Efavirenz/Lamivudine/ New  Added language to indicate precertification is required through the Tenofovir Disoproxil Fumarate) Pharmacy Benefit Manager (PBM)  Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Symproic (Naldemedine) New  Added prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Symproic for complete details Tafinlar (Dabrafenib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tafinlar for complete details Tamiflu Capsules (Brand Only) Revised  Added language to indicate precertification is required through the (Oseltamivir Phosphate) Pharmacy Benefit Manager (PBM)  Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Test Strips and Meters (Diabetic) Revised  Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Test Strips for complete details  Added notation to indicate Contour Next test strips do not require precertification Trulance (Plecanatide) Revised  Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Trulance for complete details Viberzi (Eluxadoline) Updated  Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Viberzi for complete details Vyzulta (Latanoprostene Bunod) Revised  Added step therapy guidelines; refer to Step Therapy Guidelines: Vyzulta for complete details Zelboraf (Vemurafenib) Revised  Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Zelboraf for complete details Zolpimist (Zolpidem Tartrate) Updated  Updated step therapy guidelines; refer to Step Therapy Guidelines: Zolpimist (Zolpidem Tartrate) for complete details Zypitamag (Pitavastatin) New  Added language to indicate precertification is required through the

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Date Action/Description Pharmacy Benefit Manager (PBM)  Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details  Archived previous policy version PHARMACY 098.174 T0

Drug Coverage Guidelines Page 166 of 166 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 ©1996-2018, Oxford Health Plans, LLC