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Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION acalabrutinib (CALQUENCE) PAR-427 acalabrutinib (CALQUENCE) ACTERMA PAR-287 ACTEMRA (tocilizumab) ADEMPAS® (riociguat) PAR-409 ADEMPAS® (riociguat) ADRENACLICK/SYMJEPI PAR-384 ADRENACLICK ADRENACLICK/SYMJEPI PAR-384 SYMJEPI ADUHELM (adacanumab) PAR-588 ADUHELM (adacanumab) AFINITOR (everolimus) PAR-361 AFINITOR (everolimus) AIMOVIG PAR-445 AIMOVIG Aldesleukin (PROLEUKIN) PAR-209_A aldesleukin (PROLEUKIN) ALECENSA (alectinib) PAR-360 ALECENSA (alectinib) ALINIA (nitazoxanide) PAR-429 ALINIA (nitazoxanide) Anticholinergic Beta Agonist Combo Inhalers PAR-458 BEVESPI AEROSPHERE Anticholinergic Beta Agonist Combo Inhalers PAR-458 DUAKLIR PRESSAIR Anticholinergic Beta Agonist Combo Inhalers PAR-458 UTIBRON NEOHALER ANTICHOLINERGIC INHALERS PAR-459 SEEBRI NEOHALER ANTICHOLINERGIC INHALERS PAR-459 TUDORZA PRESSAIR ANTICOAGULANTS PAR-389 BEVYXXA ANTICOAGULANTS PAR-389 PRADAXA ANTICOAGULANTS PAR-389 SAVAYSA ANTIMALARIAL AGENTS PAR-262_A ARAKODA (tafenoquine) ANTIMALARIAL AGENTS PAR-262_A ARALEN (chloroquine) ANTIMALARIAL AGENTS PAR-262_A atovaquone/ proguanil ANTIMALARIAL AGENTS PAR-262_A chloroquine ANTIMALARIAL AGENTS PAR-262_A COARTEM (artemether/lumefantrine) ANTIMALARIAL AGENTS PAR-262_A DARAPRIM (pyrimethamine) ANTIMALARIAL AGENTS PAR-262_A KRINTAFEL (tafenoquine) ANTIMALARIAL AGENTS PAR-262_A MALARONE (atovaquone/proguanil) ANTIMALARIAL AGENTS PAR-262_A mefloquine ANTIMALARIAL AGENTS PAR-262_A primaquine ARCALYST,iLARIS PAR-278_A ARCALYST (rilonacept) ARCALYST,iLARIS PAR-278_A iLARIS (canakinumab) AUVI-Q 0.1MG, 0.15MG, 0.3MG PAR-495 AUVI-Q AYVAKIT (avapritinib) PAR-505 AYVAKIT (avapritinib) BALVERSA (erdafitinib) PAR-484 BALVERSA (erdafitinib) BASAL INSULINS (Commercial) PAR-385 LANTUS

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION BASAL INSULINS (Commercial) PAR-385 TOUJEO benralizumab (FASENRA) PAR-426 benralizumab (FASENRA) BOSULIF (bosutinib) PAR-362 BOSULIF (bosutinib) BOTOX, DYSPORT, xeomin PAR-273_D BOTOX (botulinum toxin type a) BOTOX, DYSPORT, xeomin PAR-273_D DYSPORT (abobotulinumtoxina) BOTOX, DYSPORT, xeomin PAR-273_D XEOMIN (incobotulinumtoxin a) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 COTELLIC (cobietinib) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 MEKINIST (trametinib) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 TAFINLAR (dabrafenib) BRAF MUTATIONS IN MALGINANT MELANOMA PAR-299 ZELBORAF (vemurafenib) BRAFTOVI PAR-452 BRAFTOVI brigatinib (ALUNBRIG) PAR-397 ALUNBRIG (brigatinib) BRUKINSA (zanubrutinib) PAR-503 BRUKINSA (zanubrutinib) BYETTA/BYDUREON PAR-392 BYDUREON BYETTA/BYDUREON PAR-392 BYETTA BYLVAY (odevixibat) PAR-591 BYLVAY (odevixibat) C1 Inhibitor (CINRYZE) PAR-282_A CINRYZE (esterase inhibitor) C1 INHIBITOR (human) (HAEGARDA) PAR-412 HAEGARDA CABLIVI (caplacizumab) PAR-478 CABLIVI (caplacizumab) CABOMETYX (cabozantinib) PAR-380 CABOMETYX (cabozantinib) CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAGONISTS PAR-463 AJOVY CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAGONISTS PAR-463 EMGALITY CIALIS PAR-301 CIALIS (tadalafil) CIMZIA PAR-277 CIMZIA (certolizumab pegol) CINQAIR (reslizumab) PAR-358 CINQAIR (reslizumab) Compounded Products PAR-334 Compounds Non-preferred Continuous Glucose Monitor (CGM) and associated CONTINUOUS GLUCOSE MONITOR (CGM)- MNPA PAR-477 supplies (Guardian, Enlite, Real-Time, Minimed, Eversense) CONTRACEPTIVES MEDICAL EXCEPTION PAR-272 Contraceptives (oral,transdermal and vaginal) and LUNELLE COPAXONE PAR-441 COPAXONE COPIKTRA (duvelisib) PAR-466 COPIKTRA (duvelisib) CORTICOSTEROID INHALERS (Commercial only) PAR-387 AEROSPAN CORTICOSTEROID INHALERS (Commercial only) PAR-387 ALVESCO CORTICOSTEROID INHALERS (Commercial only) PAR-387 PULMICORT COSENTYX PAR-338 COSENTYX (secukinumab)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION CRYSVITA PAR-437 CRYSVITA DAKLINZA PAR-348 DAKLINZA (daclatasvir) DAURISMO (glasdegib) PAR-473 DAURISMO (glasdegib) DESOXYN PAR-381 DESOXYN (methamphetamine) DESOXYN PAR-381 methamphetamine deutetrabenazine (Austedo) PAR-395 AUSTEDO (deutetrabenazine) DIABETIC TEST STRIPS (Commercial only) PAR-386 DIABETIC TEST STRIPS (other than ONE TOUCH) diclofenac 3% gel PAR-399 diclofenac 3% gel DIFICID PAR-297 DIFICID( fidaxomicin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 alogliptin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 JUVISYNC (sitagliptin/simvastatin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 KAZANO (alogliptin-metformin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 KOMBIGLYZE (saxagliptin-metformin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 NESINA (alogliptin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 ONGLYZA (saxagliptin) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 OSENI (alogliptin-pioglitazone) DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS PAR-316 saxagliptin DOPTELET (avatrombopag) PAR-481 DOPTELET (avatrombopag) doxepin Topical PAR-433 doxepin topical doxepin Topical PAR-433 prudoxin doxepin Topical PAR-433 zonalon DUPIXENT (dupilumab) PAR-416 DUPIXENT (dupilumab) EGFR MUTATIONS PAR-319 GILOTRIF (afatinib dimaleate) EGFR MUTATIONS PAR-319 TAGRISSO (osimertinib) EGRIFTA PAR-293 EGRIFTA (tesamorelin acetate [rDNA origin]) ELZONRIS (tagraxofusp-erza) PAR-479 ELZONRIS (tagraxofusp-erza) EMFLAZA (deflazacort tablets and oral susp) PAR-394 EMFLAZA (deflazacort tablets and oral susp) EMPAVELI (pegcetacoplan) PAR-590 EMPAVELI (pegcetacoplan) Endari (glutamine) PAR-424 Endari (glutamine) ENSPRYNG (satralizumab-mwge) PAR-540 ENSPRYNG (satralizumab-mwge) ENTYVIO PAR-442 ENTYVIO EPCLUSA PAR-379 EPCLUSA (sofosbuvir-velpatasvir) EPIDIOLEX (cannabidiol) PAR-465 EPIDIOLEX (cannabidiol) (EPOGEN, PROCRIT) (ARANESP) PAR-231_E ARANESP (darbepoetin alfa) Epoetin alfa (EPOGEN, PROCRIT) Darbepoetin alfa (ARANESP) PAR-231_E EPOGEN (epoetin alfa)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION Epoetin alfa (EPOGEN, PROCRIT) Darbepoetin alfa (ARANESP) PAR-231_E PROCRIT (epoetin alfa) ERLEADA (apalutamide) PAR-430 ERLEADA (apalutamide) (ENBREL) PAR-250 ENBREL (etanercept) EVEKEO (amphetamine sulfate) PAR-340 EVEKEO (amphetamine sulfate) EVRYSDI (risdiplam) PAR-543 EVRYSDI (risdiplam) EVZIO (naloxone) PAR-383 EVZIO (naloxone) EXCLUDED/NON-FORMULARY DRUGS PAR-337 EXCLUDED/NON-FORMULARY DRUGS EXONDYS 51 PAR-391 EXTONDY 51 (antisense oligonucleotide) FAMILIAL HYPERCHOLESTEROLEMIA PAR-314 JUXTAPID (lomitapide) FAMILIAL HYPERCHOLESTEROLEMIA PAR-314 KYNAMRO (mipomersen) FINTEPLA (fenfluramine) PAR-539 FINTEPLA (fenfluramine) FIRAZYR (icatibant) PAR-434 FIRAZYR (icatibant) FIRDAPSE (amifampridine) PAR-476 FIRDAPSE (amifampridine) FLECTOR (diclofenac) PATCH PAR-354 FLECTOR PATCH (diclofenac) GALAFOLD PAR-454 GALAFOLD (migalastat) GATTEX (teduglutide) PAR-432 GATTEX (teduglutide) GLEEVEC (imatinib) PAR-363 GLEEVEC (imatinib) GLEEVEC (imatinib) PAR-363 imatinib GROWTH HORMONES PAR-233_H GENOTROPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H HUMATROPE (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NORDITROPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NORDITROPIN NORDIFLEX and FLEXPRO(somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NUTROPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NUTROPIN AQ (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H NUTROPIN AQ NUSPIN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H OMNITROPE (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H SAIZEN (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H SEROSTIM (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H ZOMACTON (somatropin [rDNA origin]) GROWTH HORMONES PAR-233_H ZORBTIVE (somatropin [rDNA origin]) H.P. ACTHAR GEL (corticotrophin) PAR-310 ACTHAR HP (corticotrophin) H2 Blocker Medical Exception PAR-497 rantidine 15mg/ml solution HARVONI (ledipasvir-sofosbuvir) PAR-335 HARVONI (ledipasvir-sofosbuvir) HEMATOPOIETIC GROWTH FACTOR(PROMACTA,NPLATE) PAR-283_A NPLATE () HEMATOPOIETIC GROWTH FACTOR(PROMACTA,NPLATE) PAR-283_A PROMACTA ( olamine)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION HUMIRA PAR-275 HUMIRA (adalimumab) ICLUSIG (ponatinib) PAR-364 ICLUSIG (ponatinib) IDHIFA® (enasidenib) PAR-419 IDHIFA® (enasidenib) IDIOPATHIC PULMONARY FIBROSIS PAR-336 ESBRIET (pirfenidone) IDIOPATHIC PULMONARY FIBROSIS PAR-336 OFEV (nintedanib) ILUMYA PAR-456 ILUMYA (tildrakizumab-asmn)

IMITREX (sumatriptan)SPRAY PAR-307 IMITREX 5 mg NASAL SPRAY (sumatriptan)

IMITREX (sumatriptan)SPRAY PAR-307 sumatriptan 5 mg nasal spray IMPAVIDO (miltefosine) PAR-571 IMPAVIDO (miltefosine) INFLAMATORY BOWEL DISEASE PAR-388 ASACOL HD INFLAMATORY BOWEL DISEASE PAR-388 DELZICOL INFLAMATORY BOWEL DISEASE PAR-388 GIAZO (balsalazide disodium) INSULIN PAR-317 ADMELOG INSULIN PAR-317 HUMULIN except Humulin R U-500 (insulin isophene & regular) INSULIN PAR-317 insulin lispro INSULIN PAR-317 AFREZZA INSULIN PAR-317 APIDRA (insulin glulisine) INSULIN PAR-317 HUMALOG (insulin lispro) INTERMEZZO PAR-312 INTERMEZZO (zolpidem tartrate) INTRAROSA/OSPHENA PAR-439 INTRAROSA (prasterone) INTRAROSA/OSPHENA PAR-439 OSPHENA (ospemifene) IRESSA (gefitinib) PAR-366 IRESSA (gefitinib) ISTURISA (osilodrostat) PAR-509 ISTURISA (osilodrostat) Itraconazole (SPORANOX Capsules and Solution, ONMEL, tolsura) PAR-216_F itraconazole (caps and solution), SPORANOX, tolsura Itraconazole (SPORANOX Capsules and Solution, ONMEL, tolsura) PAR-216_F ONMEL (itraconazole) Itraconazole (SPORANOX Capsules and Solution, ONMEL, tolsura) PAR-216_F SPORANOX (itraconazole) Itraconazole (SPORANOX Capsules and Solution, ONMEL, tolsura) PAR-216_F TOLSURA (itraconazole) JYNARQUE (tolvaptan) PAR-488 JYNARQUE (tolvaptan) KALYDECO, ORKAMBI PAR-302 KALYDECO (ivacaftor)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION KALYDECO, ORKAMBI PAR-302 ORKAMBI (lumacaftor/invacaftor) KINERET PAR-276 KINERET (anakinra) KORLYM PAR-311 KORLYM (mifepristone) KOSELUGO (selumetinib) PAR-508 KOSELUGO (selumetinib) KUVAN and generic sapropterin PAR-279_A KUVAN (sapropterin dihydrochloride) KUVAN and generic sapropterin PAR-279_A sapropterin leuprolide (LUPRON) PAR-236_B leuprolide LONSURF (trifluridine and tipiracil) PAR-367 LONSURF (trifluridine and tipiracil) LORBRENA (lorlatinib) PAR-471 LORBRENA (lorlatinib) LUCEMYRA PAR-446 LUCEMYRA LUMOXITI (moxetumomab pasudotox-tdfj) PAR-468 LUMOXITI (moxetumomab pasudotox-tdfj) LUPKYNIS (voclosporin) PAR-551 LUPKYNIS (voclosporin) LYNPARZA (olaparid) PAR-368 LYNPARZA (olaparib) LYRICA CR PAR-440 LYRICA CR (pregabalin CR) MAVENCLAD (cladribine) PAR-485 MAVENCLAD (cladribine) MAVYRET® (glecaprevir/pibrentasvir) PAR-420 MAVYRET® (glecaprevir/pibrentasvir) MEKTOVI PAR-451 MEKTOVI MEPOLIZUMAB RECOMBINANT (NUCALA®) PAR-353 NUCALA (mepolizumab) MEPSEVII (vestronidase alfa) PAR-428 MEPSEVII (vestronidase alfa) (RYDAPT) PAR-398 RYDAPT (midostaurin) MIRCERA PAR-449 MIRCERA MULPLETA (lusutrombopag) PAR-482 MULPLETA (lusutrombopag) MULTIPLE SCLEROSIS AGENTS PAR-351 EXTAVIA ( beta-1b) MULTIPLE SCLEROSIS AGENTS PAR-351 PLEGRIDY (peginterferon beta-1a) MYALEPT PAR-331 MYALEPT (metreleptin) MYCAPSSA (octreotide delayed-release capsules) PAR-545 MYCAPSSA (octreotide delayed-release capsules) NASAL CORTICOSTEROIDS PAR-350 BECONASE AQ NASAL CORTICOSTEROIDS PAR-350 DYMISTA (azelastine hydrochloride/fluticasone propionate) NASAL CORTICOSTEROIDS PAR-350 NASONEX NASAL CORTICOSTEROIDS PAR-350 OMNARIS NASAL CORTICOSTEROIDS PAR-350 QNASL NASAL CORTICOSTEROIDS PAR-350 VERAMYST NASAL CORTICOSTEROIDS PAR-350 ZETONNA NATPARA PAR-345 NATPARA (parathyroid hormone) NERLYNX® (neratinib) PAR-415 NERLYNX® (neratinib)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION NEXAVAR ( tosylate) PAR-369 NEXAVAR (sorafenib tosylate) niraparib (ZEJULA) PAR-396 ZEJULA (niraparib) NUBEQA (darolutamide) PAR-494 NUBEQA (darolutamide) NUEDEXTA PAR-436 NUEDEXTA NUPLAZID PAR-435 NUPLAZID OCALIVA (obeticholic acid) PAR-378 OCALIVA (obeticholic acid) OCREVUS (ocrelizumab) PAR-417 OCREVUS (ocrelizumab) OLUMIANT PAR-448 OLUMIANT Ombitasvir/Paritaprevir/Ritonavir (TECHNIVIE) PAR-349 Ombitasvir/Paritaprevir/Ritonavir (Technivie) OMNIPODS PAR-489 OMNIPODS ONPATTRO PAR-455 ONPATTRO (patisiran) OPSUMIT® (macitentan) PAR-411 OPSUMIT® (macitentan) ORENCIA SYRINGE & VIAL PAR-300 ORENCIA SYRINGE AND VIAL (abatacept) ORLADEYO (berotralstat) PAR-547 ORLADEYO (berotralstat) OTEZLA (apremilast) PAR-333 OTEZLA (apremilast) PALYNZIQ PAR-447 PALYNZIQ PCSK9 INHIBITORS (REPATHA (evolocumab), REPATHA PUSHTRONEX (evolocumab), PRALUENT (alirocumab) PAR-344 PRALUENT (alirocumab) PCSK9 INHIBITORS (REPATHA (evolocumab), REPATHA PUSHTRONEX (evolocumab), PRALUENT (alirocumab) PAR-344 REPATHA (evolocumab) PCSK9 INHIBITORS (REPATHA (evolocumab), REPATHA PUSHTRONEX (evolocumab), PRALUENT (alirocumab) PAR-344 REPATHA PUSHTRONIX (evolocumab) PEDICULOSIS CAPITIS (NATROBA (spinosad), SKLICE (ivermectin)) PAR-296 NATROBA (spinosad) PEDICULOSIS CAPITIS (NATROBA (spinosad), SKLICE (ivermectin)) PAR-296 SKLICE (ivermectin) PEDICULOSIS CAPITIS (NATROBA (spinosad), SKLICE (ivermectin)) PAR-296 spinosad PEMAZYRE (pemigatinib) PAR-510 PEMAZYRE (pemigatinib) PENNSAID 2% (diclofenac topical solution 2%) PAR-382 PENNSAID 2% (diclofenac topical solution 2%) PIQRAY (alpelisib) PAR-492 PIQRAY (alpelisib) POLIVY (polatuzumab vedotin-piiq) PAR-493 POLIVY (polatuzumab vedotin-piiq) POTELIGEO PAR-461 POTELIGEO (mogamulizumab-kpkc) PRESCRIBER SPECIALTY - AMPYRA (dalfampridine) PAR-305 AMPYRA (dalfampridine) PRESCRIBER SPECIALTY - ENTOCORT EC(budesonide ec) PAR-306 budesonide ec PRESCRIBER SPECIALTY - ENTOCORT EC(budesonide ec) PAR-306 ENTOCORT EC (budesonide ec) PRESCRIBER SPECIALTY - MULTAQ (dronedarone) PAR-304 MULTAQ (dronedarone) PRESCRIPTION PPI's PAR-268_D ACIPHEX and ACIPHEX SPRINKLE (rabeprazole)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION PRESCRIPTION PPI's PAR-268_D DEXILANT (dexlansoprazole) PRESCRIPTION PPI's PAR-268_D FIRST lansoprazole PRESCRIPTION PPI's PAR-268_D FIRST omeprazole PRESCRIPTION PPI's PAR-268_D NEXIUM and (esomeprazole) PRESCRIPTION PPI's PAR-268_D omeprazole + syrspend PRESCRIPTION PPI's PAR-268_D PREVACID SOLUTAB PRESCRIPTION PPI's PAR-268_D PRILOSEC SUSPENSION PRESCRIPTION PPI's PAR-268_D PROTONIX and PROTONIX SUSPENSION PRESCRIPTION PPI's PAR-268_D rabeprazole PROGESTERONE GEL (CRIONONE, PROCHIEVE), PROGESTERONE SUPPOSITORY (ENDOMETRIN), Projesterone Inj. PAR-247_C CRINONE (progesterone gel) PROGESTERONE GEL (CRIONONE, PROCHIEVE), PROGESTERONE SUPPOSITORY (ENDOMETRIN), Projesterone Inj. PAR-247_C ENDOMETRIN (progesterone) PROGESTERONE GEL (CRIONONE, PROCHIEVE), PROGESTERONE SUPPOSITORY (ENDOMETRIN), Projesterone Inj. PAR-247_C progesterone injection Proton Pump Inhibitors Medical Exception PAR-496 omeprazole 20mg Proton Pump Inhibitors Medical Exception PAR-496 pantoprazole 20mg and 40mg PROVIGIL (modafinil) NUVIGIL (armodafinil) PAR-321 armodafinil PROVIGIL (modafinil) NUVIGIL (armodafinil) PAR-321 modafinil PROVIGIL (modafinil) NUVIGIL (armodafinil) PAR-321 NUVIGIL (aromodafinil) PROVIGIL (modafinil) NUVIGIL (armodafinil) PAR-321 PROVIGIL (modafinil) QINLOCK (ripretinib) PAR-533 QINLOCK (ripretinib) RETEVMO (selpercatinib) PAR-532 RETEVMO (selpercatinib) REVATIO (sildenafil), ADCIRA (tadalafil) PAR-274_A ADCIRCA (tadalafil) REVATIO (sildenafil), ADCIRA (tadalafil) PAR-274_A ALYQ REVATIO (sildenafil), ADCIRA (tadalafil) PAR-274_A REVATIO (sildenafil citrate) REVATIO (sildenafil), ADCIRA (tadalafil) PAR-274_A sildenafil REVATIO (sildenafil), ADCIRA (tadalafil) PAR-274_A tadalafil REVCOVI (elapegademase-lvlr) PAR-472 REVCOVI (elapegademase-lvlr) RHOPRESSA PAR-450 RHOPRESSA Riluzole (RILUTEK) PAR-221_A RILUTEK Riluzole (RILUTEK) PAR-221_A riluzole RINVOQ (upadacitnib) PAR-499 RINVOQ (upadacitnib) ROZLYTREK (entrectinib) PAR-500 ROZLYTREK (entrectinib) RUBRACA (rucaparib) PAR-393 RUBRACA (rucaparib)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION RUZURGI (amifampridine) PAR-490 RUZURGI (amifampridine) SAMSCA PAR-285 SAMSCA (tolvaptan) SARCLISA (isatuximan-irfc) PAR-506 SARCLISA (isatuximan-irfc) sarilumab (KEVZARA) PAR-402 KEVZARA (sarilumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ACTEMRA (tocilizumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ACTIMMUNE (-1b) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ARANESP (darbepoetin alfa) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ARCALYST (rilonacept) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 BENLYSTA SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 CIMZIA (certolizumab pegol) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 COSENTYX (secukinumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 CUTAQUIG SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 CUVITRU SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 DUPIXENT (dupilumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 EGRIFTA (tesamorelin acetate [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ENBREL (etanercept) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 EPOGEN (epoetin alfa) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 EVENITY (romosozumab-aqqg) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 FASENRA SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 FORTEO (teriparatide [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 GATTEX (teduglutide) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 GENOTROPIN (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 GENOTROPIN MINIQUICK (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 GRANIX SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 HAEGARDA SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 HEMLIBRA SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 HIZENTRA (immune globulin) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 HUMATROPE (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 HUMIRA (adalimumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 HYQVIA (immune globulin) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ILARIS (canakinumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ILUMYA (tildrakizumab-asmn) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 INCRELEX (mecasermin [Rdna origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 INFERGEN (interferon alfacon-1) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 INTRON A (-2b)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 KINERET (anakinra) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 LEUKINE () SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 MIRCERA (methoxy polyethylene glycol/epoetin beta) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 MYALEPT (metreleptin) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NATPARA (parathyroid hormone) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NEULASTA () SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NEUMEGA (oprelvekin) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NEUPOGEN () SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NIVESTYM SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NORDITROPIN (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NORDITROPIN NORDIFLEX (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NUCALA (mepolizumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NUTROPIN (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NUTROPIN AQ (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NUTROPIN AQ NUSPIN (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 NYVEPRIA (pegfilgrastim-apgf) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 OMNITROPE (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ORENCIA SYRINGE (abatacept) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 OTREXUP (methotrexate) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 PEGASYS (peginterferon alfa-2a) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 PEG-INTRON (peginterferon alfa-2b) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 PEG-INTRON (peginterferon alfa-2b) REDIPEN SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 PRALUENT (alirocumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 PROCRIT (epoetin alfa) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 RASUVO (methotrexate) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 REDITREX (methotrexate)

SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 REPATHA (evolocumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 REPATHA PUSHTRONIX (evolocumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 RETACRIT SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SAIZEN (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SEROSTIM (somatropin [rDNA origin]) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SIGNIFOR (pasireotide) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SILIQ SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SIMPONI (golimumab)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SKYRIZI (risankizumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 STELARA (ustekinumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 STRENSIQ SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 SYLATRON (peginterferon alfa-2b) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 TAKHZYRO SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 TALTZ (ixekizumab) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 TEGSEDI SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 teriparatide SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 TREMFYA SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 TYMLOS SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 UDENYCA SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 XEMBIFY (immune globulin subcutaneous human-klhw) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ZARXIO (filgrastim-sndz) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ZOMACTON (somatropin) SELF ADMINISTERED DRUGS - PLACE OF SERVICE PAR-291 ZORBTIVE (somatropin [rDNA origin]) SGLT 2 INHIBITORS PAR-390 INVOKAMET SGLT 2 INHIBITORS PAR-390 INVOKAMET XR SGLT 2 INHIBITORS PAR-390 INVOKANA SGLT 2 INHIBITORS PAR-390 SEGLUROMET SGLT 2 INHIBITORS PAR-390 STEGLATRO SHORT ACTING BETA AGONISTS PAR-318 MAXAIR (albuterol) SHORT ACTING BETA AGONISTS PAR-318 PROVENTIL (albuterol) SHORT ACTING BETA AGONISTS PAR-318 VENTOLIN (albuterol) SHORT ACTING BETA AGONISTS PAR-318 XOPENEX HFA SILIQ® (brodalumab) PAR-408 SILIQ® (brodalumab) SIMPONI (golimumab) PAR-284 SIMPONI (golimumab) SIMPONI ARIA PAR-443 SIMPONI ARIA (golimumab) SKYRIZI (risankizumab) PAR-483 SKYRIZI (risankizumab) Sodium oxybate (Xyrem) PAR-400 Sodium Oxybate Sodium oxybate (Xyrem) PAR-400 XYREM SOVALDI (sofosbuvir) PAR-330 SOVALDI (sofosbuvir) SPRYCEL (dasatinib) PAR-371 SPRYCEL (dasatinib) STELARA PAR-286 STELARA (ustekinumab) STIVARGA (regorafenib) PAR-372 STIVARGA (regorafenib) SUNOSI® (solriamfetol) PAR-486 SUNOSI® (solriamfetol)

Updated: 9/2021 Commercial PAR List 2021

Policy TITLE Number DRUGS REQUIRING PRIOR AUTHORIZATION SYMBICORT PAR-357 SYMBICORT SYMDEKO (tezacaftor/ivacaftor, ivacaftor) PAR-431 SYMDEKO (tezacaftor/ivacaftor, ivacaftor) SYMPROIC PAR-460 SYMPROIC (naldemedine) TABRECTA (capmatinib) PAR-531 TABRECTA (capmatinib) tafamidis PAR-491 VYNDAMAX (tafamidis) tafamidis PAR-491 VYNDAQEL (tafamidis meglumine) TAKHZYRO PAR-457 TAKHZYRO (lanadelumab) TALTZ (ixekizumab) PAR-356 TALTZ (ixekizumab) TALZENNA (talazoparib) PAR-469 TALZENNA (talazoparib) TARCEVA (erlotinib) PAR-373 erlotinib TARCEVA (erlotinib) PAR-373 TARCEVA (erlotinib) TASIGNA (nilotinib) PAR-374 TASIGNA (nilotinib) tasimelteon (HETLIOZ) PAR-401 HETLIOZ tasimelteon (HETLIOZ) PAR-401 tasimelteon TAVALISSE PAR-444 TAVALISSE tazarotene (TAZORAC, FABIOR) PAR-246_A FABIOR (tazarotene)

Updated: 9/2021