Blue Cross and BCN Utilization Management Medical Drug List

Home , Bezlotoxumab, Casimersen, Evinacumab, Iron sucrose, Luspatercept, Nusinersen

Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 The Blue Cross and BCN Requirements for Drugs Covered under the Medical Benefit document outlines the various programs select drugs participate in under your medical coverage. The medical benefit contains drugs that require administration by a healthcare professional. Drugs on this list need to be approved by BCBSM/BCN before you receive them. Various programs include but are not limited to the Prior Authorization Program and the Site of Care program. This list applies to all BCN commercial members with medical coverage, and Blue Cross commercial members that are subject to the PA program.

• Prior Authorization Program: This program ensures the medication is medically necessary and appropriate for your situation. For drugs covered under the commercial Blue Cross or BCN pharmacy benefit please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines. • Site of Care Program: This program redirects members’ receiving select injectable or infusible drugs in the outpatient hospital setting to a lower cost, alternate site of care, such as the physician’s office or member’s home. • Oncology Management Program: Medical oncology and supportive care drugs require authorization. Requests can be submitted by calling 1-844-377-1278 or logging into AIM Provider Portal . Blue Cross commercial fully insured and BCN commercial Medical Oncology Prior Authorization list Note: This program does not apply to Blue Cross commercial fully insured members covered through the Federal Employee Program® and the Michigan Education Special Services Association . UAW Retiree Medical Benefits Trust PPO Medical Oncology Prior Authorization list

How to read the Blue Cross and BCN Requirements for Drugs Covered under the Medical Benefit: Authorization Summary: criteria listed is not all-inclusive. Please refer to the medical router for the complete medical drug policy and all criteria that may apply. Cell’s that are blank are not applicable. Documentation Required: providers must submit chart notes when submitting an authorization request. If field only says HMO or PPO chart notes are only required for members with that plan.

Medical benefit drug policies are a source for BCBSM and BCN medical policy information only. These documents are not to be used to determine benefits or reimbursement. Please reference the appropriate certificate or contract for benefit information. This policy may be updated and therefore subject to change.

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO . FDA approved age Affected providers: In network . Prescribed by an oncologist . Have not received prior treatment with any CAR-T therapy (such as Kymriah or Yescarta) despite HCPCS Limit: N/A indication or any other genetically-modified T-cell therapy or are being considered for treatment with any other genetically-modified T-cell therapy NDC NDC Limit . Treatment of patients with relapsed or refractory multiple myeloma 59572-0515-01 1 UN . Must have relapsed or refractory disease after at least 3 prior lines of multiple myeloma therapy 59572-0515-02 1 UN . Patients must have been treated with all of the following: 59572-0515-03 1 UN • An immunomodulatory agent • A proteasome inhibitor • An anti-CD38 antibody . Must have active disease defines by at least one of the following: • Serum M-protein greater or equal to 1.0 g/dL idecabtagene HMO HMO J3590 Abecma • Urine M-protein greater or equal to 200 mg/24 h vicleucel PPO PPO • Serum free light chain (FLC) assay greater or equal to 10 mg/dL provided the serum FLC ratio is abnormal . Patients must not have the following: • ECOG performance status of 2 or greater • Known central nervous system involvement with myeloma • No active infection including hepatitis B, hepatitis C, HIV, or systemic fungal, bacterial, or viral infection • History of class III or IV congestive heart failure (CHF) or severe non-ischemic cardiomyopathy, history of stroke, unstable angina, myocardial infarction, or ventricular arrhythmia within the previous 6 months • Second malignancies in addition to myeloma if the second malignancy has required therapy in the last 3 years or is not in complete remission

• Oncology Management Program

HMO HMO J9264 Abraxane paclitaxel PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indications Affected providers: In network Rheumatoid arthritis (RA) • FDA approved age • 8 mg/kg every 4 weeks • Diagnosis of rheumatoid arthritis (RA): HCPCS Limit: 800 units Polyarticular juvenile idiopathic arthritis (pJIA) o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include methotrexate, hydroxychloroquine, leflunomide, NDC NDC Limit • <30 kg: 10 mg/kg every 4 sulfasalazine 50242-0135-01 40 ML weeks • Diagnosis of polyarticular juvenile idiopathic arthritis (pJIA) 50242-0136-01 40 ML • > 30 kg: 8 mg/kg every 4 o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless 50242-0137-01 40 ML weeks contraindicated or not tolerated. Examples include methotrexate and leflunomide 50242-0138-01 0.9 ML Systemic juvenile idiopathic • Diagnosis of Still’s disease, including systemic juvenile idiopathic arthritis (sJIA) and adult onset Still’s 50242-0143-01 0.9 ML arthritis (sJIA) • disease (AOSD) 50242-0138-86 0.9 ML < 30 kg: 12 mg/kg every 2 Actemra, HMO HMO J3262 tocilizumab Trial and treatment failure with one of the following: methotrexate, leflunomide, glucocorticoids, or weeks Actemra Actpen o PPO PPO NSAIDs • > 30 kg: 8 mg/kg every 2 • Diagnosis of cytokine release syndrome (CRS) (intravenous formulation only) weeks o Prescribed by or in consultation with an oncologist o Severe or life threatening CRS associated with chimeric antigen receptor (CAR) T cell therapy • Diagnosis of giant cell arteritis (GCA) (subcutaneous formulation only) • Diagnosis of systemic sclerosis-associated interstitial lung disease (SSc-ILD) (subcutaneous formulation only) o Inadequate response to (as evidenced by disease progression - e.g. worsening of pulmonary function) or not a candidate for either mycophenolate mofetil OR cyclophosphamide • Not to be used in combination with other biologics or other targeted DMARDs

• Diagnosis of infantile spasms HMO J0800 Acthar Gel corticotropin • Patient is less than 2 years of age PPO • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 100 units

NDC NDC Limit J2997 Activase, Cathflo alteplase recombinant 50242-0041-63 50 UN 50242-0041-64 50 UN 50242-0044-13 2 UN 50242-0085-25 1 UN 50242-0085-27 1 UN

50242-0041-10 50 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of adenosine deaminase (ADA) deficiency in a patient with severe combined immunodeficiency Affected providers: In network Severe Combined disease (SCID) Immunodeficiency Disease • Diagnosis confirmed by evidence of combined immunodeficiency AND an absence of thymus and other HCPCS Limit: 120 units • 30 units/kg HMO HMO HMO lymphoid tissues J2504 Adagen pegademase bovine PPO PPO PPO • Evidence the patient has previously failed or is an unsuitable candidate for bone marrow transplantation NDC NDC Limit • No evidence of severe thrombocytopenia 57665-0001-01 12 ML

• Diagnosis made by or in consultation with an immune specialist • Any additional pertinent medical information • FDA approved indication Affected providers: In network • FDA approved age • Prescribed by or in consultation with a hematologist HCPCS Limit C9053: 800 units J0791/ Adakveo crizanlizumab-tmca HMO HMO HMO • Patient has experienced 2 or more sickle cell-related crises in the past 12 months HCPCS Limit J0791: 160 units C9053 PPO PPO PPO • Trial and failure for at least 6 months, contraindication, OR intolerance to hydroxyurea • Must not be using long-term red blood cell transfusion therapy NDC NDC Limit

00078-0883-61 80 ML • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 200 units J9042 Adcetris brentuximab vedotin PPO PPO NDC NDC Limit

51144-0050-01 4 UN • Coverage of Aduhelm is considered investigational/experimental for all indications and will not be J3490/ provided. Aduhelm aducanumab-avwa I/E J3590

• Prescribed by or in consultation with a geneticist or metabolic specialist Affected providers: In network Mucopolysaccharidosis I • FDA approved indications • 0.58 mg/kg once weekly HMO HMO HMO • FDA approved age HCPCS Limit: 1800 units J1931 Aldurazyme laronidase PPO PPO PPO • Confirmation of diagnosis by serum assay showing a decrease of α-L-iduronidase activity followed by genetic testing showing a mutation in the IDUA gene NDC NDC Limit 58468-0070-01 310 ML

HMO HMO • Oncology Management Program J9305 Alimta pemetrexed PPO PPO • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 60 units J9057 Aliqopa copanlisib PPO PPO NDC NDC Limit 50419-0385-01 1 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 3 units

NDC NDC Limit 25021-0221-60 3 UN 42023-0149-01 3 UN 43598-0392-48 3 UN 45963-0686-02 3 UN 63323-0760-20 3 UN J9245 Alkeran melphalan hydrochl 67457-0193-50 3 UN 67457-0195-01 3 UN 67457-0215-01 3 UN 67457-0577-50 3 UN 67457-0579-01 3 UN 70860-0214-61 3 UN 71288-0111-10 3 UN 71288-0112-90 3 UN 72266-0128-01 3 UN

• Coverage of Amondys 45 is considered investigational/experimental for all indications and will not be

J3490/ provided. Amondys 45 casimersen I/E1 C9075

• FDA approved age Affected providers: In network Alpha1-proteinase inhibitor • Must be a nonsmoker deficiency • Member must have pre-treatment serum levels of alpha-1 antitrypsin (AAT) that are less than 11 HCPCS Limit: 900 units • 60 mg/kg once weekly micromol/L measured by ELISA (less than 80 mg/dL measured by radial immunodiffusion or less than 57 mg/dL measured by nephelometry)consistent with phenotypes PiZZ, PiZ (null), or Pi (null, null) of AAT NDC NDC Limit alpha 1 proteinase HMO HMO J0256 Aralast 00944-2802-01 9000 UN inhibitor PPO PPO o Phenotype/genotype testing may be requested for additional support of alpha-1 antitrypsin deficiency diagnosis 00944-2802-02 9000 UN • Member must have symptomatic emphysema 00944-2812-01 9000 UN 00944-2814-01 9000 UN • Member must have deteriorating pulmonary function, as demonstrated by a decline in the FEV1 (35-60% of 00944-2815-01 9000 UN predictive value)

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 320 units

NDC NDC Limit J2793 Arcalyst rilonacept 61755-0001-01 2 UN 73604-0914-04 2 UN

73604-0914-01 2 UN

Affected providers: In network

HCPCS Limit: 1064

NDC NDC Limit 65757-0404-01 3.9 ML J1944 Aristada aripiprazole lauroxil 65757-0404-03 3.9 ML 65757-0401-01 1.6 ML 65757-0401-03 1.6 ML 65757-0402-01 2.4 ML 65757-0402-03 2.4 ML 65757-0403-01 3.2 ML

65757-0403-03 3.2 ML Affected providers: In network

HCPCS Limit: 1064 units J1943 Aristada Initio aripiprazole lauroxil NDC NDC Limit

65757-0500-03 2.4 ML • Oncology Management Program Affected providers: In network

HCPCS Limit: 200 units HMO HMO J9302 Arzerra ofatumumab PPO PPO NDC NDC Limit 00078-0669-13 100 ML 00078-0669-61 100 ML 00078-0690-61 100 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Calasparagase pegol- HMO HMO HCPCS Limit: 750 J9118 Asparlas mknl PPO PPO NDC NDC Limit

N/A N/A Affected providers: In network

HCPCS Limit: 25 units

J2270 Astramorph-PF morphine sulfate/pf NDC NDC Limit 63323-0291-10 500 ML 63323-0291-80 500 ML 63323-0292-10 250 ML 63323-0292-80 250 ML

Affected providers: In network

HCPCS Limit: 48 units lymphocyte immune J7504 Atgam globulin NDC NDC Limit 00009-7224-01 240 ML

00009-7224-02 240 ML • Non-preferred bevacizumab product Affected providers: In network • Pref erred bevacizumab product(s): MVASI & ZIRABEV J9035 HCPCS Limit: 450 units C9257 HCPCS Limit: 18,000 units J9035/ HMO HMO • Intravitreal Avastin does not require authorization for ocular conditions or trial of the Avastin bevacizumab Please note: C9257 PPO PPO preferred products NDC NDC Limit 50242-0060-01 180 ML 50242-0060-10 180 ML 50242-0061-01 180 ML

50242-0061-10 180 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In network Primary Hypogonadism • Diagnosis of male hypogonadism • 750 mg • Documentation of at least TWO signs/symptoms of testosterone deficiency HCPCS Limit: 750 units Hypogonadotropic hypogonadism • 750 mg • Aveed or Testopel: Requires trial and failure, contraindication or intolerance to either generic Depo- testosterone HMO J3145 Aveed testosterone or generic Delatestryl NDC NDC Limit undecanoate PPO 67979-0511-43 3 ML • Testosterone replacement products are not to be used in combination. • Exceptions to the coverage criteria will be made when necessary for female to male (FTM) transgender members.

Affected providers: In network

HCPCS Limit: 12 units J2280 Avelox IV Inj moxifloxacin 100 mg NDC NDC Limit 00085-1737-01 750 ML 50419-0537-01 750 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indications Affected providers: In network • FDA approved age • Diagnosis of Crohn’s disease HCPCS Limit: 200 units o Active Crohn’s disease: - Treatment with an adequate course of conventional therapy (such as steroids for 7 days, NDC NDC Limit immunomodulators such as azathioprine for at least 2 months) has been ineffective or is 55513-0670-01 20 UN

contraindicated or not tolerated o Fistulizing Crohn’s disease • Diagnosis of ulcerative colitis: o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated • Diagnosis of rheumatoid arthritis: o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include methotrexate, hydroxychloroquine, leflunomide, HMO HMO Q5121 Avsola infliximab-axxq sulfasalazine PPO PPO o Administered in combination with methotrexate • Diagnosis of psoriatic arthritis o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine. • Diagnosis of plaque psoriasis o Trial and failure, contraindication, or intolerance to light therapy o Trial and failure of at least 3 months of one generic oral systemic agent unless contraindicated or not tolerated. Examples include cyclosporine, methotrexate, acitretin • Diagnosis of ankylosing spondylitis • Not to be used in combination with other biologics or targeted DMARDs • Trial and failure of Inflectra • A credible explanation must be provided as to why the requested product is expected to work when the preferred product did not • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 12 units ceftazidime and J0714 Avycaz avibactam NDC NDC Limit 00456-2700-01 3 UN 00456-2700-10 3 UN

Affected providers: In network

HCPCS Limit: 1 unit Q0239 bamlanivimab bamlanivimab NDC NDC Limit

00002-7910-01 20 ML *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 9 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO HMO HMO • Oncology Management Program J9023 Bavencio avelumab PPO PPO Affected providers: In network

J3490/ HCPCS Limit: 600 units Baxdela delafloxacin C9462 NDC NDC Limit

70842-0102-03 2 UN Affected providers: In network Peripheral T-cell lymphoma (PTCL) – Relapsed or refractory HCPCS Limit: 400 units • 1,000 mg/m2 daily on days J9032 Beleodaq belinostat 1-5 of a 21 day cycle NDC NDC Limit 72893-0002-01 8 UN

68152-0108-09 8 UN HMO HMO • Oncology Management Program J9036 Belrapzo bendamustine hcl PPO PPO bendamustine HMO HMO • Oncology Management Program J9034 Bendeka hydrochloride PPO PPO • FDA approved indication Affected providers: In network Systemic lupus erythematosus • FDA approved age • 10 mg/kg every 4 weeks • Patients have tested positive for serum antibodies at 2 independent time points HCPCS Limit: 240 units • Patients must have active disease • If the patient has lupus nephritis ONLY and no other symptoms of system lupus erythematosus (SLE): NDC NDC Limit o Must have active disease of the kidney confirmed on biopsy 49401-0101-01 20 UN • Patient does not have active central nervous system lupus 49401-0102-01 6 UN HMO HMO • Previous treatment courses of at least 12 weeks each with 2 or more of the following have been 49401-0088-01 12 ML J0490 Benlysta belimumab PPO PPO ineffective: chloroquine, hydroxychloroquine, methotrexate, azathioprine, cyclophosphamide OR 49401-0088-42 12 ML mycophenolate mofetil, unless all are contraindicated or not tolerated 49401-0101-01 20 UN • Patient is currently receiving and will continue to receive a stable standard of care regimen. Standard of 49401-0102-01 6 UN care treatment regimen comprise of any of the following drug classes, alone or in combination: 49401-0088-01 12 ML o Antimalarials 49401-0088-42 12 ML o Corticosteroids 49401-0088-47 12 ML o Non-biologic immunosuppressants 49401-0088-35 12 ML • Not to be used in combination with other biologics (ex. Humira) or intravenous cyclophosphamide

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected Providers: In/Out of • FDA approved age network • Prescribed by or in consultation with an ophthalmologist HCPCS Limit: 12 units HMO • Treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or J0179 Beovu brolucizumab PPO contraindicated NDC NDC Limit 00078-0827-61 0.1ML

Max number of injections determined during PA process • Non-preferred Hereditary Angioedema product Affected providers: In network Hereditary Angioedema • Diagnosis of Type I or Type II hereditary angioedema (HAE) • 20 units/kg • Laboratory results confirming diagnosis (Include all of the following: C1q, C4, and C1 INH levels) HCPCS Limit: 1500 units HMO HMO • Diagnosed by an immunologist, allergist, or hematologist J0597 Berinert c-1 esterase PPO PPO • History of at least 2 HAE attacks per month or a history of attacks that are considered severe with swelling NDC NDC Limit

of the face, throat or gastrointestinal tract for long-term prophylaxis 63833-0825-02 30 UN • Any additional pertinent medical information • FDA approved age • Oncology Management Program Affected providers: In network

inotuzumab HMO HMO HCPCS Limit: 24 units J9229 Besponsa ozogamicin PPO PPO NDC NDC Limit

00008-0100-01 3 UN Affected providers: In network

HCPCS Limit: 48 units

NDC NDC Limit J9050 Bicnu carmustine 00015-3012-60 48 UN 23155-0647-31 48 UN 23155-0261-41 48 UN 23155-0589-31 48 UN 23155-0649-41 48 UN

• Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1556 Bivigam immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 10 units

NDC NDC Limit 00143-9240-01 5 UN 00143-9241-01 5 UN 00409-0323-20 5 UN 00409-0332-20 5 UN 00703-3154-01 10 UN J9040 Bleomycin Sulfate bleomycin sulfate 00703-3155-01 5 UN 16714-0886-01 10 UN 16714-0908-01 5 UN 61703-0323-22 5 UN 61703-0332-18 10 UN 63323-0136-10 10 UN 63323-0137-20 5 UN 70121-1567-01 10 UN 71288-0106-10 10 UN 71288-0107-20 10 UN

• Oncology Management Program Affected providers: In network

C9069 HCPCS Limit:750 units belantamab mafodotin- HMO HMO J9037 Blenrep J9037 HCPCS LIMIT: 750 units blmf PPO PPO NDC NDC Limit 00173-0896-01 4 UN

HMO HMO • Oncology Management Program J9039 Blincyto blinatumomab PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 71839-0106-01 10 ML 76014-0002-10 10 ML neostigmine 76014-0002-33 10 ML Bloxiverz J2710 methylsulfate 76014-0003-10 5 ML 76014-0003-33 5 ML 76014-0902-10 20 ML 76014-0902-33 20 ML 76014-0903-10 10 ML 76014-0903-33 10 ML 51754-1240-01 10 ML 51754-1240-03 10 ML

Affected providers: In/Out network

J1740 Boniva ibandronate HCPCS Limit: 6 units

NDC NDC Limit

N/A N/A • Diagnosis the medication is being used to treat Affected providers: In network Axillary hyperhidrosis: • Names of medications previously used to treat this condition, including dosages, dates of therapy and • 50 units response HCPCS Limit: 600 units Blepharospasm: • Any additional pertinent medical information • 15 units NDC NDC Limit Cervical dystonia • Diagnosis of chronic migraine 00023-1145-01 6 Units • 400 units Evaluated by a neurologist o Chronic migraine: There is a persistent history of recurring debilitating headaches (15 or more days per month with 00023-3919-50 12 Units o 00023-3921-02 3 Units • 155 units migraine headache lasting for 4 hours per day or longer). Detrusor overactivity associated 00023-9232-01 6 Units An evaluation has been performed to rule out medication overuse headaches and prevention steps HMO o with a neurologic condition: J0585 Botox onabotulinumtoxina have been taken PPO • 200 units o An adequate trial (at least 6 weeks) of prophylactic therapy from at least TWO different therapy Overactive bladder: classes were not effective, contraindicated, or not tolerated • 100 units o Other conditions or aggravating factors that are contributing to the development of chronic migraine Strabismus: headaches are being treated • 25 units Upper and lower limb spasticity: • 400 units Upper Limb Spasticity for pediatric patients: • 400 units

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In network • Prescribed by on in consultation with an oncologist • Treatment of patients with relapsed or refractory Non-Hodgkin’s lymphoma of the following subtypes: J3490 HCPCS Limit: 9999 units 1 UN o Diffuse large B-cell lymphoma (DLBCL) C9076 HCPCS Limit:

o Primary mediastinal B-cell lymphoma (PMBCL) o Follicular lymphoma, grade 3B NDC NDC Limit • Received ≥ 2 lines of chemotherapy, including rituximab and anthracycline 73153-0900-01 1 UN OR • Relapsed following autologous hematopoietic stem cell transplantation (HSCT) • Documentation of CD 19 tumor expression • Patients must not have the following o ECOG performance status of greater than 2 Creatinine clearance < 30 mL/min J3590/ lisocabtagene HMO HMO o Breyanzi Alanine aminotransferase > 5 times the upper limit of normal C9076 maraleucel PPO PPO o o Left ventricular ejection fraction < 40% o Active CNS involvement by primary malignancy (secondary CNS involvement is allowed) as determined by appropriate testing. Examples include: MRI and/or CSF analysis (including cytology plus molecular analysis, for example FISH) o History of another primary malignancy that has not been in remission for at least 2 years prior to consideration of CAR-T therapy o Active infection including hepatitis B, hepatitis C, HIV, or systemic fungal, bacterial, or viral infection o Presence of graft-vs-host disease (GVHD) • The prescriber needs to submit documentation of response to Breyanzi within 3 months following therapy as a follow-up to the prior approval request • If new diagnoses are FDA approved, coverage will be determined based on the FDA approved indication on a case by case basis until fully evaluated by the BCBSM Pharmacy and Therapeutics Committee

• Diagnosis of late infantile neuronal ceroid lipofuscinosis type 2 (CLN2) Affected providers: In network Late infantile neuronal ceroid • Patient must be age 3 years and older lipofuscinosis type 2 • Prescribing physician is a neurologist, geneticist, or metabolic specialist HCPCS Limit: 300 units (CLN2)/Tripeptidyl peptidase 1 • Diagnosis must be confirmed by deficiency in tripeptidyl peptidase 1 enzyme OR genetic mutation in CLN2 (TPP1) deficiency HMO HMO J0567 Brineura™ cerliponase alfa gene NDC NDC Limit • 300 mg once every other PPO PPO • N/A N/A week Patient must be ambulatory at start of treatment • Receiving standard of care regimen for CLN2 (e.g. seizure management, nutritional support, physical therapy) • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

HCPCS Limit: 48 units

NDC NDC Limit 23155-0649-41 48 UN 70121-1482-02 48 UN 70710-1525-09 48 UN J9050 Carmustine carmustine 00781-3470-90 48 UN 00781-3474-32 48 UN 23155-0788-31 48 UN 23155-0790-41 UN 48

Affected providers: In network

HCPCS Limit: 1 unit

casirivimab casirivimab NDC NDC Limit Q0243 (REGN10933) (EUA) (REGN10933) 61755-0024-00 10 ML 61755-0024-01 10 ML 61755-0026-00 10 ML

61755-0026-01 10 ML

HCPCS Limit: 40 units

NDC NDC Limit 00007-3131-16 40 UN 00143-9261-01 2 UN 00143-9261-10 2 UN 00143-9262-01 20 UN 00143-9262-25 20 UN 00143-9923-90 40 UN 00143-9924-90 20 UN 00143-9983-03 2 UN 00143-9983-91 2 UN 00264-3103-11 20 UN 00264-3105-11 10 UN 00338-3503-41 1000 ML 00338-3508-41 1000 ML 00409-0805-01 20 UN 00409-0805-11 20 UN 00409-0806-01 2 UN 00409-0806-11 2 UN 00409-2585-01 20 UN 00409-2585-11 20 UN 44567-0120-25 20 UN J0690 Cefazolin Sodium cefazolin sodium 00781-3450-70 40 UN 00781-3450-95 40 UN 00781-3451-70 20 UN 00781-3451-96 20 UN 00781-3452-46 2 UN 00781-3452-95 2 UN 25021-0100-10 40 UN 25021-0100-66 40 UN 25021-0101-10 20 UN 25021-0101-67 20 UN 25021-0102-69 2 UN 25021-0102-99 2 UN 44567-0706-25 40 UN 44567-0707-25 20 UN 44567-0708-10 2 UN 54569-4431-00 40 UN 54868-4651-00 40 UN 60505-0749-01 20 UN 60505-0749-05 20 UN 60505-0769-00 2 UN 60505-0769-01 2 UN 60505-6093-01 20 UN 60505-6093-05 20 UN 60505-6094-00 2 UN 60505-6094-01 2 UN *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 16 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 60505-6142-00 20 UN 60505-6142-05 20 UN 63323-0236-10 40 UN 60505-6143-00 2 UN 60505-6143-04 2 UN 63323-0237-10 20 UN 63323-0238-61 2 UN 63323-0449-61 1 UN 66288-1100-01 1 UN 66288-1300-01 1 UN 66860-0001-03 40 UN 66860-0002-03 20 UN 66860-0003-02 2 UN 68330-0014-25 40 UN 68330-0015-25 20 UN 70092-1017-46 200 ML 70092-1238-47 200 ML 70092-1622-03 1000 ML 71019-0029-01 20 UN 71019-0029-02 500 ML 71019-0029-03 1000 ML 71019-0029-04 20 UN

71019-0032-01 700 ML Affected providers: In network

HCPCS Limit: 40 units Cefazolin cefazolin sodium-D5W J0690 Sodium/D5W NDC NDC Limit 71019-0030-01 500 ML 71019-0033-01 700 ML

70092-1621-15 100 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00338-1301-41 500 ML 00338-1301-48 500 ML 25021-0121-20 10 UN 25021-0122-50 5 UN 44567-0240-10 10 UN 60505-6144-00 5 UN 60505-6144-04 5 UN 60505-6145-00 5 UN J0692 Cefepime hcl cefepime hcl 60505-6145-04 5 UN 60505-6146-00 10 UN 60505-6146-04 10 UN 60505-6147-00 5 UN 60505-6147-04 5 UN 63323-0326-20 10 UN 63323-0326-21 10 UN 63323-0340-21 5 UN 71288-0008-15 10 UN 71288-0009-20 5 UN 66794-0209-02 10 UN 66794-0209-41 10 UN 66794-0210-02 5 UN

66794-0210-41 5 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00039-0020-01 2 UN 00143-9930-01 28 UN 00143-9930-10 28 UN 00143-9931-01 14 UN 00143-9931-25 14 UN 00143-9933-01 7 UN cefotaxime sodium 00143-9935-01 2 UN Cefotaxime Sodium J0698 injection 00143-9935-91 2 UN 00409-3595-01 10 UN 64679-0948-02 7 UN 64679-0986-01 14 UN 64679-0986-02 14 UN 64679-0986-03 14 UN 21586-0011-01 20 UN 21586-0011-02 20 UN 66860-0041-02 28 UN 66860-0042-03 14 UN 66860-0043-03 7 UN

66860-0044-01 2 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00143-9876-10 10 UN 00143-9877-01 5 UN 00143-9877-25 2 UN 00143-9878-01 10 UN 00143-9878-25 20 UN 00264-3123-11 20 UN 00264-3125-11 10 UN 10019-0661-27 10 UN 10019-0662-03 2 UN 25021-0109-10 20 UN 25021-0110-20 10 UN 25021-0111-99 2 UN 44567-0245-25 20 UN cefoxitin sodium Cef oxitin 44567-0245-85 20 UN J0694 injection 44567-0246-25 10 UN 44567-0246-85 5 UN 44567-0247-10 2 UN 60505-0759-01 20 UN 60505-0759-05 20 UN 60505-0760-01 10 UN 60505-0760-05 10 UN 60505-0761-01 2 UN 60505-0761-04 2 UN 60505-6025-01 20 UN 60505-6025-05 20 UN 60505-6026-01 10 UN 60505-6026-05 10 UN 63323-0341-25 20 UN 63323-0341-29 20 UN 63323-0342-25 10 UN 63323-0342-29 10 UN

63323-0343-66 2 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00264-3143-11 10 UN 00264-3145-11 5 UN 00409-5086-11 2 UN 00409-5092-16 10 UN 00409-5093-11 5 UN 00409-5084-13 5 UN 00409-5092-11 10 UN J0713 Ceftazidime ceftazidime injection 00409-5093-14 5 UN 00781-3177-80 10 UN 00781-3177-96 10 UN 25021-0127-20 10 UN 25021-0127-66 10 UN 25021-0128-50 5 UN 25021-0128-67 5 UN 25021-0129-69 2 UN 25021-0129-99 2 UN 44567-0235-25 10 UN 44567-0236-10 5 UN

44567-0237-06 2 UN

HCPCS Limit: 20 units

NDC NDC Limit 00143-9678-01 0.5 UN 00143-9856-01 3 UN 00143-9856-25 3 UN 00143-9857-01 5 UN 00143-9857-25 5 UN 00143-9858-01 10 UN 00143-9858-25 10 UN 00143-9859-01 20 UN 00143-9859-25 20 UN 00264-3153-11 5 UN 00264-3155-11 3 UN 00338-5002-41 250 ML 00338-5003-41 150 ML 00409-7332-01 5 UN 00409-7332-11 10 UN 00409-7332-20 10 UN 00409-7332-21 10 UN 00409-7333-31 5 UN 00409-7333-04 5 UN ceftriaxone sodium J0696 Ceftriaxone 00409-7333-49 5 UN injection 00409-7334-10 0.5 UN 00409-7334-20 1 UN 00409-7335-03 3 UN 00409-7335-13 3 UN 00409-7335-20 5 UN 00409-7335-21 5 UN 00409-7336-04 3 UN 00409-7336-11 3 UN 00409-7337-01 20 UN 00409-7337-11 20 UN 00409-7337-20 20 UN 00409-7338-01 10 UN 00409-7338-11 10 UN 00409-7338-20 10 UN 00781-3206-85 20 UN 00781-3206-95 20 UN 00781-3207-85 10 UN 00781-3207-95 10 UN 00781-3208-85 5 UN 00781-3208-95 5 UN 00781-3209-90 3 UN 00781-3209-95 3 UN 00781-3210-46 0.5 UN 00781-9328-85 5 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

63323-0346-10 5 UN 63323-0347-20 3 UN 63323-0348-61 0.5 UN 64679-0701-01 20 UN 64679-0701-02 20 UN 64679-0701-03 20 UN 64679-0702-01 10 UN 64679-0702-02 10 UN 64679-0703-01 3 UN 64679-0703-02 3 UN 64679-0983-01 5 UN 64679-0983-02 5 UN 66288-6100-01 0.05 UN 66794-0211-02 20 UN 66794-0211-42 20 UN 66794-0212-02 10 UN 66794-0212-42 10 UN 66794-0213-02 5 UN 66794-0213-42 5 UN 66794-0214-02 2.5 UN 66794-0214-42 2.5 UN 66794-0215-15 0.5 UN 66860-0071-02 20 UN 66860-0072-02 10 UN 66860-0073-02 5 UN 66860-0074-02 3 UN 68180-0611-01 20 UN 68180-0611-10 20 UN 68180-0622-01 10 UN 68180-0622-10 10 UN 68180-0633-01 5 UN 68180-0633-10 5 UN 68180-0644-01 3 UN

68180-0644-10 3 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 10 units

NDC NDC Limit 00001-4399-79 10 UN 00143-9567-01 5 UN 00143-9567-25 5 UN 00143-9568-01 10 UN 00143-9568-25 10 UN 00143-9569-01 1 UN 00143-9569-10 1 UN 00143-9976-03 1 UN sterile cefuroxime J0697 Cefuroxime sodium 00143-9977-22 5 UN injection 00143-9977-90 5 UN 00143-9979-22 1 UN 00143-9979-90 10 UN 25021-0118-10 10 UN 25021-0119-20 5 UN 25021-0120-59 1 UN 63323-0352-45 10 UN 63323-0353-45 5 UN 63323-0354-45 1 UN 66860-0030-03 10 UN 66860-0031-03 5 UN 66860-0032-02 1 UN

70360-0007-35 750 ML Affected providers: In network

HCPCS Limit: 496 units

NDC NDC Limit 00004-0260-01 248 UN mycophenolate mofetil 00004-0260-43 248 UN Cellcept J7517 oral 00004-0259-01 496 UN 00004-0259-43 496 UN 49999-0936-00 496 UN 49999-0936-30 496 UN 00004-0261-29 620 ML 49999-0937-30 248 UN

00004-0259-05 496 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 1500 units

J2724 Ceprotin protein c concentrate NDC NDC Limit 00944-4175-05 300 UN 00944-4175-10 150 UN 00944-4177-05 300 UN

00944-4179-10 150 UN • FDA approved indication • FDA approved age • Prescribed by or in consultation with a geneticist or metabolic specialist HMO HMO HMO • Confirmation of diagnosis by biochemical assay showing decreased glucocerebrosidase activity in white J1786 Cerezyme imiglucerase PPO PPO PPO blood cells or skin fibroblasts AND genotyping revealing two pathogenic mutations of the glucocerebrosidase gene • Two symptomatic manifestations of the disease are present, such as anemia, thrombocytopenia, bone disease, hepatomegaly, or splenomegaly Affected providers: In/Out network

HCPCS Limit: 1 unit human papillomavirus Cervarix (types 16, 18) bivalent 90650 NDC NDC Limit vaccine, recombinant 58160-0830-32 0.5 ML 58160-0830-52 0.5 ML

3 doses/lifetime

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication. Affected providers: In network Crohn's Disease, Psoriatic • FDA approved age. Arthritis, Ankylosing Spondylitis, • Diagnosis of rheumatoid arthritis (RA) HCPCS Limit: 800 units Rheumatoid Arthritis, Plaque Psoriasis o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, hydroxychloroquine, leflunomide, NDC NDC Limit • 400 mg every 4 weeks sulfasalazine 50474-0700-62 2 UN • Diagnosis of psoriatic arthritis (PsA) 50474-0710-79 2 UN Trial and failure of at least 3 months trial of one disease-modifying anti-rheumatic agent (DMARD) o 50474-0710-81 2 UN unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine. HMO HMO • Diagnosis of ankylosing spondylitis (AS) J0717 Cimzia certolizumab pegol PPO PPO • Diagnosis of Crohn’s disease (CD) o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated • Diagnosis of psoriasis (PsO) o Trial and failure, contraindication, or intolerance to light therapy o Trial and failure of at least 3 months trial of one generic oral systemic agent unless contraindicated or not tolerated. Examples include cyclosporine, methotrexate, acitretin. • Diagnosis of Non-Radiographic Axial Spondyloarthritis (NRAS) • Not to be used in combination with other biologics or targeted DMARDs • Any additional pertinent medical information • Used as add-on maintenance treatment for the diagnosis of severe eosinophilic asthma confirmed by: Affected providers: In network o Blood eosinophils > 400 cells/mcL at initiation of treatment AND HCPCS Limit: 450 units o Repeated hospital/ED visits AND NDC NDC Limit Chronic administration of systemic corticosteroids or high dose inhaled corticosteroids in combination o 59310-0610-33 45 ML with long acting inhaled beta-agonists or a leukotriene modifier for at least 3 months fails to maintain HMO HMO adequate control J2786 Cinqair reslizumab PPO PPO 1. If the member is using an inhaler that contains a steroid along with other drugs, the corticosteroid component must be high dose AND • Confirmation Cinqair will not be used in combination with another biologic for asthma • FDA approved age • Patient will continue to receive standard of care regimen • Prescriber physician is an allergist, immunologist, or pulmonologist • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Non-preferred Hereditary Angioedema product Affected providers: In network Hereditary Angioedema • Diagnosis of Type I or Type II hereditary angioedema (HAE) • 2500 units • Laboratory results confirming diagnosis (Include all of the following: C1q, C4, and C1INH levels) HCPCS Limit: 2500 units • Documented history of at least 2 HAE attacks per month OR history of attacks that are considered severe HMO with swelling of face, throat or gastrointestinal tract for long-term prophylaxis NDC NDC Limit J0598 Cinryze c-1 esterase PPO • FDA approved age 42227-0083-01 50 UN • Diagnosed by an immunologist, allergist, or hematologist 42227-0081-05 50 UN • For patients 12 years of age or older, previous treatment failure of Haegarda and Takhzyro • For patients between 6 and 12 years of age, previous treatment failure of Haegarda • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 130 units Cinvanti aprepitant J0185 NDC NDC Limit

47426-0201-01 18 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00085-1761-01 400 ML 00085-1763-03 400 ML 00085-1781-01 2000 ML 00409-4765-86 400 ML 00409-4777-02 2000 ML 00409-4777-11 2000 ML 00409-4777-21 2000 ML 00409-4777-23 2000 ML 00409-4777-49 2000 ML J0744 Cipro I.V. ciprofloxacin lactate 00409-4777-50 2000 ML 00409-4777-62 2000 ML 00781-3239-09 2000 ML 00781-3239-46 2000 ML 00781-3240-09 2000 ML 00781-3240-48 2000 ML 25021-0114-87 2000 ML 36000-0008-24 2000 ML 36000-0009-24 2000 ML 36000-0010-01 400 ML 36000-0011-01 400 ML 36000-0297-24 2000 ML 36000-0298-24 2000 ML

50419-0759-01 2000 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 60 units

NDC NDC Limit 00143-9504-01 600 ML 00143-9505-01 600 ML 00703-5747-11 600 ML 00703-5748-11 600 ML 16729-0288-11 600 ML 16729-0288-38 600 ML 44567-0509-01 600 ML 44567-0510-01 600 ML 44567-0511-01 600 ML J9060 Cisplatin cisplatin 44567-0530-01 12 un 47781-0609-25 600 ML 47781-0610-23 600 ML 63323-0103-51 600 ML 63323-0103-64 600 ML 63323-0103-65 600 ML 67457-0424-10 600 ML 67457-0425-51 600 ML 68001-0283-24 600 ML 68001-0283-27 600 ML 68001-0283-32 600 ML 68001-0283-33 600 ML 70806-0206-50 600 ML

70806-0206-51 600 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 14 units

NDC NDC Limit 00039-0017-10 28 UN 00039-0018-01 14 UN 00039-0018-10 14 UN 00039-0018-11 14 UN 00039-0018-25 14 UN 00039-0018-49 14 UN 00039-0018-50 14 UN 00039-0019-01 7 UN 00039-0019-10 7 UN J0698 Claforan cefotaxime sodium 00039-0019-11 7 UN 00039-0019-25 7 UN 00039-0019-49 7 UN 00039-0019-50 7 UN 00039-0020-49 2 UN 00039-0023-25 14 UN 00039-0023-49 14 UN 00039-0023-50 14 UN 00039-0023-61 14 UN 00039-0024-25 7 UN 00039-0024-49 7 UN 00039-0024-50 7 UN 00143-9933-25 7 UN 54868-3429-00 14 UN

54868-3429-01 14 UN Affected providers: In network

HCPCS Limit: 220 units

NDC NDC Limit 43598-0309-20 220 ML J9027 Clofarabine clofarabine 50742-0512-20 220 ML 60505-6166-00 220 ML 63323-0572-70 220 ML 67457-0546-20 220 ML 70121-1236-01 220 ML

72266-0108-01 220 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 220 units J9027 Clolar clofarabine NDC NDC Limit 00024-5860-01 220 ML

00024-5917-01 220 ML Affected providers: In network

prochlorperazine HCPCS Limit: 8 units Compazine J0780 edisylate NDC NDC Limit

00007-3352-16 16 ML Affected providers: In network

HCPCS Limit: 18 units 90748 Comvax hepB/Hib NDC NDC Limit

00006-4898-00 0.5 ML • Oncology Management Program Affected providers: In Network

J3490 HCPCS Limit: 9999 J3490/ trilaciclib HMO HMO Cosela C9078 HCPCS Limit: 600 C9078 dihydrochloride PPO PPO NDC NDC Limit

73462-0101-01 2 UN Affected providers: In network

HCPCS Limit: 9 units

NDC NDC Limit J9120 Cosmegen dactinomycin 55292-0811-55 9 UN 67386-0811-55 9 UN 39822-2100-01 9 UN 39822-2100-02 9 UN

67457-0928-02 9 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 1116 units J1833 Cresemba isavuconazonium NDC NDC Limit

00469-0420-99 3 UN • FDA approved age Affected providers: In network X-linked hypophosphatemia • Prescribed by, or in consultation with, an endocrinologist • 90 mg every 4 weeks • Diagnosis of X-linked hypophosphatemia (XLH) confirmed by: HCPCS Limit: 180 units

o Genetic testing OR NDC NDC Limit Elevated serum fibroblast growth factor 23 (FGF23) level based on the normal range for age 69794-0102-01 18 ML o Low serum phosphate level based on the normal range for age 69794-0203-01 9 ML Presence of clinical signs and symptoms of the disease (e.g. rickets, growth retardation, o 69794-0304-01 6 ML musculoskeletal pain, bone fractures) HMO HMO HMO J0584 Crysvita burosumab-twza Measurable bone/joint pain (≥4 on the brief pain inventory (BPI) question 3 on pain at its worst) PPO PPO PPO o • Diagnosis of FGF23-related hypophosphatemia in tumor induced osteomalacia (TIO) associated with phosphaturic mesenchymal tumors that cannot be resected or localized confirmed by: o Elevated FGF23 level based on the normal range for age o Low serum phosphate level based on the normal range for age o Ratio of renal tubular maximum reabsorption rate of phosphate to glomerular filtration rate (TmP/GFR) <2.5 mg/dL o Presence of clinical signs and symptoms of the disease (e.g. bone pain, fractures, difficulty walking, muscle weakness and fatigue) • Trial and failure, contraindication, or intolerance to active vitamin D and phosphate supplements • Diagnosis of a primary humoral immunodeficiency disease (i.e., X-linked agammaglobulinemia, Max daily limit to be determined in hypogammaglobulinemia, common variable immunodeficiency (CVID), immunoglobulin subclass Novologix through Prior deficiency, combined immunodeficiency syndromes) Authorization process • Pertinent laboratory results to confirm diagnosis (for example, baseline IgG level plus laboratory findings to support diagnosis) • Names of medications previously used to treat this condition, including: HMO HMO HMO J1599 Cutaquig immune globulin Dosages PPO PPO PPO o o Dates of therapy o Response to therapy • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of a primary humoral immunodeficiency disease (i.e., X-linked agammaglobulinemia, Max daily limit to be determined in hypogammaglobulinemia, common variable immunodeficiency (CVID), immunoglobulin subclass Novologix through Prior deficiency, combined immunodeficiency syndromes) Authorization process • Pertinent laboratory results to confirm diagnosis (for example, baseline IgG level plus laboratory findings to support diagnosis) • Names of medications previously used to treat this condition, including: HMO HMO HMO J1555 Cuvitru immune globulin Dosages PPO PPO PPO o o Dates of therapy o Response to therapy • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 3 units

NDC NDC Limit 00143-9619-01 3 ML 00143-9619-10 3 ML 00143-9620-01 3 ML 00143-9620-10 3 ML 00143-9621-01 3 ML 00143-9621-25 3 ML 00517-0031-01 3 ML 00517-0031-25 3 ML 00517-0032-25 3 ML 00517-0130-05 3 ML 49836-0527-01 3 UN 53879-0301-10 3 ML J3420 Cyanocobalamin vitamin b12 54569-6380-00 3 ML 54868-0762-00 3 ML 54868-0762-01 3 ML 63323-0044-01 3 ML 63323-0044-41 3 ML 63323-0044-44 3 ML 69680-0112-25 3 ML 69680-0113-99 3 ML 70069-0005-01 3 ML 70069-0005-10 3 ML 70069-0172-01 3 ML 70069-0172-10 3 ML 70069-0171-01 3 ML 70069-0171-10 3 ML 76420-0527-01 3 ML 55150-0364-25 3 UN

55150-0364-01 3 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 216 units

NDC NDC Limit 00093-5740-19 216 UN 00093-5740-65 216 UN 00093-5741-65 108 UN 00093-5742-65 54 UN 00172-7310-00 216 UN 00172-7310-46 216 UN 00172-7311-00 108 UN J7515 Cyclosporine cyclosporine 00172-7311-46 108 UN 00185-0932-30 216 UN 51862-0458-47 216 UN 51862-0458-01 216 UN 54868-5522-00 54 UN 60505-0133-00 216 UN 60505-0134-00 54 UN 60505-4630-03 216 UN 60505-4631-03 108 UN 68084-0879-25 216 UN 68084-0879-95 216 UN 68084-0921-25 54 UN 68084-0921-95 54 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 54 units

NDC NDC Limit 00093-5742-65 54 UN 00172-7312-00 54 UN 00172-7312-46 54 UN 00172-7313-20 54 ML Cyclosporine 00185-0933-30 54 UN cyclosporine J7502 modified 00185-0933-86 54 UN 00591-2224-55 54 ML 51862-0460-47 54 UN 51862-0460-01 54 UN 54868-5522-00 54 UN 54868-6232-00 54 UN 60505-0134-00 54 UN 60505-4632-03 54 UN 68084-0921-25 54 UN 68084-0921-95 54 UN

• Oncology Management Program Affected providers: In network

HCPCS Limit: 600 units HMO HMO J9308 Cyramza ramucirumab PPO PPO NDC NDC Limit 00002-7669-01 300 ML

00002-7678-01 300 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 240 units

NDC NDC Limit 61703-0305-38 1200 ML 61703-0319-22 240 ML 63323-0120-20 240 ML 67457-0452-20 240 ML 61703-0303-46 1200 ML J9100 Cytarabine cytarabine hcl 61703-0304-36 1200 ML 67457-0454-50 1200 ML 67457-0455-52 1200 ML 55390-0131-10 240 UN 55390-0132-10 48 UN 55390-0133-01 24 UN 55390-0807-10 48 UN 67457-0455-00 240 UN 71288-0109-20 240 UN

61703-0305-58 1200 ML Affected providers: In network

HCPCS Limit: 9 units

J9120 dactinomycin dactinomycin NDC NDC Limit 66993-0489-83 9 UN

71288-0129-02 9 UN

Affected providers: In network

HCPCS Limit: 300 units J0875 Dalvance dalbavancin NDC NDC Limit

57970-0100-01 3 UN • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 150 units J9348 Danyelza naxitamab-gqgk PPO PPO NDC NDC Limit

73042-0201-01 40 mL

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO HMO HMO • Oncology Management Program J9145 Darzalex daratumumab PPO PPO • Oncology Management Program Affected providers: In network

daratumumab- HMO HMO J9144 HCPCS Limit: 180 units J9144 Darzalex Faspro hyaluronidase-fihj PPO PPO NDC NDC Limit

57894-0503-01 15 ML Affected providers: In network

HCPCS Limit: 400 units J3121 Delatestryl testosterone enanthate NDC NDC Limit

67979-0501-40 2 ML Affected providers: In network

HCPCS Limit: 400 units

NDC NDC Limit 00009-0085-10 4 ML 00009-0086-01 2 ML 00009-0086-10 2 ML 00009-0347-02 4 ML 00009-0417-01 2 ML J1071 Depo-testosterone testosterone cypionate 00009-0417-02 2 ML 00009-0520-01 2 ML 00009-0520-10 2 ML 35356-0058-10 4 ML 52536-0625-01 2 ML 52536-0625-10 2 ML 54569-5301-00 4 ML 54868-0216-00 2 ML 72627-2100-03 2 ML 72627-2100-06 2 ML 72833-0678-30 2 ML

Affected providers: In network

HCPCS Limit: 5 units J9098 Depocyt cytarabine liposome NDC NDC Limit

57665-0331-01 5 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

dexamethasone HCPCS Limit: 4 units J1096 Dextenza ophthalmic insert, 0.4mg NDC NDC Limit 70382-0204-01 1 UN

70382-0204-10 1 UN Affected providers: In network

HCPCS Limit: 1034 units J1095 Dexycu 9 % SUSP dexamethasone/PF NDC NDC Limit

71879-0001-01 0.01 ML Affected providers: In network

HCPCS Limit: 6 units

NDC NDC Limit 00409-2634-10 150 ML 00409-2634-10 2.4 ML 00409-2634-25 2.4 ML 59011-0442-25 6 ML 59011-0445-01 30 ML 59011-0445-05 30 ML hydromorphone Dilaudid 59011-0441-10 12 ML J1170 injection 59011-0442-10 6 ML 59011-0444-10 3 ML 76045-0009-00 24 ML 76045-0009-03 24 ML 76045-0010-00 12 ML 76045-0009-05 24 ML 76045-0009-10 24 ML 76045-0010-10 12 ML 76045-0011-10 6 ML 76045-0121-01 20 ML

76045-0121-11 20 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 8 units

NDC NDC Limit 00409-2290-03 8 ML 00409-2290-31 8 ML 00641-0376-21 8 ML diphenhydramine hcl 00641-0376-25 8 ML Diphenhydramine J1200 injection 54569-2219-00 8 ML 54569-5608-00 8 ML 54569-5815-00 8 ML 63323-0664-01 8 ML 63323-0664-16 8 ML 67457-0124-10 8 ML 72485-0101-01 8 ML 72485-0101-25 8 ML

76045-0102-10 8 ML Affected providers: In network

HCPCS Limit: 400 units

J1267 Doribax doripenem injection NDC NDC Limit 59630-0309-01 16 UN 59630-0309-10 16 UN 59630-0320-01 8 UN

59630-0320-10 8 UN Affected providers: In network

HCPCS Limit: 400 units

J1267 Doripenem doripenem NDC NDC Limit 60505-6160-00 16 UN 60505-6160-04 16 UN 60505-6161-00 8 UN 60505-6161-04 8 UN

HMO HMO • Oncology Management Program Q2050 Doxil doxorubicin liposomal PPO PPO

HCPCS Limit: 24 units

NDC NDC Limit 00378-8170-91 12 UN 00378-8171-91 12 UN 00527-1450-06 12 UN 00527-1451-06 6 UN 00527-1452-06 3 UN 00591-3591-60 12 UN 00591-3592-60 12 UN 00591-3593-60 3 UN 00904-6745-61 12 UN 00904-6746-04 6 UN 17478-0761-06 12 UN 17478-0762-06 12 UN 17478-0763-06 3 UN 31722-0960-60 12 UN 31722-0961-60 6 UN 31722-0962-60 3 UN 42291-0449-60 24 UN 42291-0450-60 12 UN 42291-0451-60 6 UN Q0167 Dronabinol dronabinol oral 42858-0867-06 24 UN 42858-0868-06 12 UN 42858-0869-06 6 UN 49884-0867-02 12 UN 49884-0868-02 12 UN 49884-0869-02 3 UN 60687-0375-01 12 UN 60687-0375-11 12 UN 60687-0386-11 6 UN 60687-0386-21 6 UN 67877-0568-60 12 UN 67877-0569-60 6 UN 67877-0570-60 3 UN 67877-0754-60 12 UN 67877-0755-60 6 UN 68084-0174-01 12 UN 68084-0174-11 12 UN 68084-0175-11 12 UN 68084-0175-21 12 UN 00904-7144-61 24 UN 00904-7145-04 12 UN

67877-0753-60 24 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 25 units

NDC NDC Limit J2270 Duramorph morphine sulfate/pf 00641-6019-01 250 ML 00641-6019-10 250 ML 00641-6020-01 500 ML 00641-6020-10 500 ML 00641-6020-01 500 ML

00641-6020-10 500 ML J7318 Durolane sodium hyaluronate Covered/preferred hyaluronic acid product Affected providers: In network

J7351/C J7351 HCPCS Limit: 10 units 9399 Durysta bimatoprost C9399 HCPCS Limit: 9999 units

NDC NDC Limit

00023-9652-01 1 UN • Diagnosis the medication is being used to treat Affected providers: In network Cervical Dystonia • Names of medications previously used to treat this condition, including dosages, dates of therapy and • 1,000 units every 12 weeks response HCPCS Limit: 300 units Upper Limb Spasticity • Any additional pertinent medical information • 1,000 units every 12 weeks NDC NDC Limit Lower Limb Spasticity HMO J0586 Dysport abobotulinumtoxina 15054-0500-01 3 UN • (< 18 years of age) PPO 15054-0530-06 5 UN • 1,000 units every 12 weeks Upper Limb Spasticity Pediatric 99207-0500-30 5 UN • 640 units every 12 weeks Lower Limb Spasticity Pediatric • 1000 units every 12 weeks • Prescribed by or in consultation with a geneticist or metabolic specialist Affected providers: In network Mucopolysaccharidosis II • FDA approved indication • 0.5 mg/kg once weekly HMO HMO HMO • FDA approved age HCPCS Limit: 150 units J1743 Elaprase idursulfase PPO PPO PPO • Confirmation of diagnosis by serum assay showing a decrease of iduronate sulfatase activity followed by genetic testing showing a mutation in the I2S gene NDC NDC Limit

54092-0700-01 75 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network Type 1 Gaucher Disease ages 4 • FDA approved age years and older • Prescribed by or in consultation with a geneticist or metabolic specialist HCPCS Limit: 1800 units • 60 units/ kg every 2 weeks HMO HMO HMO • Confirmation of diagnosis by biochemical assay showing decreased glucocerebrosidase activity in white J3060 Elelyso taliglucerace alfa PPO PPO PPO blood cells or skin fibroblasts AND genotyping revealing two pathogenic mutations of the NDC NDC Limit

glucocerebrosidase gene 00069-0106-01 90 UN • Two symptomatic manifestations of the disease are present, such as anemia, thrombocytopenia, bone disease, hepatomegaly, or splenomegaly Affected providers: In network Prostate cancer • 7.5 mg given monthly in males HCPCS Limit: 6 units • Maximum of 7.5 mg per month

NDC NDC Limit J9217 Eligard leuprolide acetate 62935-0222-05 2 UN 62935-0223-05 2 UN 62935-0303-30 2 UN 62935-0453-45 1 UN

62935-0753-75 6 UN • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 240 units J9269 Elzonris tagraxofusp-erzs PPO PPO NDC NDC Limit 72187-0401-01 3 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network • FDA approved age • Prescribed by or in consultation with a hematologist HCPCS Limit: N/A

• Flow cytometric confirmation of PNH type III red cells • Had at least 1 transfusion in 12 months preceding Empav eli NDC NDC Limit 73606-0010-01 20 mL OR • Documented history of major adverse thrombotic vascular events from thromboembolism OR • Patient has high disease activity defined as a lactic dehydrogenase (LDH) level ≥ 1.5 times the upper limit of normal with one of the following symptoms: o Weakness o Fatigue J3490/ HMO HMO Hemoglobinuria Empaveli pegcetacoplan o J3590 PPO PPO o Abdominal pain o Dyspnea o Hemoglobin < 10 g/dL o A major vascular event o Dysphagia o Erectile dysfunction • Must not be used in combination with Soliris®, Ultomiris®, or other medications to treat PNH • Trial and failure, contraindication, OR intolerance to the preferred drugs as listed in BCBSM/BCN’s utilization management medical drug list and/or BCBSM/BCN’s prior authorization and step therapy documents • Renewal Criteria: Clinical documentation must be provided to confirm that current criteria are met and that the medication is providing clinical benefit

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 150 units

NDC NDC Limit 68001-0421-22 1 UN 69097-0830-37 1 UN 70860-0780-10 1 UN 71288-0418-10 1 UN 00006-3061-00 1 UN 00006-3061-01 2 UN 00006-3061-02 3 UN 00006-3061-03 4 UN fosaprepitant J1453 Emend 00006-3061-04 5 UN dimeglumine 00006-3061-05 6 UN 16714-0929-01 1 UN 16729-0240-03 1 UN 71839-0104-01 1 UN 72603-0106-01 1 UN 72606-0569-01 1 UN 72205-0054-01 1 UN 00781-3497-75 1 UN 68180-0690-01 1 UN 43598-0948-11 1 UN 00338-0008-01 1 UN 72205-0083-01 1 UN

55150-0299-01 1 UN HMO HMO • Oncology Management Program J9176 Empliciti elotuzumab PPO PPO • Oncology Management Program Affected providers: In network

fam-trastuzumab HMO HMO HCPCS Limit: 1000 units J9358 Enhertu deruxtecan-nxki PPO PPO NDC NDC Limit

65597-0406-01 10 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication. Affected providers: In/Out of Crohn's disease and Ulcerative • FDA approved age. network colitis • Diagnosis of Crohn’s Disease (CD) • 300mg every 8 weeks 300 units o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, HCPCS Limit: immunomodulators such as azathioprine for at least 2 months) has been ineffective or is HMO HMO contraindicated or not tolerated NDC NDC Limit J3380 Entyvio vedolizumab PPO PPO • Diagnosis of Ulcerative Colitis (UC) 64764-0300-20 1 UN - Treatment with an adequate course of conventional therapy (such as steroids for 7 days, immunomodulators such as azathioprine for at least 2 months) has been ineffective or is Max number of injections contraindicated or not tolerated determined during PA process • Not to be used in combination with other biologics or targeted DMARDs

HMO HMO • Oncology Management Program J9055 Erbitux cetuximab PPO PPO Affected providers: In network

HCPCS Limit: 4 units

NDC NDC Limit 42023-0221-01 2 UN 42023-0221-10 2 UN 42023-0221-85 2 UN 43598-0901-11 2 UN J1335 Ertapenem ertapenem sodium 43598-0901-58 2 UN 44567-0820-01 4 UN 44567-0820-10 4 UN 5515-0028-209 2 UN 42023-0221-89 2 UN 63323-0823-01 2 UN 63323-0823-20 2 UN 00143-9398-01 2 UN

00143-9398-10 2 UN Affected providers: In network

HCPCS Limit: 100 units

J9019 Erwinaze asparaginase NDC NDC Limit 57902-0249-01 10 UN 57902-0249-05 10 UN 81561-0413-01 10 UN

81561-0413-05 10 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 1 unit etesevimab (EUA) etesevimab Q0245 NDC NDC Limit

0002-7950-01 40 ML J7323 Euflexxa hyaluronate sodium Covered/preferred hyaluronic acid product • Treatment of postmenopausal women with osteoporosis Affected providers: In network Osteoporosis • BMD T-score at or below -2.5 at the lumbar spine or total hip • 210 mg once monthly • At least one bisphosphonate (if patient has intolerance to oral administration, IV administration will be HCPCS Limit: 9999 units required) is not effective after at least a 24-month treatment period based on objective documentation NDC NDC Limit HMO HMO J3111 Evenity romosozumab-aqqg except if: 55513-0880-01 2.34 ML PPO PPO • Bisphosphonates (oral and intravenous formulations) are contraindicated OR 55513-0880-02 2.34 ML • Not tolerated due to clinical side effects despite taking it as recommended Patient will supplement with daily calcium and vitamin D • Will not be used in combination with another anabolic bone modifying agent or denosumab • FDA approved indication Affected providers: In network • FDA approved age • Trial and therapeutic failure of one high-intensity statin J3590 HCPCS Limit: 9999 units OR C9079 HCPCS Limit: 450 • History of statin-associated side effects or intolerance (e.g., skeletal muscle related symptoms) after a J3590/ HMO HMO Evkeeza evinacumab-dgnb trial of two generic statins NDC NDC Limit C9079 PPO PPO OR 61755-0010-01 16 ML • History of rhabdomyolysis after a trial of one statin 61755-0013-01 16.1 ML • Trial and failure, contraindication or intolerance to a preferred PCSK9 inhibitor approved for use in homozygous familial hypercholesterolemia

• Oncology Management Program Affected providers: In network

HCPCS Limit: 150 units melphalan HMO HMO J9246 Evomela hydrochloride PPO PPO NDC NDC Limit 72893-0001-01 16 UN

68152-0109-00 16 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 4 units

NDC NDC Limit 00054-0080-13 4 UN 47781-0108-30 4 UN 51991-0005-33 4 UN 59762-2858-01 4 UN 60687-0132-21 4 UN S0156 Exemestane exemestane 00009-7663-04 4 UN 49999-0986-30 4 UN 54868-5261-00 4 UN 60687-0132-11 4 UN 00378-5001-93 4 UN 69097-0316-02 4 UN 00832-0595-30 4 UN 68382-0383-06 4 UN 63629-2056-01 4 UN

71921-0190-33 4 UN Coverage of Exondys 51™ is considered investigational/experimental for all indications and will not be J1428 Exondys 51 eteplirsen I/E1 provided. • FDA approved indication Affected providers: In/OUT of Diabetic macular edema (DME) & • FDA approved age network macular edema following retinal • Prescribed by or in consultation with an ophthalmologist vein occlusion (RVO) • Treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or HCPCS Limit: 4 units • 2 mg every 4 weeks x 5 doses, contraindicated then every 8 weeks thereafter HMO J0178 Eylea aflibercept Trial and failure of bevacizumab is NOT required for those with a diagnosis of diabetic macular NDC NDC Limit Wet age-related macular PPO o edema when visual acuity in the affected eye(s) is less than or equal to 20/50 61755-0005-01 0.1 ML degeneration (AMD) 61755-0005-02 0.1 ML • 2 mg every 4 weeks

Max number of injections determined during PA process • Diagnosis of Fabry disease Affected providers: In network Fabry Disease • o Male diagnosis: deficient activity of enzyme α-galactosidase in plasma and/or leukocytes AND GLA 1 mg/kg every 2 weeks mutation HCPCS Limit: 300 units HMO HMO HMO J0180 Fabrazyme agalsidase beta o Female diagnosis: GLA mutation PPO PPO PPO • Evidence of symptomatic manifestations of disease NDC NDC Limit • Diagnosis made by or in consultation with a geneticist or metabolic specialist 58468-0040-01 10 UN • Any additional pertinent medical information 58468-0041-01 60 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In network Severe Eosinophilic Asthma • Documentation of a consult with an allergist/immunologist or pulmonologist prior to initiation of Fasenra • 30 mg every 8 weeks therapy HCPCS Limit: 30 units • Must be used as add on maintenance treatment with severe uncontrolled eosinophilic asthma • Patient is currently receiving, and will continue to receive standard of care regimen NDC NDC Limit • Severe eosinophilic asthma identified by: 00310-1730-30 30 ML o Blood eosinophils greater than or equal to 150 cells/microliter in the past 12 months 00310-1830-30 1 ML AND 00310-1830-85 1 UN HMO HMO Repeated hospital/ED visits J0517 Fasenra benralizumab o PPO PPO AND o Chronic administration of systemic corticosteroids or high dose inhaled corticosteroids in combination with long acting inhaled β2 agonist or leukotriene modifier for at least 3 months fails to maintain adequate control 1. If the member is using an inhaler that contains a steroid along with other drugs, the corticosteroid component must be high dose • Cannot be used in combination with other biologics for asthma • Administered by a health care professional (unless requesting the Fasenra prefilled syringes or autoinjectors for self-administration)

HCPCS Limit: 100 units

NDC NDC Limit 00409-9094-09 200 ML 00409-1276-03 200 ML 00409-1276-32 200 ML 00409-9093-09 200 ML 00409-9093-11 200 ML 00409-9093-31 200 ML 00409-9093-32 200 ML 00409-9093-35 200 ML 00409-9093-36 200 ML 00409-9093-37 200 ML 00409-9093-38 200 ML 00409-9093-45 200 ML 00409-9094-11 200 ML 00409-9094-12 200 ML 00409-9094-16 200 ML 00409-9094-17 200 ML 00409-9094-18 200 ML 00409-9094-22 200 ML 00409-9094-25 200 ML fentanyl citrate Fentanyl citrate 00409-9094-28 200 ML J3010 injection 00409-9094-31 200 ML 00409-9094-41 200 ML 00409-9094-61 200 ML 71449-0013-32 200 ML 00641-6024-01 200 ML 00641-6024-10 200 ML 00641-6025-01 200 ML 00641-6025-10 200 ML 00641-6026-01 200 ML 00641-6026-05 200 ML 00641-6027-01 200 ML 00641-6027-25 200 ML 00641-6028-01 200 ML 00641-6028-25 200 ML 00641-6029-01 200 ML 00641-6029-25 200 ML 00641-6030-01 200 ML 54868-3738-00 200 ML 54868-3738-01 200 ML 61553-0107-50 2000 ML 61553-0111-14 1000 ML 61553-0111-48 1000 ML 61553-0112-52 1000 ML 61553-0113-50 1000 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

61553-0116-48 500 ML 61553-0118-41 200 ML 61553-0153-04 200 ML 61553-0273-48 200 ML 61553-0303-28 200 ML 61553-0303-79 200 ML 61553-0306-70 200 ML 61553-0431-61 200 ML 61553-0439-61 500 ML 61553-0525-69 200 ML 61553-0665-20 1000 ML 61553-0671-76 200 ML 61553-0672-44 200 ML 61553-0672-68 200 ML 61553-0673-76 200 ML 63323-0806-01 200 ML 63323-0806-02 200 ML 63323-0806-05 200 ML 63323-0806-11 200 ML 63323-0806-12 200 ML 63323-0806-13 200 ML 63323-0806-14 200 ML 63323-0806-20 200 ML 69374-0996-05 200 ML 66647-2003-11 200 ML 66647-2003-25 200 ML 66647-2003-94 200 ML 69374-0978-02 200 ML 70092-1093-37 1000 ML 70092-1097-43 200 ML 70092-1099-49 200 ML 70092-1100-50 200 ML 70092-1274-50 1000 ML 70092-1400-43 1000 ML 70092-1444-05 2000 ML 70092-1454-44 200 ML

70092-9544-36 200 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 100 units

NDC NDC Limit 70004-0200-16 12 ML J3010 Fentanyl Citrate fentanyl citrate/PF 70004-0200-32 12 ML 70004-0211-06 12 ML 70004-0222-09 12 ML 70004-0222-30 12 ML 71449-0013-11 200 ML 00641-6247-01 200 ML

00641-6247-25 200 ML Affected providers: In network

fentanyl citrate Fentanyl citrate -0.9% HCPCS Limit: 100 units injection -0.9% J3010 NACL/PF NACL/PF NDC NDC Limit

63323-0806-50 1000 ML Affected providers: In network

HCPCS Limit: 100 units fentanyl citrate Fentanyl citrate -0.9% J3010 injection -0.9% NACL NDC NDC Limit NACL/PF 70004-0200-20 12 ML 70004-0205-22 24 ML

70004-0205-32 24 ML Affected providers: In network

HCPCS Limit: 510 units

Feraheme ferumoxytol Q0138 NDC NDC Limit 59338-0775-01 17 ML 59338-0775-10 17 ML

00781-3154-01 17 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Non-preferred Hereditary Angioedema product Affected providers: In network Hereditary angioedema • Diagnosis of Type I or Type II hereditary angioedema (HAE) • 30 mg • Laboratory results confirming diagnosis (Include all of the following: C1q, C4, and C1 INH levels) HCPCS Limit: 90 units • Diagnosed by an immunologist, allergist, or hematologist • FDA approved age NDC NDC Limit HMO HMO • Any additional pertinent medical information 54092-0702-02 9 ML J1744 Firazyr icatibant PPO PPO 54092-0702-03 9 ML 00093-3066-19 9 ML 00093-3066-34 9 ML 00093-3066-93 9 ML 54092-0135-01 9 ML

54092-0135-02 9 ML Affected providers: In network

HCPCS Limit: 240 units

NDC NDC Limit J9155 Firmagon degarelix acetate 55566-8401-01 2 UN 55566-8401-02 2 UN 55566-8403-01 2 UN 55566-8301-01 3 UN 55566-8301-02 3 UN

55566-8303-01 3 UN • Diagnosis the medication is being used to treat • Pertinent lab results to confirm diagnosis • Names of medications previously used to treat this condition, including dosages, dates of therapy and HMO HMO HMO response J1572 Flebogamma immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 120 units J9307 Folotyn pralatrexate injection NDC NDC Limit 48818-0001-01 6 ML

48818-0001-02 6 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 52565-0105-01 20 UN 52565-0105-10 20 UN 52565-0106-01 10 UN 52565-0106-10 10 UN J0713 Fortaz inj ceftazidime 52565-0107-01 5 UN 52565-0107-10 5 UN 24987-0382-37 2 UN 24987-0379-34 5 UN 24987-0435-00 5 UN 24987-0378-10 10 UN 24987-0434-00 10 UN 24987-0377-10 20 UN 00173-0434-00 12 UN

00173-0435-00 6 UN • Non-preferred pegfilgrastim product Affected providers: In network • Pref erred pegfilgrastim product(s): NEULASTA, NEULASTA ONPRO & NYVEPRIA HMO HMO HCPCS Limit: 12 units Q5108 Fulphila pegfilgrastim-jmdb PPO PPO NDC NDC Limit

67457 0833 06 0.6 ML HMO HMO • Oncology Management Program J0641 Fusilev levoleucovorin PPO PPO Affected providers: In network

HCPCS Limit: 2000 units injection, J9210 Gamifant emapalumab-lzsg, 1 NDC NDC Limit mg 66658-0505-01 400 ML 66658-0510-01 400 ML 72171-0501-01 400 ML

72171-0505-01 400 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1569 Gammagard immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1566 Gammagard S/D immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1557 Gammaplex immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process Gamunex-C/ HMO HMO HMO response J1561 immune globulin Gammaked PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 100 units J9301 Gazyva obinutuzumab PPO PPO NDC NDC Limit

50242-0070-01 40 ML J7326 Gel-One hyaluronate sodium Not covered hyaluronic acid product J7328 GelSyn-3 hyaluronate sodium Covered/preferred hyaluronic acid product

HCPCS Limit: 25 units

NDC NDC Limit 00409-0181-01 132 ML 00409-0181-25 132 ML 00409-0182-01 132 ML 00409-0182-25 132 ML 00409-0183-01 132 ML 00409-0183-25 132 ML 00409-0185-01 25 UN 00409-0186-01 5 UN 00409-0187-01 3 UN 00703-5775-01 25 UN 00703-5778-01 5 UN 00781-3282-75 25 UN 00781-3283-79 5 UN 16714-0909-01 25 UN 16714-0930-01 25 UN 16729-0092-03 25 UN 16729-0117-11 5 UN 16729-0118-38 3 UN 16729-0391-30 50 ML 16729-0419-03 50 ML J9201 Gemcitabine HCL gemcitabine hcl 16729-0423-33 50 ML 23155-0213-31 25 UN 23155-0214-31 5 UN 23155-0483-31 25 UN 23155-0484-31 5 UN 23155-0528-31 25 UN 23155-0529-31 5 UN 25021-0234-10 25 UN 25021-0235-50 5 UN 25021-0239-05 25 UN 25021-0239-26 5 UN 25021-0239-52 2.5 UN 45963-0612-57 25 UN 45963-0619-59 5 UN 45963-0620-60 3 UN 45963-0623-57 131.5 ML 45963-0624-58 131.5 ML 45963-0636-60 131.5 ML 47335-0153-40 25 UN 47335-0154-40 5 UN 55111-0686-07 25 UN 55111-0687-25 5 UN 60505-6113-06 132 ML 60505-6115-00 132 ML 60505-6115-02 132 ML *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 57 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

61553-0153-04 50 ML 62756-0614-60 3 UN 63323-0102-13 25 UN 63323-0102-94 25 UN 63323-0125-53 5 UN 63323-0125-94 5 UN 63323-0126-00 3 UN 63323-0126-03 2.5 UN 67457-0462-01 5 UN 67457-0463-02 3 UN 67457-0464-20 25 UN 67457-0616-10 132 ML 67457-0617-30 5 UN 67457-0618-10 2.5 UN 68001-0282-23 5 UN 68001-0282-25 25 UN 68001-0282-26 5 UN 68001-0282-27 3 UN 68001-0342-34 50 UN 68001-0348-36 50 UN 68001-0359-37 50 UN 70860-0205-50 5 UN 71288-0113-10 25 UN 71288-0114-50 5 UN 71288-0117-06 131.5 ML 71288-0117-28 131.5 ML 71288-0117-54 157.8 ML 72485-0221-02 132 ML 72485-0222-10 132 ML

72485-0223-20 132 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network Breast cancer: • 1,250 mg/m2 given 2 days of HCPCS Limit: 25 units each 21-day cycle Non-small cell lung cancer NDC NDC Limit (NSCLC) 00002-7501-01 25 UN • 1,000 mg/m2 given on 3 d ay s of each 28-day cycle 00002-7502-01 5 UN • 1,250 mg/m2 given for 2 days J9201 Gemzar gemcitabine of each 21-day cycle Ovarian cancer: • 1,000 mg/m2 given weekly for 7 weeks, then weekly every 3 weeks of each 21-day cycle Pancreatic cancer: • 1,000 mg/m2 given weekly for 7 weeks, then weekly for 3 weeks of each 28-day cycle Affected providers: In network

HCPCS Limit: 54 units

Gengraf cyclosporine oral J7502 NDC NDC Limit 00074-3109-32 54 UN 00074-6479-32 54 UN

00074-7269-50 54 ML Affected providers: In network

HCPCS Limit: 216 units J7515 Gengraf cyclosporine modified NDC NDC Limit 00074-0541-30 108 UN

00074-3108-32 216 UN J7320 GenVisc hyaluronate sodium Not covered hyaluronic acid product

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In networks • Diagnosis of acute hepatic porphyria (AHP) which includes: ALA-dehydratase deficiency porphyria (ADP), acute intermittent porphyria (AIP), hereditary corproporphyria (HCP), or variegate porphyria (VP) HCPCS Limit: 189 units • Prescribed by or in consultation with a physician that has experience managing AHP • Documentation of elevated urinary aminolevulinic acid (ALA) OR porphobilinogen (PBG) levels above the NDC NDC Limit

lab tests upper level of normal obtained during an acute attack AND/OR genetic testing positive for a 71336-1001-01 2 ML mutation consistent with ADP, AIP, HCP, or VP • Have active disease with at least 2 documented porphyria attacks in the last 6 months OR chronic baseline disease activity with symptoms such as: J0223/ HMO HMO HMO Givlaari givosiran Pain in the abdomen, back, and/or chest C9056 PPO PPO PPO o o Cardiovascular conditions including hypertension, and tachycardia o Gastrointestinal involvement including nausea, vomiting, and constipation o Neurological involvement including neuropathic pain, sensory loss, muscle weakness, paralysis, confusion, anxiety, depression, memory loss, fatigue, hallucinations, or seizures o Other system involvement including respiratory failure, skin lesions, or hyponatremia • Have taken the appropriate lifestyle modifications to prevent acute attacks including but not limited to: dietary modifications, quitting smoking, stopping alcohol use, and removing medications known to cause acute attacks when possible • Must not have had a previous liver transplant or have a scheduled liver transplant • FDA approved age Affected providers: In network Alpha1-proteinase inhibitor • Must be a nonsmoker deficiency • Member must have pre-treatment serum levels of alpha-1 antitrypsin (AAT) that are less than 11 HCPCS Limit: 900 units • 60 mg/kg once weekly micromol/L measured by ELISA (less than 80 mg/dL measured by radial immunodiffusion or less than 57 mg/dL measured by nephelometry)consistent with phenotypes PiZZ, PiZ (null), or Pi (null, null) of AAT NDC NDC Limit alpha 1 proteinase HMO HMO J0257 Glassia 00944-2884-01 9 UN inhibitor PPO PPO o Phenotype/genotype testing may be requested for additional support of alpha-1 antitrypsin deficiency diagnosis 00944-2884-02 9 UN • Member must have symptomatic emphysema • Member must have deteriorating pulmonary function, as demonstrated by a decline in the FEV1 (35-60% of predictive value)

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00078-0401-34 20 UN 00078-0438-15 5 UN 00078-0649-30 5 UN S0088 Gleevec imatinib 54868-5289-00 20 UN 54868-5289-01 20 UN 54868-5289-02 20 UN 54868-5289-04 20 UN 54868-5427-00 20 UN 54868-5427-03 20 UN 72485-0202-90 20 UN

72485-0203-30 5 UN Affected providers: In network

HCPCS Limit: 30 units

NDC NDC Limit 00143-9744-01 3 ML 00143-9745-01 3 ML J1626 Granisetron hcl granisetron hcl/pf 00703-7891-01 30 ML 25021-0778-01 30 ML 25021-0778-66 30 ML 63323-0317-01 30 ML 66860-0081-06 30 ML 67457-0863-01 3 ML

67457-0864-04 3 ML Affected providers: In network

Granisetron extended granisetron extended- HCPCS Limit: 100 units J1627 release release NDC NDC Limit

47426-0101-06 0.4 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 5 units

NDC NDC Limit 00054-0143-08 5 UN 00054-0143-87 5 UN 00093-7485-12 5 UN 00093-7485-19 5 UN 00093-7485-20 5 UN 00143-9744-10 5 ML 00143-9745-05 5 ML 00703-7971-03 5 ML 00703-7973-01 5 ML 16714-0221-01 5 UN 16714-0221-10 5 UN 16714-0221-12 5 UN 16714-0221-30 5 UN 16714-0221-32 5 UN Q0166 Granisetron hcl granisetron hcl oral 17478-0546-02 5 ML 17478-0546-05 5 ML 25021-0779-01 5 ML 25021-0781-04 5 ML 42043-0390-00 5 UN 42043-0390-02 5 UN 42043-0390-20 5 UN 42043-0390-21 5 UN 42043-0390-40 5 UN 51672-4138-06 5 ML 51991-0735-20 5 UN 51991-0735-32 5 UN 51991-0735-99 5 UN 63323-0318-01 5 ML 63323-0319-04 5 ML 64720-0198-02 5 UN 64720-0198-98 5 ML 66758-0035-01 5 ML 66860-0082-06 5 ML

66860-0083-01 5 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Non-preferred filgrastim product Affected providers: In network • Preferred filgrastim product(s): NIVESTYM & ZARXIO HCPCS Limit: 1500 units

NDC NDC Limit 63459-0910-11 2.5 ML 63459-0910-15 2.5 ML 63459-0910-17 2.5 ML HMO HMO 63459-0910-36 2.5 ML J1447 Granix tbo-filgrastim PPO PPO 63459-0912-11 3,2 ML 63459-0912-12 3.2 ML 63459-0912-15 3.2 ML 63459-0912-17 3.2 ML 63459-0912-36 3.2 ML 63459-0918-53 5 ML 63459-0918-59 5 ML 63459-0920-53 6.4 ML

63459-0920-59 6.4 ML HMO HMO • Oncology Management Program J9179 Halaven eribulin mesylate PPO PPO • For prophylaxis of bleeding episodes in patients diagnosed with hemophilia A with inhibitors Affected providers: In network • Prescribed by or in consultation with a specialist that works in a hemophilia treatment center • Documentation of a historical or current high titer for factor VIII inhibitors measuring ≥ 5 Bethesda HCPCS Limit: 3600 units Units per milliliter (BU/mL) • Will not be used in combination with Immune Tolerance Induction (ITI) NDC NDC Limit • Medication is dispensed by a treatment center associated with hemophilia that provides high quality 50242-0920-01 60 ML hemophilia care with outcome-based results (ie: hemophilia treatment center) 50242-0921-01 12 ML HMO HMO HMO • For prophylaxis of bleeding episodes in patients diagnosed with hemophilia A without inhibitors J7170 Hemlibra emicizumab-kxwh PPO PPO PPO • Prescribed and dispensed by a specialist that works in a hemophilia treatment center 50242-0922-01 12 ML • Documentation of severe hemophilia A with factor VIII level <1% or moderate hemophilia A with factor 50242-0923-01 12 ML

VIII level between 1% - 5% • Documentation of optimal treatment with factor VIII has not been effective in adequately controlling the disease (member experienced spontaneous bleeding events or joint pain while on optimal therapy) • Documentation of the number of bleeds experienced within the past 12 months • Medication is dispensed by a treatment center associated with hemophilia that provides high quality hemophilia care with outcome-based results (ie: hemophilia treatment center) • Non-preferred trastuzumab product HMO HMO J9355 Herceptin trastuzumab • Pref erred trastuzumab product(s): KANJITI and TRAZIMERA PPO PPO

trastuzumab and HMO HMO • Oncology Management Program J9356 Herceptin Hylecta hyaluronidase-oysk PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Non-preferred trastuzumab product HMO HMO Q5113 Herzuma trastuzumab-pkrb • Pref erred trastuzumab product(s): KANJITI and TRAZIMERA PPO PPO

• Diagnosis the medication is being used to treat Max daily limit to be determined in Novologix through Prior o Pertinent lab results to confirm diagnosis • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1559 Hizentra immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information

J7321 Hyalgan hyaluronate sodium Not covered hyaluronic acid product

HCPCS Limit: 6 units

NDC NDC Limit 00074-1283-01 24 ML 00409-1283-03 24 ML 00409-1283-04 24 ML 00409-1283-05 24 ML 00409-1283-09 24 ML 00409-1283-10 24 ML 00409-1283-31 24 ML 00409-1304-03 6 ML 00409-1304-31 6 ML 00409-1312-03 12 ML 00409-1312-09 12 ML 00409-1312-10 12 ML 00409-1312-30 12 ML 00409-2540-01 12 ML 00409-2540-11 6 ML 00409-2552-01 24 ML 00409-2552-11 24 ML 00409-2634-01 30 ML 00409-2634-05 30 ML hydromorphone hcl 00409-2634-10 150 ML Hydromorphone HCL J1170 injection 00409-2634-10 2.4 ML 00409-2634-50 30 ML 00409-3356-01 12 ML 00409-3356-11 12 ML 00409-3365-01 12 ML 00409-3459-07 12 ML 00641-0121-21 12 ML 00641-0121-25 12 ML 00641-2341-39 12 ML 00641-2341-41 12 ML 00641-6151-01 12 ML 00641-6151-25 12 ML 00703-0018-01 30 ML 00703-0100-01 3 ML 00703-0110-03 30 ML 00703-0113-01 30 ML 00703-0113-03 30 ML 17478-0540-01 30 ML 17478-0540-05 30 ML 17478-0540-50 30 ML 61553-0520-69 30 ML 61553-0684-78 12 ML 61553-0685-76 55 ML 63323-0851-03 3 ML 63323-0851-07 3 ML *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 65 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

63323-0851-10 3 ML 63323-0851-15 3 ML 63323-0851-15 3 ML 63323-0851-50 3 ML 63323-0852-03 24 ML 63323-0852-03 24 ML 63323-0852-25 24 ML 63323-0853-03 12ML 63323-0853-25 12 ML 63323-0854-03 6 ML 63323-0854-10 6 ML

69374-0983-01 24 ML

HCPCS Limit: 6 units

NDC NDC Limit 61553-0161-41 120 ML 61553-0161-74 120 ML 61553-0162-44 120 ML 61553-0162-67 125 ML 61553-0163-75 150 ML 61553-0165-41 50 ML 61553-0165-78 24 ML 61553-0166-44 30 ML 61553-0166-67 25 ML 61553-0167-75 50 ML 61553-0206-48 120 ML 61553-0207-01 120 ML 61553-0208-37 120 ML 61553-0209-02 120 ML 61553-0242-48 24 ML 61553-0352-40 48 ML 61553-0501-69 240 ML 61553-0502-69 120 ML 61553-0504-69 60 ML Hydromorphone HCL- hydromorphone hcl in 61553-0505-69 60 ML J1170 0.9% NACL 0.9% nacl 61553-0508-68 30 ML 61553-0510-69 30 ML 61553-0601-20 24 ML 61553-0612-75 150 ML 61553-0624-52 120 ML 61553-0627-68 120 ML 61553-0629-75 50 ML 61553-0633-75 50 ML 61553-0637-68 30 ML 61553-0641-67 75 ML 61553-0678-67 250 ML 61553-0679-76 275 ML 61553-0680-67 125 ML 61553-0682-67 25 ML 61553-0683-76 55 ML 61553-0691-68 60 ML 61553-0702-68 120 ML 61553-0704-68 60 ML 61553-0705-68 60 ML 61553-0706-68 60 ML 61553-0710-68 30 ML 61553-0823-48 100 ML 61553-0830-41 150 ML 61553-0832-41 150 ML 61553-0890-48 200 ML *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 67 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

61553-0903-41 50 ML 61553-0956-02 24 ML 61553-0962-48 24 ML 61553-0970-96 12 ML 61553-0989-41 24 ML 70004-0322-55 120 ML 70004-0300-16 120 ML 70004-0300-18 120 ML 70004-0323-30 24 ML 70004-0300-30 120 ML 70092-1110-50 55 ML 70092-1112-49 120 ML 70092-1113-79 120 ML 70092-1114-50 150 ML 70092-1116-75 200 ML 70092-1117-79 30 ML 70092-1118-50 50 ML 70092-1168-35 48 ML 70092-1285-44 120 ML 70092-1287-35 120 ML 70092-1294-74 50 ML 70092-1532-43 24 ML 70092-1533-43 12 ML 70092-1546-35 24 ML 70092-9115-36 120 ML 70092-9287-35 120 ML 70092-9294-74 24 ML 70092-9546-35 24 ML

71030-0072-05 50 ML • Administered by a healthcare professional Affected providers: In network Intramuscular: 250 mg • Gestational ages between 16 weeks 0 days and 20 weeks 6 days at treatment initiation Subcutaneous: 275 mg weekly • Singleton pregnancy HCPCS Limit: 125 units starting at 16 weeks. 0 days gestation to 36 weeks, 6 days Hydroxyprogesterone hydroxyprogesterone HMO • Previous history of spontaneous preterm delivery in a singleton pregnancy J1729 caproate caproate NOS NDC NDC Limit gestation for maximum of 21 PPO • No known fetal anomalies incompatible with life 00517-1791-01 5 ML doses 62559-0540-15 5 ML

67457-0886-05 5 ML

HCPCS Limit: 16 units

NDC NDC Limit 00115-1670-01 16 UN 00115-1670-02 16 UN 00115-1671-01 8 UN 00115-1671-02 8 UN 00115-1804-02 8 UN 00185-0615-01 8 UN 00185-0615-05 8 UN 00185-0674-05 16 UN 00555-0302-02 8 UN 00555-0302-04 8 UN 00555-0323-02 16 UN 00555-0323-04 16 UN 00555-0324-02 4 UN 00591-0800-01 16 UN 00591-0800-05 16 UN 00591-0801-01 8 UN 00591-0801-05 8 UN 21695-0537-20 16 UN 35356-0938-20 16 UN Hydroxyzine 42291-0322-50 16 UN hydroxyzine pamoate Q0177 pamoate 42291-0322-90 16 UN 42291-0323-50 8 UN 42291-0323-90 8 UN 43063-0251-10 4 UN 43353-0094-30 16 UN 43353-0094-53 16 UN 43353-0094-60 16 UN 43353-0094-70 16 UN 43353-0199-30 16 UN 43353-0199-53 16 UN 43353-0199-60 16 UN 43353-0199-70 16 UN 43353-0199-80 16 UN 49999-0701-20 16 UN 49999-0701-30 16 UN 50090-2984-02 16 UN 50090-3284-01 8 UN 50090-2984-05 16 UN 50090-0355-05 16 UN 50090-0374-01 8 UN 50268-0398-11 16 UN 50268-0398-50 16 UN 50268-0399-11 8 UN 50268-0399-50 8 UN 51079-0077-01 16 UN *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 69 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 51079-0077-20 16 UN 51079-0078-01 8 UN 51079-0078-20 8 UN 52959-0433-10 16 UN 52959-0433-15 16 UN 52959-0433-20 16 UN 52959-0433-30 16 UN 52959-0433-40 16 UN 52959-0433-60 16 UN 52959-0833-06 8 UN 52959-0833-20 8 UN 54569-2353-05 16 UN 54569-2571-01 8 UN 54868-2892-00 16 UN 54868-2892-03 16 UN 54868-2892-04 16 UN 54868-2892-05 16 UN 55289-0226-10 16 UN 55289-0226-15 16 UN 55289-0354-10 8 UN 55700-0202-20 16 UN 55700-0202-30 16 UN 55700-0237-30 16 UN 55700-0635-30 8 UN 55700-0635-90 8 UN 59762-5420-01 8 UN 60429-0294-01 16 UN 60429-0294-05 16 UN 60429-0295-01 8 UN 60429-0295-05 8 UN 61919-0357-15 16 UN 61919-0357-30 16 UN 62584-0741-01 8 UN 62584-0741-11 8 UN 63187-0763-30 16 UN 63629-1533-01 16 UN 63629-1533-02 16 UN 63629-1533-03 16 UN 63629-1533-04 16 UN 64980-0169-01 16 UN 64980-0169-05 16 UN 64980-0170-01 8 UN 64980-0170-05 8 UN 68084-0847-01 16 UN 68084-0847-11 16 UN 71205-0123-30 16 UN 71610-0397-60 16 UN 71610-0095-30 16 UN 71610-0095-53 16 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

71610-0095-60 16 UN 71610-0095-70 16 UN 71610-0095-80 16 UN 71610-0217-60 16 UN 71610-0239-60 16 UN 71610-0397-30 16 UN 71610-0397-53 16 UN 71610-0397-70 16 UN 71610-0397-80 16 UN 71205-0433-30 16 UN 71335-1714-02 16 UN

71205-0558-30 16 UN

J7322 Hymovis hyaluronate sodium Not covered hyaluronic acid product • Diagnosis of a primary humoral immunodeficiency disease (i.e., X-linked agammaglobulinemia, Max daily limit to be determined in hypogammaglobulinemia, common variable immunodeficiency (CVID), immunoglobulin subclass Novologix through Prior deficiency, combined immunodeficiency syndromes) Authorization process • Pertinent laboratory results to confirm diagnosis (for example, baseline IgG level plus laboratory findings to support diagnosis) • Names of medications previously used to treat this condition, including: HMO HMO HMO J1575 Hyqvia immune globulin Dosages PPO PPO PPO o o Dates of therapy o Response to therapy • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Preferred Hereditary Angioedema product Affected providers: In network Hereditary angioedema • Diagnosis of Type I or Type II hereditary angioedema (HAE) • 30 mg • Laboratory results confirming diagnosis (Include all of the following: C1q, C4, and C1 INH levels) HCPCS Limit: 90 units • Diagnosed by an immunologist, allergist, or hematologist • FDA approved age NDC NDC Limit • Any additional pertinent medical information 00093-3066-19 9 ML 00093-3066-34 9 ML 00093-3066-93 9 ML HMO HMO J1744 Icatibant Icatibant hcl 24201-0207-01 9 ML PPO PPO 24201-0207-03 9 ML 54092-0135-01 9 ML 54092-0135-02 9 ML 60505-6214-01 9 ML 63323-0574-01 9 ML 63323-0574-86 9 ML 63323-0574-93 9 ML

69097-0664-68 9 ML Affected providers: In network

HCPCS Limit: 10 units

Idamycin PFS idarubicin hcl J9211 NDC NDC Limit 00013-2576-91 48 ML 00013-2586-91 48 ML

00013-2596-91 48 ML Affected providers: In network

HCPCS Limit: 10 units

NDC NDC Limit 00143-9306-01 48 ML 00143-9307-01 48 ML J9211 Idarubicin HCL idarubicin hcl 00143-9308-01 48 ML 00703-4154-11 48 ML 00703-4155-11 48 ML 00703-4156-11 48 ML 59762-2586-01 48 ML 63323-0194-05 48 ML 63323-0194-10 48 ML

63323-0194-20 48 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network Cryopyrin-associated periodic • FDA approved age syndrome (CAPS) Adult and • Diagnosis of: HCPCS Limit: 300 units Pediatric ≥ 4years (>40kg): • 150 mg every 8 weeks o Still’s Disease, including adult-onset Still’s disease and systemic juvenile idiopathic arthritis (sJIA) . Trial and failure with one of the following: methotrexate, leflunomide, glucocorticoids, NSAIDs NDC NDC Limit Tumor Necrosis Factor Receptor . Trial and failure, contraindication or intolerance to Kineret and Actemra 00078-0582-61 2 UN Associated Periodic Syndrome Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPS) (TRAPS): o 00078-0734-61 2 ML • 300 mg every 4 weeks o Hyperimmunoglobulin D Syndrome (HIDS)/Mevalonate Kinase Deficiency (MKD) o Familial Mediterranean Fever (FMF) in patients who have tried and failed colchicine Hyperimmuneglobulin D o Cryopyrin-Associated Periodic Syndromes (CAPS) with phenotypes: Familial Cold Auto- Syndrome (HIDS)/Mevalonate Inflammatory Syndrome (FCAS) or Muckle-Wells Syndrome (MWS) Kinase Deficiency (MKD): HMO HMO HMO . Laboratory evidence of a genetic mutation (such as in the Cold-Induced Auto-inflammatory • 300 mg every 4 weeks J0638 Ilaris canakinumab PPO PPO PPO Syndrome 1 (CIAS1 – also referred to as the NLRP-3)) Familial Mediterranean Fever OR (FMF): . Elevated inflammatory markers (C-reactive protein [CRP] and serum amyloid A) plus at least • 300 mg every 4 weeks two of six typical CAPS manifestations: Systemic Juvenile Idiopathic - Urticaria-like rash Arthritis (SJIA): - Cold-triggered episodes • 300 mg - Sensorineural hearing loss Cryopyrin-associated periodic - Musculoskeletal symptoms syndrome (CAPS) Pediatric - Chronic aseptic meningitis Pediatric ≥ 4years (15-40 kg): - Skeletal abnormalities • 3 mg/kg every 8 weeks • Not to be used in combination with other biologics or targeted DMARDs

• FDA approved indication. • FDA approved age. • Diagnosis of psoriasis (PsO) HMO HMO Trial and failure, contraindication, or intolerance to light therapy J3245 Ilumya tildrakizumab - asmn o PPO PPO o Trial and failure of at least 3 months of one generic oral systemic agent unless contraindicated or not tolerated. Examples include cyclosporine, methotrexate, acitretin. Not to be used in combination with other biologics or targeted disease-modifying anti-rheumatic drugs (DMARDs) Affected providers: In network

injection, fluocinlone HCPCS Limit: 38 units J7313 Iluvien acetonide, intravitreal implant, 0.01 mg NDC NDC Limit

68611-0190-02 2 UN

HCPCS Limit: 20 units

NDC NDC Limit 00054-0248-22 20 UN 00054-0249-13 5 UN 00093-7629-98 20 UN 00093-7630-56 5 UN 51407-0269-90 20 UN 51407-0270-30 5 UN 00378-2245-77 20 UN 00378-2246-93 5 UN 00904-6621-04 5 UN 00904-6901-04 20 UN 16714-0705-01 5 UN 16714-0705-01 5 UN 42291-0351-90 20 UN 42291-0352-30 5 UN 42292-0043-01 20 UN 42292-0043-03 20 UN 42292-0044-01 5 UN 42292-0044-03 5 UN 43598-0344-90 20 UN 43598-0345-30 5 UN S0088 Imatinib mesylate imatinib mesylate 43598-0344-31 20 UN 43598-0344-79 20 UN 43598-0345-31 5 UN 43598-0345-79 5 UN 47335-0472-81 20 UN 47335-0475-83 20 UN 50268-0426-11 20 UN 50268-0426-12 20 UN 50268-0427-11 5 UN 50268-0427-12 5 UN 59923-0723-90 20 UN 59923-0724-30 5 UN 59651-0240-90 20 UN 59651-0241-30 5 UN 60429-0925-90 20 UN 60429-0926-30 5 UN 60505-2900-09 20 UN 60505-2901-03 5 UN 72606-0556-01 20 UN 72606-0557-01 5 UN 63629-2067-01 20 UN 63629-2068-01 5 UN 60687-0192-11 5 UN 60687-0192-21 5 UN 60687-0203-25 20 UN *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 74 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

60687-0203-95 20 UN 67877-0633-90 20 UN 67877-0634-30 5 UN 68001-0490-05 20 UN

68001-0491-04 20 UN

Affected providers: In network

HCPCS Limit: 1 unit imdevimab imdevimab NDC NDC Limit Q0243 (REGN10987) (EUA) (REGN10987) 61755-0025-00 10 ML 61755-0025-01 10 ML 61755-0027-00 10 ML

61755-0027-01 10 ML • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 300 units J9173 Imf inzi durvalumab PPO PPO NDC NDC Limit 00310-4500-12 30 ML

00310-4611-50 30 ML talimogene HMO HMO • Oncology Management Program J9325 Imlygic laherparepvec PPO PPO • Diagnosis the medication is being used to treat • Pertinent lab results to confirm diagnosis Immune Globulin HMO HMO HMO **90283 immune globulin • Names of medications previously used to treat this condition, including dosages, dates of therapy and (IgIV) PPO PPO PPO response • Any additional pertinent medical information • Diagnosis the medication is being used to treat • Pertinent lab results to confirm diagnosis Immune globulin HMO HMO HMO **90284 immune globulin • Names of medications previously used to treat this condition, including dosages, dates of therapy and (SCIg) PPO PPO PPO response • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit J1750 Infed iron dextran complex 00023-6082-01 20 ML 00023-6082-10 20 ML 52544-0931-02 20 ML 52544-0931-07 20 ML

54569-3846-00 20 ML • FDA approved indications Affected providers: In network Ankylosing spondylitis • FDA approved age • 10mg/kg every 6 weeks • Diagnosis of Crohn’s disease HCPCS Limit: 200 units Crohn's disease (pediatric) • o Active Crohn’s disease: Psoriasis / psoriatic arthritis - Treatment with an adequate course of conventional therapy (such as steroids for 7 days, NDC NDC Limit • Ulcerative colitis immunomodulators such as azathioprine for at least 2 months) has been ineffective or is • 10mg/kg every 8 weeks 00069-0809-01 20 UN contraindicated or not tolerated Rheumatoid Arthritis o Fistulizing Crohn’s disease • 10 mg/kg every 4 weeks • Diagnosis of ulcerative colitis: Crohn's Disease (adult) o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, • 10 mg/kg every 8 weeks immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated • Diagnosis of rheumatoid arthritis: HMO HMO Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless Q5103 Inflectra infliximab-dyyb o PPO PPO contraindicated or not tolerated. Examples include methotrexate, hydroxychloroquine, leflunomide, sulfasalazine o Administered in combination with methotrexate • Diagnosis of psoriatic arthritis o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine. • Diagnosis of plaque psoriasis o Trial and failure, contraindication, or intolerance to light therapy o Trial and failure of at least 3 months of one generic oral systemic agent unless contraindicated or not tolerated. Examples include cyclosporine, methotrexate, acitretin • Diagnosis of ankylosing spondylitis • Not to be used in combination with other biologics or targeted DMARDs • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 50 units

NDC NDC Limit 62756-0008-60 4 UN 62756-0073-60 5 UN J9198 Infugem gemcitabine hcl 62756-0102-60 4 UN 62756-0219-60 4 UN 62756-0321-60 4 UN 62756-0438-60 3 UN 62756-0533-60 3 UN 62756-0746-60 3 UN

62756-0974-60 3 UN Affected providers: In network

HCPCS Limit: 25 units J2270 Infumorph morphine sulfate/pf NDC NDC Limit 00641-6039-01 25 ML

00641-6040-01 10 ML Affected providers: In network

HCPCS Limit: 750 units J1439 Injectafer ferric carboxymaltose NDC NDC Limit 00517-0650-01 15 ML

00517-0650-02 15 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network AIDS-related Kaposi's Sarcoma • 30 million IU/m2 per dose 3 HCPCS Limit: 120 units times weekly Chronic hepatitis B NDC NDC Limit • 10 million IU/dose given daily 00085-1133-01 12 ML or 3 times weekly 00085-1168-01 20 ML • Maximum of 140 million IU 00085-1242-01 40 UN per month 00085-4350-01 12 UN Chronic hepatitis B (pediatrics) • 00085-4351-01 7 UN 3 million IU/m2 per dose given 3 times weekly up to

00085-4352-01 3 UN 16-24 weeks • Maximum of 36 million IU/m2 per month Chronic Hepatitis C • 3 million IU 3 times weekly • Maximum of 36 million IU per month Congylomata Acuminata • 1 million IU per lesion 3 times weekly x 3 weeks J9214 Intron-A interferon alfa-2b • Given in a maximum of 5 lesions Follicular lymphoma • 5 million IU 3 times weekly x 18 months • Maximum of 60 million IU per month Hairy Cell Leukemia • 2 million IU/m2 3 times weekly • Maximum of 24 million IU/m2 per month Malignant melanoma • Induction: 20 million IU/m2 for 5 consecutive days per week for 4 weeks (maximum of 400 million IU/m2 per month) • Maintenance: 10 million IU/m2 3 times weekly for 48 weeks (maximum of 120 million IU/m2 per month)

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 4 units

Invanz ertapenem injection J1335 NDC NDC Limit 00006-3843-71 2 UN 00006-3845-01 2 UN

00006-3845-71 2 UN • Oncology Management Program Affected providers: In network

J9315/ HMO HMO HCPCS Limit: 60 units Istodax romidepsin C9065 PPO PPO NDC NDC Limit

59572-0984-01 6 UN • Oncology Management Program Affected providers: In network

HCPCS Limit: 90 units

HMO HMO J9207 Ixempra ixabepilone NDC NDC Limit PPO PPO 00015-1910-12 6 UN 00015-1911-13 2 UN 70020-1910-01 6 UN

70020-1911-01 2 UN HMO HMO • Oncology Management Program J9281 Jelmyto mitomycin PPO PPO HMO HMO • Oncology Management Program J9999 Jemperli dostarlimab-gxly PPO PPO HMO HMO • Oncology Management Program J9043 Jevtana cabazitaxel PPO PPO ado-trastuzumab HMO HMO • Oncology Management Program J9354 Kadcyla emtansine PPO PPO • Non-preferred Hereditary Angioedema product Affected providers: In network Hereditary angioedema • Diagnosis of Type I or Type II hereditary angioedema (HAE) • 60mg HMO HMO • Laboratory results confirming diagnosis (Include all of the following: C1q, C4, and C1 INH levels) HCPCS Limit: 180 units J1290 Kalbitor ecallantide PPO PPO • Diagnosed by an immunologist, allergist, or hematologist • Any additional pertinent medical information NDC NDC Limit • FDA approved age 47783-0101-01 18 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network • Pref erred trastuzumab product(s): KANJITI and TRAZIMERA HMO HMO HCPCS Limit: 9999 units Q5117 Kanjinti trastuzumab-anns PPO PPO NDC NDC Limit

N/A N/A • Diagnosis of lysosomal acid lipase deficiency (LAL-d) confirmed by blood test measuring LAL activity OR Affected providers: In network Lysosomal acid lipase (LAL) genetic testing deficiency within the first 6 • Symptomatic manifestation of the disease are present (i.e., elevated liver enzymes, microvesicular HCPCS Limit: 300 units months of life: HMO HMO HMO J2840 Kanuma sebelipase alfa steatosis, elevated low-density lipoprotein, low high-density lipoprotein, or coronary artery disease • 3 mg/kg PPO PPO PPO • Diagnosis made by or in consultation with a geneticist or metabolic specialist NDC NDC Limit Lysosomal acid lipase (LAL) • Any additional pertinent medical information deficiency: 25682-0007-01 150 ML • 1 mg/kg Affected providers: In network

HCPCS Limit: 5000 units prothrombin complex Kcentra J7168 concentrate (human) NDC NDC Limit 63833-0386-02 5000 UN

63833-0387-02 5000 UN Affected providers: In network

HCPCS Limit: 20 units

J3301 Kenalog-10 triamcinolone acet NDC NDC Limit 35356-0082-01 20 ML 54868-0234-00 20 ML 68258-8903-05 20 ML

00003-0494-20 20 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 21695-0360-01 5 ML Kenalog-40/Kenalog- 21695-0360-10 5 ML triamcinolone acet J3301 80 49999-0415-05 5 ML 76420-0085-01 5 ML 00003-0293-05 5 ML 00003-0293-20 5 ML 00003-0293-28 5 ML 00003-0315-05 5 ML

00003-0315-20 5 ML

HCPCS Limit: 8 units

NDC NDC Limit 00074-2287-54 4 ML 00338-0069-10 8 ML 00338-0076-10 4 ML 00409-2287-04 4 ML 00409-2287-20 4 ML 00409-2287-23 4 ML 00409-2287-31 4 ML 00409-2287-61 4 ML 00409-2288-21 8 ML 00409-2288-31 8 ML 00409-3793-01 8 ML 00409-3793-19 8 ML 00409-3795-01 4 ML 00409-3795-19 4 ML 00409-3796-01 4 ML 00409-3796-19 4 ML 00409-3796-61 4 ML 00548-9021-00 4 ML 00641-6041-01 8 ML Ketorolac ketorolac 00641-6041-25 8 ML J1885 tromethamine tromethamine 00641-6042-01 4 ML 00641-6042-25 4 ML 00641-6043-01 4 ML 00641-6043-25 4 ML 25021-0700-01 8 ML 25021-0701-01 4 ML 25021-0701-02 4 ML 47781-0583-68 8 ML 47781-0583-93 8 ML 47781-0584-68 4 ML 47781-0584-93 4 ML 47781-0585-46 4 ML 47781-0585-68 4 ML 54569-5189-00 4 ML 54569-6369-00 4 ML 54569-6494-00 4 ML 54569-6494-01 4 ML 55154-0120-05 4 ML 55154-9366-05 8 ML 55390-0480-01 8 ML 55390-0481-01 4 ML 55390-0481-02 4 ML 55390-0481-10 4 ML 63323-0161-01 8 ML 63323-0161-12 8 ML *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 82 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

63323-0162-00 4 ML 63323-0161-16 8 ML 63323-0162-01 4 ML 63323-0162-02 4 ML 63323-0162-12 4 ML 63323-0162-14 4 ML 63323-0162-16 4 ML 63323-0162-26 4 ML 63323-0161-21 8 ML 63323-0162-23 4 ML 66860-0084-03 8 ML 66860-0085-03 4 ML 66860-0086-03 4 ML 69374-0990-32 4 ML 69543-0386-25 4 ML 69543-0386-30 4 ML 70860-0700-02 8 ML 70860-0701-03 4 ML 70860-0701-04 4 ML 72266-0118-01 4 ML 72266-0118-25 4 ML 72266-0119-01 4 ML 72266-0119-25 4 ML 72611-0719-01 4 ML 72611-0719-25 4 ML 72611-0722-01 4 ML 72611-0722-25 4 ML 72611-0725-01 4 ML 72611-0725-25 4 ML 76045-0104-10 4 ML 76045-0105-20 4 ML

76045-0107-10 8 ML • Oncology Management Program Affected providers: In network

HCPCS Limit: 600 units

HMO HMO NDC NDC Limit J9271 Keytruda pembrolizumab PPO PPO 00006-3029-01 24 UN 00006-3029-02 24 UN 00006-3026-02 24 ML 00006-3026-01 24 ML

000063026-04 24 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO HMO HMO • Oncology Management Program J0642 Khapzory levoleucovorin PPO PPO • FDA approved indication Affected providers: In network Gout • FDA approved age • 8 mg every 2 weeks • Patient has one of the following: HCPCS Limit: 8 units

o Three gouty flares or more in previous 18 months o Presence of one or more tophi NDC NDC Limit o Chronic gouty arthritis (defined clinically or radiographically as joint damage due to gout) 60809-0801-01 1 ML • Baseline serum uric acid ≥ 8 mg/ dL 54396-0801-01 1 ML • Member has undertaken appropriate lifestyle modifications, (i.e. limiting alcohol consumption, 75987-0080-10 1 ML discontinuing or changing other medications known to precipitate gout attacks when possible) HMO HMO • Treatment with maximally titrated dose of allopurinol (800 mg) is contraindicated, not tolerated, or has J2507 Krystexxa pegloticase PPO PPO been ineffective. If allopurinol is contraindicated or not tolerated probenecid can be used, unless contraindicated itself • Treatment with an uricosuric agent (example: probenecid) and allopurinol unless contraindicated, not tolerated, or has been ineffective. • Krystexxa will NOT be used concomitantly with oral urate-lowering therapies (examples: allopurinol, febuxostat, probenecid) • Coverage will NOT be provided for the following indications: o Hyperuricemia not associated with gout o Asymptomatic hyperuricemia • Any additional pertinent medical information

*Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 84 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 • FDA approved indications only Affected providers: In network AND • Have not received prior treatment with any CAR-T therapy despite indication or any other genetically- HCPCS Limit: 1 unit modified T-cell therapy or are being considered for treatment with any other genetically-modified T-cell therapy NDC NDC Limit AND 00078-0846-19 1 UN • Only to be administered at certified bone marrow/stem cell transplant centers 00078-0958-19 1 UN • Prescribed by or in consultation with an oncologist • Diagnosis of pediatric and young adult with B-cell precursor acute lymphoblastic leukemia (ALL) that is refractory or in second or later relapse: o FDA approved age o Primary refractory as defined by not achieving a complete response after 2 cycles of a standard chemotherapy regimen or chemo refractory as defined by not achieving a complete response after 1 cycle of standard chemotherapy for relapsed leukemia o Patients with Philadelphia chromosome positive (Ph+) ALL are eligible if they are intolerant to or have failed 2 lines of tyrosine kinase inhibitor therapy (TKI), or if TKI therapy is contraindicated o Ineligible for allogeneic stem cell transplant (SCT) o Any bone marrow (BM) relapse after allogenic SCT o Do not have any of the following: a) Burkitt’s lymphoma b) Active hepatitis B, C c) Any uncontrolled infection d) Grade 2 to 4 graf t-versus-host disease e) Concomitant genetic syndrome with the exception of Down’s syndrome HMO HMO f) Received allogeneic cellular therapy, such as donor lymphocyte infusion within 6 weeks Q2042 Kymriah tisagenlecleucel-t PPO PPO prior to tisagenlecleucel infusion o Documentation of CD 19 tumor expression • Treatment of adult patients with relapsed or refractory (r/r) large B-cell lymphoma after two or more lines of systemic therapy including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, high grade B-cell lymphoma and DLBCL arising from follicular lymphoma: o FDA approved age o Received ≥ 2 lines of chemotherapy, including rituximab and anthracycline OR o Relapsed following autologous hematopoietic stem cell transplantation (HSCT) o Do not have any of the following: a) Active central nervous system malignancy as determined by appropriate testing. Examples include: MRI and/or CSF analysis (including cytology plus molecular analysis, for example FISH) b) Prior allogenic HSCT c) ECOG performance status ≥ 2 d) Creatinine clearance < 60 mL/min e) Alanine aminotransferase > 5 times normal f) Cardiac ejection fraction < 45% g) Absolute lymphocyte concentration less than 300/µL • The prescriber needs to submit documentation of response to Kymriah within 3 months following therapy as a follow-up to the prior approval request • If new diagnoses are FDA approved, coverage will be determined based on the FDA approved indication on a case by case basis until fully evaluated by the BCBSM Pharmacy and Therapeutics Committee

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network

HCPCS Limit: 240 units HMO HMO J9047 Kyprolis carfilzomib PPO PPO NDC NDC Limit 76075-0101-01 4 UN 76075-0102-01 8 UN

76075-0103-01 24 UN Affected providers: In network

HCPCS Limit: 30 units J1626 Kytril granisetron hcl NDC NDC Limit

00004-0240-09 3 ML • Prescribed by a neurologist Affected providers: In/Out Multiple Sclerosis • FDA approved age network • 12 mg • FDA approved indication HMO HMO 12 units J0202 Lemtrada alemtuzumab • Will not be used in combination with other disease modifying agents for multiple sclerosis HCPCS Limit: PPO PPO • Lemtrada/Tysabri Site of Care program – FAQ document NDC NDC Limit

N/A N/A HMO HMO • Oncology Management Program J2820 Leukine sargramostim PPO PPO Affected providers: In network

HCPCS Limit: 45 units

Leuprolide acetate leuprolide acetate J9218 NDC NDC Limit 00703-4014-18 45 UN 00781-4003-32 45 UN

47335-0936-40 45 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 8 units

NDC NDC Limit 17478-0107-20 80 ML 17478-0107-30 80 ML Levofloxacin levofloxacin J1956 23155-0201-31 80 ML 23155-0201-32 80 ML 25021-0130-20 80 ML 25021-0130-30 80 ML 36000-0045-01 80 ML 55150-0156-20 80 ML

55150-0157-30 80 ML Affected providers: In network

HCPCS Limit: 8 units

NDC NDC Limit 17478-0107-20 80 ML 17478-0107-30 80 ML 25021-0130-20 80 ML J1956 Levaquin levofloxacin 25021-0130-30 80 ML 23155-0201-31 80 ML 23155-0201-32 80 ML 55150-0156-20 80 ML 55150-0157-30 80 ML 36000-0045-01 80 ML 17478-0107-20 80 ML 17478-0107-30 80 ML

25021-0130-20 80 ML

HCPCS Limit: 8 units

NDC NDC Limit 00143-9315-01 400 ML 00143-9315-24 400 ML 00143-9316-01 400 ML 00143-9316-24 400 ML 00143-9317-01 450 ML 00143-9317-24 450 ML 00143-9720-01 400 ML 00143-9720-24 400 ML 00143-9721-01 400 ML 00143-9721-24 400 ML 00143-9722-01 400 ML 00143-9722-24 400 ML 00409-0528-13 400 ML 00409-0528-15 400 ML 00409-0528-23 400 ML 00409-0528-25 400 ML 00409-0528-31 400 ML 00409-0528-35 450 ML 00781-3341-09 400 ML 00781-3342-09 400 ML J1956 Levofloxacin-D5W levofloxacin 00781-3342-46 400 ML 00781-3343-09 400 ML 00781-3343-55 450 ML 25021-0132-66 400 ML 25021-0132-67 400 ML 25021-0132-68 400 ML 25021-0132-81 400 ML 25021-0132-82 400 ML 25021-0132-83 400 ML 25021-0825-81 400 ML 25021-0825-82 400 ML 25021-0825-83 400 ML 36000-0046-24 400 ML 36000-0047-24 400 ML 36000-0048-24 400 ML 36000-0294-24 400 ML 36000-0295-24 400 ML 36000-0296-24 450 ML 44567-0435-24 400 ML 44567-0436-24 400 ML 44567-0437-24 450 ML 55150-0243-46 400 ML 55150-0244-47 400 ML 55150-0245-52 400 ML 63323-0355-50 400 ML 63323-0355-60 400 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO

63323-0355-65 400 ML • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 350 units J9119 Libtayo Cemiplimab-rwic PPO PPO NDC NDC Limit

61755-0008-01 7 ML Affected providers: In network

HCPCS Limit: 27 units

NDC NDC Limit J2010 Lincocin lincomycin 00009-0555-01 27 ML 00009-0555-02 27 ML 39822-0350-01 27 ML 39822-0350-02 27 ML 39822-0353-05 27 ML

39822-0353-06 27 ML Affected providers: In network

HCPCS Limit: 30 units

NDC NDC Limit 00409-4882-01 3000 ML 00409-4883-01 3000 ML J2020 Linezolid-0.9% NACL linezolid 00703-9060-31 3000 ML 00703-9060-33 3000 ML 00781-3433-46 3000 ML 00781-3433-95 3000 ML 55150-0242-51 3000 ML 57664-0683-31 3000 ML 57664-0683-57 3000 ML

63323-0713-13 3000 ML HMO HMO • Oncology Management Program Q2049 Lipodox doxorubicin liposomal PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In/OUT o f Diabetic macular edema (DME) • FDA approved age network • 0.3 mg every 4 weeks • Prescribed by or in consultation with an ophthalmologist • Maximum of 0.3 mg per month • Treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or HCPCS Limit: 10 units contraindicated Wet age-related macular • Any additional pertinent medical information NDC NDC Limit degeneration (AMD) and macular 50242-0080-01 0.1 ML edema following retinal vein HMO J2778 Lucentis ranibizumab 50242-0080-02 0.1 ML occlusion (RVO) PPO 50242-0082-01 0.2 ML • 0.5 mg every 4 weeks 50242-0082-02 0.2 ML • Maximum of 0.5 mg per month 50242-0082-03 0.2 ML Myopic choroidal neovascularization (mCNV) Max number of injections • 0.5mg every 4 weeks, determined during PA process Maximum of 0.5mg per month for 3 months • Diagnosis of infantile-onset or late-onset (non-infantile) Pompe disease without evidence of cardiac Affected providers: In network Pompe Disease hypertrophy • 20 mg/kg every 2 weeks • Diagnosis confirmed by the absence of acid alpha glucosidase (GAA) activity confirmed by GAA mutation HCPCS Limit: 600 units HMO HMO HMO testing or GAA activity testing in fibroblasts or muscle J0221 Lumizyme alglucosidase alfa PPO PPO PPO • Diagnosis supported by a series of screening tests (e.g., chest X-ray, electrocardiogram [ECG], NDC NDC Limit electromyogram [EMG], creatine kinase [CK], among other laboratory tests) 58468-0160-01 120 UN

• Diagnosis made by or in consultation with a geneticist or metabolic specialist 58468-0160-02 120 UN • Any additional pertinent medical information • Oncology Management Program Affected providers: In network

moxetumomab HMO HMO HCPCS Limit: 1200 units J9313 Lumoxiti pasudotox-tdfk PPO PPO NDC NDC Limit

00310-4700-01 12 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network Lupron Depot (pediatrics) • Central precocious puberty HCPCS Limit: 6 units • Males < 9 years of age and females < 8 years of age NDC NDC Limit o 1 month regimen: 7.5 mg, 00074-3346-03 2 UN 11.25 mg and 15 mg (given 00074-3473-03 1 UN monthly) 00074-3641-03 6 UN o 3 month regimen: 11.25 mg 00074-3642-03 6 UN and 30 mg (given every 3 00074-3663-03 4 UN months) Lupron Depot 00074-3683-03 2 UN • Endometriosis (females) o 3.75 mg monthly for 6 months J1950 Lupron Depot leuprolide acetate o 11.25 mg every 3 months for 6 months o 1 additional treatment of both regimens is allowed • Fibroids (females) o 3.75 mg monthly for 3 months o 11.25 mg once in 3 months o 1 additional treatment of both regimens is allowed • Prostate cancer (males) o 1 month regimen: 7.5 mg o 3 month regimen: 22.5 mg o 4 month regimen: 30 mg o 6 month regimen: 45 mg Affected providers: In network

HCPCS Limit: 180 units J1951 Fensolvi leuprolide acetate NDC NDC Limit 62935-0153-50 1 UN

62935-0154-50 1 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network Lupron Depot (pediatrics) • Central precocious puberty HCPCS Limit: 6 units • Males < 9 years of age and females < 8 years of age NDC NDC Limit 1 month regimen: 7.5 mg, J9217 Lupron Depot-PED leuprolide acetate o 00074-2108-03 6 UN 11.25 mg and 15 mg (given 00074-2282-03 4 UN monthly) 00074-2440-03 3 UN o 3 month regimen: 11.25 mg 00074-3779-03 4 UN and 30 mg (given every 3

00074-9694-03 2 UN months) Lupron Depot • FDA approved indication Affected providers: In network One injection per eye for life. • Prescribed and administered by an ophthalmologist • Patient is 12 months of age or older HCPCS Limit: 2 units voretigene HMO HMO • Documented biallelic RPE65 gene mutation J3398 Luxturna neparvovec PPO PPO • Retinal thickness greater than 100 microns within the posterior pole NDC NDC Limit • Submission of baseline full field light sensitivity prior to approval and full field light sensitivity one year 71394-0065-01 0.5 ML

after administration as a follow-up to the prior approval request 71394-0415-01 0.5 ML

• FDA approved indication Affected providers: In/OUT of • FDA approved age network • Prescribed by or in consultation with an ophthalmologist • Treatment with bevacizumab or a bevacizumab biosimilar has been ineffective, not tolerated or HCPCS Limit: 2 units HMO J2503 Macugen pegaptanib PPO contraindicated NDC NDC Limit 68782-0001-02 0.18 ML Max number of injections determined during PA process • FDA approved age Affected providers: In network Intramuscular: 250 mg • Administered by a healthcare professional Subcutaneous: 275 mg • Ultrasound confirmed gestational age between 16w0d and 20w6d at treatment initiation HCPCS Limit: 138 units weekly starting at 16 weeks. 0 Makena/ hydroxyprogesterone J1726 HMO • Singleton pregnancy days gestation to 36 weeks, 6 hydroxyprogesterone caproate PPO • NDC NDC Limit days gestation for maximum of 21 caproate Previous history of spontaneous preterm delivery (<37 weeks gestation) in singleton pregnancy • No known fetal anomalies incompatible with life 64011-0243-01 5 ML doses • Patient does not have any other risk factors for pre-term delivery 64011-0247-02 5 ML

64011-0301-03 5 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network

HCPCS Limit: 450 units HMO HMO J9353 Margenza margetuximab-cmkb PPO PPO NDC NDC Limit 74527-0022-02 90 ML 74527-0022-03 90 ML

74527-0022-01 90 ML Affected providers: In network

HCPCS Limit: 24 units

NDC NDC Limit 00051-0021-21 12 UN Q0167 Marinol dronabinol oral 00051-0022-21 6 UN 00051-0023-21 3 UN 53097-0568-60 24 UN 53097-0569-60 12 UN 53097-0570-60 6 UN 54868-3084-00 12 UN

54868-3084-01 12 UN Affected providers: In network

HCPCS Limit: 5 units injection, vincristine J9371 Marqibo sulfate liposome NDC NDC Limit 72893-0008-03 1 UN

20536-0322-01 1 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00003-7731-99 20 UN 00409-0217-01 10 UN 00409-0217-11 10 UN 00409-0218-01 5 UN 00409-0218-11 5 UN 00409-0219-01 10 UN 00409-0219-11 10 UN 00409-0220-01 5 UN 00409-0220-11 5 UN 00409-9566-01 10 UN 00409-9566-10 10 UN Maxipime cefepime hcl J0692 00409-9735-01 5 UN 00409-9735-10 5 UN 25021-0121-66 10 UN 25021-0122-67 5 UN 44567-0241-10 5 UN 60505-0681-00 5 UN 60505-0681-01 5 UN 60505-0681-04 5 UN 60505-0834-00 10 UN 60505-0834-01 10 UN 60505-0834-04 10 UN 60505-6030-01 10 UN 60505-6030-04 10 UN 60505-6031-01 5 UN 60505-6031-04 5 UN

63323-0340-20 5 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00006-3356-45 20 UN 00006-3357-53 10 UN Mef oxin cefoxitin sodium J0694 00006-3368-71 20 UN 00006-3369-73 10 UN 00006-3388-67 2 UN 00006-3548-45 20 UN 00006-3549-53 10 UN 67457-0189-01 1000 ML

67457-0216-50 500 ML Affected providers: In network

HCPCS Limit: 16 units

NDC NDC Limit 25021-0221-60 16 UN 42023-0149-01 16 UN 43598-0392-48 16 UN 45963-0686-02 16 UN 72266-0128-01 16 UN melphalan J9245 Melphalan HCL 72266-0128-01 16 UN hydrochloride 72266-0144-01 16 UN 72266-0144-01 16 UN 63323-0760-20 16 UN 67457-0195-01 16 UN 67457-0215-01 16 UN 67457-0579-01 16 UN 67457-0193-50 16 UN 67457-0577-50 16 UN 70700-0277-22 16 UN

70700-0278-97 16 UN Affected providers: In network

HCPCS Limit: 1 unit meningococcal c/y- **90644 Menhibrix hib-prp NDC NDC Limit 58160-0801-11 1 UN

58160-0809-01 1 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 1 unit

**90733 Menomune meningococcal mpsv4 NDC NDC Limit 49281-0487-58 1 UN 49281-0489-01 1 UN

49281-0489-91 1 UN Affected providers: In network

HCPCS Limit: 1 unit mening vac Menquadfi **90619 A,C,Y,W135,c-tet/PF NDC NDC Limit 49281-0590-05 0.5 ML

49281-0590-58 0.5 ML • Prescribed by or in consultation with a geneticist or metabolic specialist Mucopolysaccharidosis VII • FDA approved indication • 600mg every 2 weeks vestronidase HMO HMO HMO J3397 Mepsevii • FDA approved age alfa-vjbk PPO PPO PPO • Confirmation of diagnosis by serum assay showing a decrease in β-glucoronidase activity followed by genetic testing showing a mutation in the GUSB gene

HCPCS Limit: 100 units

NDC NDC Limit 00409-1390-21 20 UN 00409-1390-51 20 UN 00409-1391-21 20 UN 00409-1391-22 20 UN 00409-3505-01 20 UN 00409-3505-11 20 UN 00409-3506-01 10 UN 00409-3506-11 10 UN 00781-3000-94 20 UN 00781-3000-95 20 UN 00781-3000-96 20 UN 00781-3098-94 10 UN 00781-3098-95 10 UN 00781-3098-96 10 UN 25021-0155-15 20 UN 25021-0156-30 10 UN 42023-0191-01 20 UN 42023-0191-10 20 UN 42023-0192-01 10 UN 42023-0192-10 10 UN J2185 Meropenem meropenem 44567-0401-01 10 UN 44567-0400-01 20 UN 44567-0400-10 20 UN 44567-0401-10 10 UN 55150-0207-20 20 UN 55150-0208-30 10 UN 63323-0507-20 20 UN 63323-0507-21 20 UN 63323-0507-25 20 UN 63323-0508-25 10 UN 63323-0508-30 10 UN 63323-0508-31 10 UN 68001-0446-29 20 UN 68001-0446-31 20 UN 68001-0447-57 10 UN 68001-0447-58 10 UN 72572-0415-01 20 UN 72572-0415-10 20 UN 72572-0416-01 10 UN 72572-0416-10 10 UN 71288-0014-20 20 UN 71288-0014-21 20 UN 71288-0015-30 10 UN 71288-0015-31 10 UN 70121-1453-01 10 UN 70121-1453-07 10 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 70121-1454-01 20 UN 70121-1454-07 20 UN 63323-0508-01 10 UN 70594-0075-01 20 UN 70594-0075-02 20 UN 70594-0076-01 10 UN

70594-0076-02 10 UN Affected providers: In network

HCPCS Limit: 100 units

NDC NDC Limit J2185 Merrem meropenem 00069-0313-01 20 UN 00069-0313-10 20 UN 00069-0314-01 10 UN 00069-0314-10 10 UN 00310-0321-30 10 UN

00310-0325-20 20 UN Affected providers: In network

HCPCS Limit: 4000 units

NDC NDC Limit 00143-9830-01 400 ML 16729-0277-03 800 ML 16729-0277-30 800 ML 16729-0277-35 800 ML 61703-0350-09 800 ML 61703-0350-10 800 ML J9250 Methotrexate methotrexate sodium 61703-0350-37 800 ML 61703-0350-38 800 ML 63323-0121-08 800 ML 63323-0121-10 800 ML 63323-0121-40 800 ML 63323-0122-50 20 UN 63323-0122-59 20 UN 63323-0123-02 800 ML 63323-0123-10 800 ML 67457-0221-02 800 ML

67457-0221-10 800 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 4000 units

NDC NDC Limit 00143-9519-01 800 ML 00143-9519-10 800 ML 00143-9367-01 200 UN 00703-3671-01 800 ML 00703-3671-03 800 ML 00703-3671-91 800 ML J9260 Methotrexate sodium methotrexate sodium 00703-3671-93 800 ML 00703-3675-01 800 ML 00703-3675-91 800 ML 00703-3678-01 800 ML 00703-3678-81 800 ML 61703-0408-25 800 ML 61703-0408-41 800 ML 67457-0466-10 800 ML 67457-0480-40 800 ML 67457-0485-08 800 ML 67457-0485-99 800 ML

67457-0486-99 800 ML

HCPCS Limit: 50 units

NDC NDC Limit 00074-2307-60 10 ML 00409-2305-05 50 ML 00409-2305-17 50 ML 00409-2305-21 50 ML 00409-2305-50 50 ML 00409-2305-61 50 ML 00409-2305-62 50 ML 00409-2306-12 50 ML 00409-2306-22 50 ML 00409-2306-62 50 ML 00409-2307-21 10 ML 00409-2307-60 10 ML 00409-2308-01 10 ML 00409-2308-02 10 ML 00409-2308-49 10 ML 00409-2308-50 10 ML 00409-2308-69 10 ML 00409-2305-55 50 ML 00409-2596-13 10 ML 00409-2587-05 50 ML midazolam J2250 Midazolam hcl 00409-2587-53 50 ML hydrochloride 00409-2596-03 10 ML 00409-2596-05 10 ML 00409-2596-52 10 ML 00409-2596-53 10 ML 00409-2308-22 10 ML 00409-2308-70 10 ML 00409-2587-04 50 ML 00409-2305-04 50 ML 00409-2305-16 50 ML 00409-2596-15 10 ML 00641-6056-01 50 ML 00641-6056-10 50 ML 00641-6057-01 50 ML 00641-6057-10 50 ML 00641-6057-25 50 ML 00641-6059-01 50 ML 00641-6059-10 50 ML 00641-6060-01 10 ML 00641-6060-10 10 ML 00641-6061-10 10 ML 00641-6061-25 10 ML 00641-6063-10 10 ML 00641-6063-25 10 ML 00641-6190-01 10 ML 00641-6190-10 10 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 63323-0412-10 10 ML 63323-0412-25 10 ML 63323-0411-15 50 ML 66758-0018-02 50 ML 66758-0019-02 10 ML 66860-0130-02 50 ML 66860-0132-02 10 ML 66860-0133-02 10 ML 66860-0140-02 50 ML 66860-0141-02 50 ML 66860-0142-02 50 ML 66860-0145-02 10 ML 66860-0146-02 10 ML 70860-0600-02 50 ML 70860-0600-41 50 ML 70860-0601-05 10 ML 70860-0601-10 10 ML 70860-0601-41 10 ML 70860-0601-42 10 ML 71449-0130-32 10 ML 72572-0430-01 50 ML 72572-0430-25 50 ML 72572-0432-01 50 ML 72572-0432-10 50 ML 72611-0749-01 10 ML 72611-0749-10 10 ML 72611-0741-01 50 ML 72611-0741-25 50 ML 76045-0001-20 50 ML 76045-0002-10 10 ML

76045-0003-20 10 ML Affected providers: In network

HCPCS Limit: 800 units

NDC NDC Limit minocycline Minocin 14290-0545-92 8 UN J2265 hydrochloride 54531-0100-01 8 UN 65293-0014-01 8 UN 65293-0014-10 8 UN 70842-0160-01 8 UN

70842-0160-10 8 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 16 units

NDC NDC Limit 00143-9279-01 4 UN 00143-9280-01 4 UN 16729-0108-11 4 UN 16729-0115-05 16 UN 16729-0116-38 2 UN 16729-0246-05 16 UN 16729-0247-11 4 UN J9280 Mitomycin mitomycin 16729-0248-38 2 UN 55390-0251-01 16 UN 55390-0252-01 4 UN 55390-0253-01 2 UN 67457-0518-05 16 UN 67457-0519-20 4 UN 67457-0520-40 2 UN 68001-0389-28 16 UN 68001-0389-36 16 UN 68001-0390-77 4 UN 68001-0390-78 4 UN 68001-0391-79 2 UN

68001-0391-80 2 UN Affected providers: In network

HCPCS Limit: 16 units

NDC NDC Limit 00006-4681-00 1 UN 00703-4680-01 40 ML J9293 Mitoxantrone HCL mitoxantrone hcl 00703-4685-01 40 ML 00703-4686-01 40 ML 61703-0343-18 40 ML 61703-0343-65 40 ML 61703-0343-66 40 ML 63323-0132-10 40 ML 63323-0132-12 40 ML

63323-0132-15 40 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network

J9070 HCPCS Limit: 900 units HMO HMO J9349 Monjuvi tafasitamab-cxix PPO PPO NDC NDC Limit

73535-0208-01 9 UN J7327 Monovisc hyaluronic acid Not covered hyaluronic acid product

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 25 units

NDC NDC Limit 61553-0119-40 500 ML 61553-0177-41 250 ML 61553-0178-52 250 ML 61553-0179-48 250 ML 61553-0181-02 250 ML 61553-0188-48 25 ML 61553-0259-01 250 ML 61553-0259-79 250 ML 61553-0344-33 250 ML 61553-0353-28 250 ML 61553-0425-39 50 ML 61553-0619-75 250 ML 61553-0649-75 250 ML 61553-0650-67 250 ML Morphine sulfate- morphine sulfate/0.9% 61553-0656-44 50 ML J2270 0.9% nacl nacl/pf 61553-0657-76 50 ML 61553-0825-48 100 ML 61553-0856-41 250 ML 70004-0100-22 250 ML 70004-0100-16 250 ML 70004-0100-18 250 ML 70004-0100-30 250 ML 70004-0100-62 250 ML 70004-0103-16 50 ML 70004-0110-59 250 ML 71449-0022-32 50 ML 70092-1127-35 250 ML 70092-1129-50 250 ML 70092-1130-36 250 ML 70092-1133-43 250 ML 70092-1197-36 50 ML 70092-1380-36 250 ML 70092-1519-48 250 ML 70092-1523-50 250 ML

70092-1524-50 250 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 25 units

Morphine Sulfate- morphine sulfate/d5w/ NDC NDC Limit J2270 D5W pf 61553-0183-48 250 ML 61553-0183-52 250 ML 61553-0185-02 250 ML

61553-0186-67 125 ML

HCPCS Limit: 25 units

NDC NDC Limit 00074-1260-11 4 ML 00074-6178-14 3 ML 00409-1134-03 5 ML 00409-1134-05 5 ML 00409-1135-02 10 ML 00409-1890-01 125 ML 00409-1890-03 125 ML 00409-1890-10 125 ML 00409-1891-01 63 ML 00409-1891-03 63 ML 00409-1891-10 63 ML 00409-1891-11 63 ML 00409-1892-01 32 ML 00409-1892-11 32 ML 00409-1893-01 25 ML 00409-1893-03 25 ML 00409-1893-11 25 ML 00409-2029-02 240 ML 00409-3814-12 500 ML 00409-3815-12 250 ML morphine sulfate J2270 Morphine sulfate 00409-6028-04 50 ML injection 00409-6177-14 10 ML 00409-6179-14 10 ML 00641-6068-01 25 ML 00641-6071-01 17 ML 00641-6071-25 17 ML 00641-6072-01 17 ML 00641-6075-01 32 ML 00641-6075-25 32 ML 00641-6125-01 63 ML 00641-6125-25 63 ML 00641-6126-01 32 ML 00641-6126-25 32 ML 00641-6127-01 25 ML 00641-6127-25 25 ML 72572-0440-01 62.5 ML 72572-0440-25 62.5 ML 11704-0235-01 18 ML 60793-0063-01 25 ML 60793-0064-01 25 ML 60793-0067-01 17 ML 60793-0093-40 10 ML 70092-1132-43 125 ML 76045-0004-10 125 ML 76045-0005-10 63 ML 76045-0006-10 50 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 76045-0007-10 32 ML 76045-0008-10 25 ML

76329-1911-01 250 ML

• Oncology Management Program Affected providers: In network

HCPCS Limit: 40 units HMO HMO J2562 Mozobil plerixafor injection PPO PPO NDC NDC Limit 00024-5862-01 2.4 ML

58468-0140-01 2.4 ML

HCPCS Limit: 496 units

NDC NDC Limit 00054-0163-25 496 UN 00054-0163-29 496 UN 00054-0166-25 248 UN 00054-0166-29 248 UN 00093-7334-01 496 UN 00093-7334-05 496 UN 00093-7477-01 248 UN 00093-7477-05 248 UN 00378-2250-01 496 UN 00378-2250-05 496 UN 00378-4472-01 248 UN 00378-4472-05 248 UN 00781-2067-01 496 UN 00781-2067-05 496 UN 00781-2067-89 496 UN 00781-5175-01 248 UN 00781-5175-05 248 UN 16729-0019-01 248 UN 16729-0019-16 248 UN 16729-0094-01 496 UN Mycophenolate mycophenolate mofetil J7517 16729-0094-16 496 UN mof etil oral 50268-0581-11 248 UN 50268-0581-15 248 UN 51079-0379-01 248 UN 51079-0379-20 248 UN 51079-0721-01 496 UN 51079-0721-20 496 UN 60429-0059-01 496 UN 60429-0059-05 496 UN 60429-0070-01 248 UN 60429-0070-05 248 UN 60505-2967-01 248 UN 60505-2967-07 248 UN 60505-2968-01 496 UN 60505-2968-07 496 UN 64380-0725-06 248 UN 64380-0725-07 248 UN 64380-0726-06 496 UN 64380-0726-07 496 UN 66689-0307-08 62 ML 67877-0225-01 248 UN 67877-0225-05 248 UN 67877-0230-22 620 ML 67877-0266-01 496 UN 67877-0266-05 496 UN 68084-0795-01 496 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 68084-0795-11 496 UN 68084-0801-01 248 UN

68084-0801-11 248 UN gemtuzumab HMO HMO • Oncology Management Program J9203 Mylotarg ozogamicin PPO PPO • Diagnosis the medication is being used to treat Affected providers: In network Cervical Dystonia • Names of medications previously used to treat this condition, including dosages, dates of therapy and • 10,000 units every 12 weeks response HCPCS Limit: 200 units HMO • Any additional pertinent medical information J0587 Myobloc rimabotulinumtoxinb PPO NDC NDC Limit 10454-0710-10 4 ML 10454-0711-10 4 ML

10454-0712-10 4 ML • Oncology Management Program HMO HMO • Preferred bevacizumab product(s): MVASI & ZIRABEV Q5107 Mvasi bevacizumab-awwb PPO PPO • Please note: Mvasi does not require prior authorization for eye conditions • Prescribed by or in consultation with a geneticist or metabolic specialist Affected providers: In network Mucopolysaccharidosis VI • FDA approved indication • 1 mg/kg once weekly HMO HMO HMO • FDA approved age HCPCS Limit: 200 units J1458 Naglazyme galsulfase PPO PPO PPO • Confirmation of diagnosis by serum assay of enzyme deficiency of N-acetylgalactosamine-4-sulfatase activity followed by genetic testing showing a mutation in the ARSB gene NDC NDC Limit

68135-0020-01 200 ML Affected providers: In network

HCPCS Limit: 54 units

Neoral cyclosporine J7502 NDC NDC Limit 00078-0248-15 54 UN 00078-0248-61 54 UN

00078-0274-22 54 ML Affected providers: In network

HCPCS Limit: 216 units J7515 Neoral cyclosporine NDC NDC Limit 00078-0246-15 216 UN

00078-0246-61 216 UN

HCPCS Limit: 20 units

NDC NDC Limit 00517-1133-01 20 ML 00517-1133-05 20 ML 00517-1134-01 10 ML 00517-1134-05 10 ML 00548-9601-00 20 ML 00548-9602-00 10 ML 00641-6149-10 10 ML 00641-6149-25 10 ML 00641-6150-10 20 ML 00641-6150-25 20 ML 00641-6149-01 20 ML 00641-6149-25 20 ML 00641-6150-01 40 ML 00641-6150-25 40 ML 31722-0995-10 10 ML 31722-0995-31 10 ML 43598-0528-11 20 ML 43598-0528-36 20 ML 43598-0529-11 10 ML 43598-0529-36 10 ML Neostigmine neostigmine J2710 61553-0326-33 10 ML methylsulfate methylsulfate 61553-0326-70 10 ML 61553-0550-28 10 ML 61553-0551-34 10 ML 61553-0552-38 10 ML 63323-0413-10 20 ML 63323-0413-36 20 ML 63323-0415-10 10 ML 63323-0415-36 10 ML 66647-6065-25 10 ML 69374-0902-05 10 ML 69374-0922-03 12.5 ML 69374-0942-04 10 ML 69374-0932-03 12 ML 69374-0902-35 10 ML 69374-0932-33 12 ML 71839-0105-01 20 ML 70092-1317-44 10 ML 70092-2084-44 10 ML 70121-1478-01 20 ML 70121-1478-07 20 ML 70121-1479-01 10 ML 70121-1479-07 10 ML 70700-0171-22 20 ML 70700-0171-23 20 ML 70700-0172-22 10 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 70700-0172-23 10 ML 71019-0205-10 10 ML 71019-0205-12 10 ML 71019-0205-13 10 ML 71019-0205-14 10 ML 71019-0205-15 10 ML 71019-0205-16 10 ML 71449-0103-11 10 ML 72572-0462-01 10 ML 72572-0462-10 10 ML 72572-0460-01 20 ML 72572-0460-24 20 ML 72572-0461-01 10 ML 72572-0461-24 10 ML 76045-0383-13 12.5 ML 76045-0383-30 12.5 ML 65302-0501-03 10 ML 65302-0501-05 10 ML 71288-0500-10 20 ML 71288-0500-11 20 ML 71288-0501-10 10 ML

71288-0501-11 10 ML • Oncology Management Program Affected providers: In network • Pref erred pegfilgrastim product(s): NEULASTA, NEULASTA ONPRO & NYVEPRIA HCPCS Limit: 1 unit Neulasta, Neulasta HMO HMO J2505 pegfilgrastim Onpro PPO PPO NDC NDC Limit 54868-5229-00 0.6 ML 55513-0190-01 0.6 ML

55513-0192-01 0.6 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Non-preferred filgrastim product Affected providers: In network • Preferred filgrastim product(s): NIVESTYM & ZARXIO HCPCS Limit: 3000 units

NDC NDC Limit 55513-0209-01 5 ML 55513-0209-10 5 ML HMO HMO J1442 Neupogen filgrastim 55513-0209-91 5 ML PPO PPO 55513-0530-01 10 ML 55513-0530-10 10 ML 55513-0546-01 10 ML 55513-0546-10 10 ML 55513-0924-01 5 ML 55513-0924-10 5 ML

55513-0924-91 5 ML Affected providers: In network

avalglucosidase alfa- HCPCS Limit: 9999 units Nexviazyme J3490 ngpt NDC NDC Limit

58468-0426-01 20 UN Affected providers: In network

HCPCS Limit: 10 units J9268 Nipent pentostatin NDC NDC Limit 00409-0801-01 2 UN

00409-0801-09 800 UN • Oncology Management Program Affected providers: In network • Preferred filgrastim product(s): NIVESTYM & ZARXIO HCPCS Limit: 2000 units

NDC NDC Limit 00069-0291-01 3.5 ML HMO HMO Q5110 Nivestym filgrastim-aafi 00069-0291-10 3.5 ML PPO PPO 00069-0292-01 4 ML 00069-0292-10 4 ML 00069-0293-01 7 ML 00069-0293-10 7 ML 00069-0294-01 8 ML

00069-0294-10 8 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis the drug is being used to treat • Age of the member • Specialty of the prescribing physician • Names of medications previously used to treat this condition, including dosages, dates of therapy and J9999 NOC chemotherapy drug HMO HMO response • Any additional pertinent medical information

Note: New drugs approved by FDA may require a medical necessity review based on BCBSM policies until the drug is officially added to prior authorization. • Diagnosis the drug is being used to treat • Age of the member • Specialty of the prescribing physician • Names of medications previously used to treat this condition, including dosages, dates of therapy and HMO J7999 NOC compounded drug PPO response • Any additional pertinent medical information

Note: New drugs approved by FDA may require a medical necessity review based on BCBSM policies until the drug is officially added to prior authorization. • Diagnosis the medication is being used to treat • Age of the member • Specialty of the prescribing physician • Names of medications previously used to treat this condition, including dosages, dates of therapy and HMO J3490 NOC drugs unclassified HMO response PPO • Any additional pertinent medical information

Note: New drugs approved by FDA may require a medical necessity review based on BCBSM policies until the drug is officially added to prior authorization. • Diagnosis the drug is being used to treat • Age of the member • Specialty of the prescribing physician • Names of medications previously used to treat this condition, including dosages, dates of therapy and J3590 NOC unclassified biologics HMO HMO response • Any additional pertinent medical information

Note: New drugs approved by FDA may require a medical necessity review based on BCBSM policies until the drug is officially added to prior authorization.

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis the drug is being used to treat • Age of the member • Specialty of the prescribing physician • Names of medications previously used to treat this condition, including dosages, dates of therapy and unclassified drugs or NOC C9399 biologicals HMO HMO response • Any additional pertinent medical information

Note: New drugs approved by FDA may require a medical necessity review based on BCBSM policies until the drug is officially added to prior authorization. • FDA approved age Affected providers: In network Chronic Immune • Diagnosis confirmed by, or in consultation with a hematologist Thrombocytopenia • Diagnosis of immune thrombocytopenic purpura (ITP) defined by the following: HCPCS Limit: 300 units • 10 mcg/kg once weekly

o Thrombocytopenia (platelet count < 100,000 mcL) - Current platelet count < 20,000 mcL NDC NDC Limit OR HMO 55513-0222-01 6 UN J2796 Nplate romiplostim - Current platelet count < 30,000 mcL AND symptoms of active bleeding 55513-0221-01 12 UN PPO AND 55513-0223-01 24 UN o Inadequate response to therapy with corticosteroids, immunoglobulins, or splenectomy o Dose is ≤ 10 mcg/kg/week OR • A diagnosis of hematopoetic syndrome of acute radiation syndrome (HS-ARS)

*Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 115 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 • For the diagnosis of severe uncontrolled eosinophilic asthma Affected providers: In network o Prescriber is an allergist, immunologist or pulmonologist o Administered by a health care professional (unless requesting the Nucala prefilled syringes or HCPCS Limit: 300 units autoinjectors for self-administration) o FDA approved age NDC NDC Limit o Must be used as add on maintenance treatment with severe uncontrolled eosinophilic asthma 00173-0881-01 3 UN o Patient is currently receiving and will continue to receive standard of care regimen 00173-0892-01 3 UN Severe eosinophilic asthma identified by: o 00173-0892-42 3 UN - Blood eosinophils greater than or equal to 150 cells/microliter at initiation of treatment OR - Blood eosinophils greater than or equal to 300 cells/microliter in the past 12 months AND - Repeated hospital/ED visits AND - Chronic administration of systemic corticosteroids or high dose inhaled corticosteroids in combination with long acting inhaled β2 agonist or leukotriene modifier for at least 3 months fails to maintain adequate control. 1. If the member is using an inhaler that contains a steroid along with other drugs, the corticosteroid component must be high dose OR • A diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA), and o Documentation of a consult with an allergist/immunologist or pulmonologist prior to initiation of Nucala therapy HMO HMO History or presence of asthma J2182 Nucala mepolizumab o PPO PPO o At least 2 of the following criteria that are typical of EGPA - Histopathological evidence of eosinophilic vasculitis, perivascular eosinophilic infiltration, or eosinophil-rich granulomatous inflammation - Neuropathy - Pulmonary infiltrates - Allergic rhinitis and nasal polyps - Cardiomyopathy - Glomerulonephritis - Alveolar hemorrhage - Palpable purpura - Antineutrophil cytoplasmic antibody (ANCA) positivity OR • A diagnosis of hypereosinophilic syndrome (HES), and o At least 2 HES flares within the past 12 months - Defined as documented HES-related worsening of clinical symptoms or blood eosinophil counts requiring an escalation in therapy o Stable on HES therapy for at least 4 weeks - Examples include oral corticosteroids, immunosuppressive or cytotoxic therapy o Eosinophil counts of 1,000 cells/microL or higher at initiation of therapy o Member does not have eosinophilia of unknown clinical significance, non-hematologic secondary HES (drug hypersensitivity, parasitic helminth infection, HIV infection, non-hematologic malignancy), or FIP1L1-PDGFRα kinase-positive HES • Not to be used in combination with other biologics for asthma • Any additional pertinent medical information • FDA approved indication Affected providers: In network • FDA approved age HMO HMO J3590 Nulibry fosdenopterin • Confirmed genetic diagnosis of molybdenum cofactor deficiency (MoCD) Type A (MOCS1 mutation) HCPCS Limit: 9999 units PPO PPO and/or biochemical profile consistent with MoCD Type A NDC NDC Limit *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 116 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Examples: elevated urinary sulfite and/or S-sulfocysteine (SSC), elevated xanthine in urine or blood, o 73129-0001-01 5 UN or low or absent uric acid in the urine or blood • Documentation of clinical presentation consistent with MoCD Type A o Examples: intractable seizures, exaggerated startle response, high-pitched cry, axial hypotonia, limb hypertonia, feeding difficulties • No current or planned treatment for MoCD Type A with another investigational drug or device o Exception: Recombinant Escherichia coli-derived cyclic pyranopterin monophosphate (rcPMP) through day 1

Affected providers: In network

HCPCS Limit: 1600 units J0121 Nuzyra omadacycline tosylate NDC NDC Limit 71715-0001-01 16 UN

71715-0001-02 16 UN • Oncology Management Program Affected providers: In network • Pref erred pegfilgrastim product(s): NEULASTA, NEULASTA ONPRO & NYVEPRIA HMO HMO HCPCS Limit: 12 units Q5122 Nyvepria pegfilgrastim - apgf PPO PPO NDC NDC Limit

00069 0324 01 0.6 ML • Prescribed by a neurologist Affected providers: In network Relapsing Multiple Sclerosis, • FDA approved age Primary Progressive Multiple HMO HMO • FDA approved indication HCPCS Limit: 600 units Sclerosis J2350 Ocrevus ocrelizumab • 600 mg every 6 months PPO PPO • Will not be used in combination with other disease modifying agents for multiple sclerosis NDC NDC Limit

50242-0150-01 20 ML • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1568 Octagam immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information

HCPCS Limit: 180 units

NDC NDC Limit 00641-6174-01 90 ML 00641-6174-10 90 ML 00641-6175-01 45 ML 00641-6175-10 45 ML 00641-6176-01 9 ML 00641-6176-10 9 ML 00641-6177-01 23 ML 00641-6178-01 5 ML 00703-3301-01 30 ML 00703-3301-04 30 ML 00703-3311-01 15 ML 00703-3311-04 15 ML 00703-3321-01 3 ML 00703-3321-04 3 ML 00703-3333-01 8 ML 00703-3343-01 2 ML 00781-3164-75 2 ML 00781-3165-75 8 ML octreotide inj, 25021-0451-01 30 ML Octreotide acetate J2354 nondepot 25021-0452-01 15 ML 25021-0453-01 3 ML 25021-0454-05 8 ML 25021-0455-05 2 ML 62756-0094-44 15 ML 62756-0348-44 30 ML 62756-0349-44 15 ML 62756-0350-40 8 ML 62756-0351-44 3 ML 62756-0352-40 2 ML 63323-0365-01 30 ML 63323-0365-04 30 ML 63323-0376-01 15 ML 63323-0376-04 15 ML 63323-0377-01 3 ML 63323-0377-04 3 ML 63323-0378-05 8 ML 63323-0379-05 2 ML 67457-0239-00 30 ML 67457-0239-01 30 ML 67457-0245-00 15 ML 67457-0245-01 15 ML 67457-0246-00 3 ML

67457-0246-01 3 ML • Non-preferred trastuzumab product HMO HMO Q5114 Ogivri trastuzumab-dkst • Pref erred trastuzumab product(s): KANJITI and TRAZIMERA PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network phenylephrine 10.16 mg/ml and ketorolac HCPCS Limit: 9999units J1097 Omidria 2.88 mg/ml ophthalmic irrigation solution, 1 ml NDC NDC Limit

N/A N/A Affected providers: In network • Acute lymphoblastic leukemia (ALL) HCPCS Limit: 3 units o 2,500 IU/m2 given no more J9266 Oncaspar pegaspargase frequently then every 14 NDC NDC Limit days 54482-0301-01 15 ML o Maximum of 5,000 IU/m2 per month 00944-3810-01 15 ML

HCPCS Limit: 12 units

NDC NDC Limit 00054-0064-47 60 ML 00179-0099-44 12 UN 00179-0100-44 12 UN 00378-0315-93 12 UN 00378-0344-93 12 UN 00378-7732-93 12 UN 00378-7734-93 12 UN 00378-7734-97 12 UN 00781-1679-31 12 UN 00781-1679-33 12 UN 00781-1681-31 12 UN 00781-1681-33 12 UN 00781-5238-06 12 UN 00781-5238-64 12 UN 00781-5239-06 12 UN 00781-5239-64 12 UN 00781-5239-80 12 UN 00904-6551-61 12 UN 00904-6552-61 12 UN 10544-0575-06 12 UN S0119 Ondansetron hcl/ODT ondansetron 16714-0671-02 60 ML 17856-0691-05 60 ML 71335-1314-01 12 UN 35356-0652-10 24 UN 35356-0652-20 24 UN 35356-0678-30 24 UN 35356-0679-10 12 UN 35356-0679-30 12 UN 35356-0755-10 24 UN 35356-0755-65 24 UN 35356-0853-06 24 UN 35356-0853-09 24 UN 35356-0853-10 24 UN 35356-0853-20 24 UN 35356-0853-30 24 UN 43063-0052-02 24 UN 43063-0052-04 24 UN 43063-0273-04 12 UN 43063-0560-02 24 UN 43063-0560-03 24 UN 43063-0560-04 24 UN 43063-0560-05 24 UN 43063-0560-06 24 UN 43063-0560-10 24 UN 43063-0560-20 24 UN 43063-0592-10 12 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 68071-2011-01 24 UN 68084-0220-01 12 UN 68084-0220-11 12 UN 68084-0221-01 12 UN 68084-0221-11 12 UN 68094-0763-59 60 ML 68094-0763-62 60 ML 68462-0105-30 12 UN 68462-0106-30 12 UN 68462-0157-13 12 UN 68462-0157-40 24 UN 68462-0158-11 12 UN 68462-0158-13 12 UN 68462-0158-40 12 UN 69677-0182-30 12 UN 70934-0148-04 12 UN 71205-0109-50 60 ML 71335-0650-02 12 UN 71335-1314-01 3 UN 71335-1314-01 12 UN 71930-0017-52 24 UN 71930-0018-52 12 UN 72572-0520-01 25 ML 72572-0520-25 25 ML 71610-0119-88 6 UN 16714-0160-01 6 UN 16714-0200-10 12 UN 16714-0200-30 12 UN 16714-0201-10 6 UN

16714-0201-30 6 UN HMO HMO • Oncology Management Program J9205 Onivyde irinotecan liposomal PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network Hereditary Transthyretin Mediated • FDA approved age Amyloidosis Polyneuropathy • Must have diagnosis of peripheral nerve disease caused by hereditary transthyretin amyloidosis (hATTR; Max daily limit to be determined in • 30 mg every 3 weeks formerly known as familial amyloidosis polyneuropathy or FAP) with documented TTR mutation Novologix through Prior Authorization process o Signs and symptoms of ocular or cerebral area involvement (such as in ocular amyloidosis or primary/leptomeningeal amyloidosis), if present, must not predominate over polyneuropathy symptomology associated with hATTR • Documentation of clinical signs and symptoms of peripheral neuropathy (such as: tingling or increased pain in the hands, feet and/or arms, loss of feeling in the hands and/or feet, numbness or tingling in the HMO HMO HMO wrists, carpal tunnel syndrome, loss of ability to sense temperature, difficulty with fine motor skills, J0222 Onpattro patisiran PPO PPO PPO weakness in the legs, difficulty walking) AND/OR Documentation of clinical signs and symptoms of autonomic neuropathy symptoms (such as: orthostasis, abnormal sweating, dysautonomia [constipation and/or diarrhea, nausea, vomiting, anorexia, early satiety]) • Must have a baseline polyneuropathy disability (PND) score ≤ IIIb and/or a baseline FAP Stage 1 or 2 • Onpattro will not be used in combination with any of the following: o Oligonucleotide agents (such as: inotersen) o TTR stabilizers (such as: tafamidis) • No prior liver transplant • Must not have New York Heart Association heart failure classification >2 • Non-preferred trastuzumab product HMO HMO Q5112 Ontruzant trastuzumab-dttb • Pref erred trastuzumab product(s): KANJITI and TRAZIMERA PPO PPO

• Oncology Management Program Affected providers: In network

HCPCS Limit: 900 units HMO HMO J9299 Opdivo nivolumab PPO PPO NDC NDC Limit 00003-3734-13 90 ML 00003-3772-11 90 ML

00003-3774-12 90 ML Affected providers: In network

HCPCS Limit: 120 units

NDC NDC Limit J2407 Orbactiv oritavancin 65293-0015-01 3 UN 65293-0015-03 3 UN 65293-0004-03 3 UN 65293-0004-01 3 UN 70842-0140-01 3 UN

70842-0140-03 3 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network Rheumatoid arthritis • FDA approved age • Induction (doses given at 0, • Diagnosis of rheumatoid arthritis (RA) Max daily limit to be determined in 2, and 4 weeks): Novologix through Prior < 60 kg: 500 mg o Trial and failure of at least a 3-month trial of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, Authorization process 60 - 100 kg: 750 mg hydroxychloroquine, leflunomide, sulfasalazine > 100 kg: 1,000 mg • Diagnosis of juvenile idiopathic arthritis (JIA) • Maintenance (doses given o Trial and failure of at least a 3-month trial of one disease-modifying anti-rheumatic agent monthly): (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate and < 60 kg: 500 mg leflunomide 60 - 100 kg: 750 mg

Orencia, abatacept, HMO HMO • > 100 kg: 1,000 mg J0129 Diagnosis of psoriatic arthritis (PsA) Orencia Clickject abatacept/maltose PPO PPO Juvenile arthritis o Trial and failure of at least a 3-month trial of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, • Induction (doses given at 0, cyclosporine, leflunomide, sulfasalazine 2, and 4 weeks): • Not to be used in combination with other biologics or targeted DMARDs < 75 kg: 10 mg/kg • Any additional pertinent medical information 75 - 100 kg: 750 mg > 100 kg: 1,000 mg • Maintenance (doses given monthly): < 75 kg: 10 mg/kg 75 - 100 kg: 750 mg > 100kg: 1,000 mg

J7324 Orthovisc hyaluronate sodium Not covered hyaluronic acid product • Diagnosis of primary hyperoxaluria type 1 (PH1) confirmed by genetic testing of the AGXT mutation Affected providers: In network • Patient has an eGFR ≥30 mL/min/1.73 m2 • Patient is not on dialysis HCPCS Limit: 900 units • Patient does not have a history of kidney or liver transplant HMO HMO • Patient does not have clinical evidence of systemic oxalosis NDC NDC Limit J0224 Oxlumo lumarisan PPO PPO • Prescriber is a nephrologist OR another board-certified prescriber with qualifications to treat the 71336-1002-01 2.5 ML specified genetic disorder. • Patient has attempted to increase fluid intake to 3 L/m2 BSA per day. • Trial and failure to at least 3 months, contraindication, OR intolerance to a course of high-dose vitamin B-6 therapy. • Oncology Management Program Affected providers: In network

HCPCS Limit: 500 units enfortumab vedotin- HMO HMO J9177 Padcev ejfv PPO PPO NDC NDC Limit 51144-0020-01 7 UN

51144-0030-01 5 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 9999 units

NDC NDC Limit 68135-0756-20 2 ML 68135-0058-90 8 ML J3590 Palynziq pegvaliase-pqpz 68135-0673-40 2 ML 68135-0058-89 8 ML 68135-0673-39 2 ML 68135-0756-19 2 ML 68135-0058-89 2 ML 68135-0673-39 2 ML 68135-0673-45 2 ML

68135-0756-19 2 ML • FDA approved age • FDA approved diagnosis • Prescribed by or in consultation with an allergist or immunologist • Documentation of clinical history of allergic reaction following peanut consumption • Documentation of a confirmed diagnosis of peanut allergy confirmed by one of the following: peanut (Arachis Peanut-specific skin prick test (SPT) HMO HMO o J3590 Palforzia hypogaea) allergen Peanut-specific IgE antibodies PPO PPO o powder-dnfp • Provider attestation that the member will be on a peanut-avoidant diet while on Palforzia therapy • Must have a current prescription for epinephrine and access to an epinephrine autoinjector while using Palforzia • Must not have severe or uncontrolled asthma, severe or life-threatening anaphylaxis in the past 60 days, or eosinophilic esophagitis • Must not be used in combination with Viaskin Peanut or other peanut desensitization therapy • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1599 Panzyga immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information • Oncology Management Program Affected providers: In network

J9999 HCPCS Limit: 9999 units J9999/ HMO HMO Pepaxto melphalan flufenamide C9080 HCPCS Limit: 40 units C9080 PPO PPO NDC NDC Limit

73657-0020-01 2 UN *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 128 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 840 units J9306 Perjeta pertuzumab PPO PPO NDC NDC Limit

50242-0145-01 28 ML

Affected providers: In network

HCPCS Limit: 6 units

NDC NDC Limit 00641-6082-01 12 ML J2550 Phenergan promethazine hcl 00641-6082-25 12 ML 00641-6083-01 6 ML 00641-6083-25 6 ML 00641-6084-01 12 ML 00641-6084-25 12 ML 00641-6085-01 6 ML

00641-6085-25 6 ML Affected providers: In network

HCPCS Limit: 12 units

NDC NDC Limit 49999-0594-05 6 UN Q0169 Phenergan promethazine hcl 49999-0594-30 6 UN 52959-0451-02 6 UN 52959-0451-30 6 UN 54868-1285-00 6 UN 54868-1285-01 6 UN 71205-0126-10 6 UN

71205-0126-12 6 UN Affected providers: In network

HCPCS Limit: 4 units Photrexa Viscous riboflavin 5-phos/20 %

J2787 0.146-20 % SOSY dextran NDC NDC Limit 25357-0022-01 12 ML

25357-0025-03 12 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network

pertuzumab, HCPCS Limit: 120 units HMO HMO J9316 Phesgo trastuzumab, PPO PPO hyaluronidase -zzxf NDC NDC Limit 50242-0245-01 15 ML

50242-0260-01 10 ML polatuzumab vedotin- HMO HMO • Oncology Management Program J9309 Polivy piiq PPO PPO HMO HMO • Oncology Management Program J9295 Portrazza necitumumab PPO PPO • Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 300 units J9204 Poteligeo mogamuliziumab-kpkc PPO PPO NDC NDC Limit

42747-0761-01 75 ML • Diagnosis the medication is being used to treat Max daily limit to be determined in • Pertinent lab results to confirm diagnosis Novologix through Prior • Names of medications previously used to treat this condition, including dosages, dates of therapy and Authorization process HMO HMO HMO response J1459 Privigen immune globulin PPO PPO PPO • Dosing must be based on ideal body weight (IBW) unless the patient's BMI is greater than 30. If the patient’s BMI is greater than 30 or if actual body weight is 20-30% greater than IBW, adjusted body weight must be used • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 8 units J0780 Prochlorperazine prochlorperazine NDC NDC Limit

55390-0077-10 16 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 8 units

NDC NDC Limit 23155-0294-31 16 ML 23155-0294-42 16 ML 23155-0497-31 16 ML 23155-0497-42 16 ML 23155-0523-31 16 ML 23155-0523-41 16 ML Prochlorperazine prochlorperazine 55390-0077-01 16 ML

J0780 edisylate edisylate 00641-6135-01 16 ML 00641-6135-25 16 ML 23155-0294-41 16 ML 70860-0778-02 8 UN 70860-0778-10 16 UN 70860-0778-41 8 UN 72572-0580-01 16 ML 72572-0580-25 16 ML 14789-7000-02 8 UN 67457-0640-02 16 UN 67457-0640-99 16 UN

14789-0700-07 8 UN • FDA approved age Affected providers: In network Alpha1-proteinase inhibitor • Must be a nonsmoker deficiency • Member must have pre-treatment serum levels of alpha-1 antitrypsin (AAT) that are less than 11 HCPCS Limit: 900 units • 60 mg/kg once weekly micromol/L measured by ELISA (less than 80 mg/dL measured by radial immunodiffusion or less than 57 mg/dL measured by nephelometry)consistent with phenotypes PiZZ, PiZ (null), or Pi (null, null) of AAT NDC NDC Limit alpha 1 proteinase HMO HMO 13533-0700-01 9000 UN J0256 Prolastin C Phenotype/genotype testing may be requested for additional support of alpha-1 antitrypsin deficiency inhibitor PPO PPO o 13533-0700-02 9000 UN diagnosis 13533-0701-01 9000 UN • Member must have symptomatic emphysema 13533-0703-10 9000 UN • Member must have deteriorating pulmonary function, as demonstrated by a decline in the FEV1 (35-60% of 13533-0705-01 9000 UN predictive value)

13533-0705-11 9000 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of one of the following: Affected providers: In network Osteoprosis, Glucocorticoid o Osteoporosis confirmed by a BMD T-score at or below -2.5 at the lumbar spine or total hip induced Osteoporosis, Prevention o Men at high risk for fracture receiving androgen-deprivation therapy for nonmetastatic prostate cancer HCPCS Limit: 60 units of bone loss in men with Prostate o Women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for nonmetastatic breast Cancer, and Prevention of bone HMO HMO cancer NDC NDC Limit loss in women with Breast Cancer J0897 Prolia denosumab • 60 mg every 6 months PPO PPO AND 55513-0710-01 1 ML • Previous treatment failure with at least one bisphosphonate (if patient has intolerance to oral administration, IV administration will be required) • Will not be used in combination with any anabolic bone modifying agent • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 6 units

NDC NDC Limit 00409-2312-02 12 ML 00409-2312-31 12 ML 00641-0928-21 6 ML 00641-0928-25 12 ML 00641-0929-21 6 ML 00641-0929-25 6 ML 00641-0948-31 12 ML 00641-0948-35 12 ML 00641-0949-31 6 ML 00641-0949-35 6 ML 00641-0955-21 12 ML 00641-0955-25 12 ML J2550 Promethazine HCL promethazine hcl 00641-0956-21 6 ML 00641-0956-25 6 ML 00641-1495-31 12 ML 00641-1495-35 12 ML 00641-1496-31 6 ML 00641-1496-35 6 ML 00703-2191-04 12 ML 00703-2201-04 6 ML 39822-5525-02 12 ML 39822-5525-03 12 ML 39822-5550-05 6 ML 39822-5550-06 6 ML 54569-5609-00 6 ML 54569-5609-01 6 ML 54868-4021-00 12 ML 66860-0098-03 12 ML

66860-0099-03 6 ML

HCPCS Limit: 12 units

NDC NDC Limit 00591-5307-01 12 UN 00591-5307-10 6 UN 00591-5319-01 3 UN 00603-1584-54 120 ML 00603-1584-58 120 ML 00603-5437-21 12 UN 00603-5438-21 6 UN 00603-5438-30 6 UN 00603-5438-32 6 UN 00603-5439-21 3 UN 00641-6208-01 3 ML 00641-6208-25 3 ML 00781-1830-01 6 UN 00781-1830-10 6 UN 00781-1832-01 3 UN 00904-6461-61 6 UN 10135-0495-01 6 UN 10135-0495-10 6 UN 10135-0496-01 3 UN 10544-0941-12 6 UN Q0169 Promethazine HCL promethazine hcl oral 10702-0002-01 12 UN 10702-0003-01 6 UN 10702-0003-10 6 UN 10702-0003-50 6 UN 10702-0004-01 3 UN 17856-0608-05 120 ML 43063-0049-02 6 UN 43063-0049-06 6 UN 43063-0405-02 6 UN 43063-0405-04 6 UN 43063-0405-05 6 UN 43063-0405-10 6 UN 43063-0405-12 6 UN 43063-0405-15 6 UN 43063-0405-20 6 UN 43063-0405-25 6 UN 43063-0405-30 6 UN 43063-0405-60 6 UN 43063-0405-79 6 UN 43063-0447-04 3 UN 43063-0874-01 6 UN 43063-0874-04 6 UN 43063-0874-05 6 UN 43063-0874-06 6 UN 43063-0874-10 6 UN 43063-0874-12 6 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO 63187-0829-10 6 UN 63187-0829-30 6 UN 63629-1591-01 12 UN 63629-1591-02 12 UN 63629-1591-03 12 UN 63629-1591-04 12 UN 63629-1591-05 12 UN 63629-1591-06 12 UN 63629-1742-01 6 UN 63629-1742-02 6 UN 63629-1742-03 6 UN 63629-1742-04 6 UN 63629-1742-05 6 UN 63629-1742-06 6 UN 63629-1742-07 6 UN 63629-1742-08 6 UN 63629-1870-01 120 ML 63739-0213-10 6 UN 65162-0521-10 6 UN 65162-0521-11 6 UN 65162-0522-10 3 UN 65162-0745-10 12 UN 66267-0177-20 6 UN 66267-0177-30 6 UN 68001-0161-00 12 UN 68001-0162-00 6 UN 68001-0162-08 6 UN 68001-0163-00 3 UN 68071-0448-60 12 UN 68084-0154-01 12 UN 68084-0154-11 12 UN 68084-0155-01 6 UN 68084-0155-11 6 UN 68382-0040-01 12 UN 68382-0040-10 12 UN 68382-0041-01 6 UN 68382-0041-10 6 UN 68382-0042-01 3 UN 68382-0042-10 3 UN 70408-0146-31 120 ML 70408-0146-34 120 ML

71205-0126-30 6 UN HMO HMO • Oncology Management Program Q2043 Provenge sipuleucel-t PPO PPO *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 136 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 1120 units capsaicin 8% topical Qutenza J7336 patch NDC NDC Limit 72512 0928 01 4 UN

72512 0929 01 2 UN Affected providers: In network

HCPCS Limit C9057: 10 units HCPCS Limit J1201: 20 units J1201/C Quzyttir Cetirizine 9057 NDC NDC Limit 70720-0100-10 1 ML 70720-0100-01 1 ML

70720-0100-25 1 ML • FDA approved indication Affected providers: In network Amyotrophic lateral sclerosis • FDA approved age (ALS) • Prescribed by or in consultation with a neurologist HCPCS Limit: 60 units • Induction: 60mg once daily • Start of treatment is within 2 years of diagnosis with amyotrophic lateral sclerosis (ALS) for 14 days, followed by a HMO HMO HMO J1301 Radicava edaravone OR NDC NDC Limit 14-day drug-free period PPO PPO PPO After 2 years of diagnosis, with a percent predicted forced vital capacity (FVC) value of ≥ 80 %. 70510-2171-01 200 ML • Maintenance: 60mg once daily for 10 days within a 14- • Submission of a baseline metrics from the ALSFRS-R (Revised ALS Functional Rating Scale) 70510-2171-02 200 ML • Receiving treatment with Riluzole day period, followed by a 14- • Any additional pertinent medical information day drug-free period Affected providers: In network

HCPCS Limit: 24 units

NDC NDC Limit 68382-0422-02 24 ML ranitidine 68382-0423-06 24 ML J2780 Ranitidine HCL hydrochloride 55390-0616-01 24 ML 55390-0616-10 24 ML 55390-0618-01 24 ML 67457-0397-20 24 ML 67457-0397-99 24 ML 67457-0398-62 24 ML

70710-1550-01 24 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 600 units

J2547 Rapivab peramivir NDC NDC Limit 61364-0181-01 60 ML 61364-0181-03 60 ML 72769-0181-01 60 ML

72769-0181-03 60 ML • FDA approved age Affected providers: In network • Diagnosis of anemia in adult patients with beta-thalassemia who require regular red blood cell (RBC) transfusions HCPCS Limit: 1050 units o Genetic testing confirming diagnosis of β-thalassemia o Must not have hemoglobin S/β-thalassemia or α-thalassemia NDC NDC Limit o Must be considered transfusion dependent with a history of at least 100 mL/kg/year of packed red 59572-0711-01 10.5 UN

blood cells (pRBC) in the previous two years OR be managed under standard thalassemia 59572-0775-01 3.5 UN guidelines with ≥ 8 transfusions of pRBCs per year in the previous two years o Have not received prior treatment with any gene therapy (such as Lentiglobin) or are being considered for treatment with any other gene therapy for beta-thalassemia • Diagnosis of myelodysplastic syndrome (MDS) o Must have anemia requiring at least 2 units of red blood cells over 8 weeks o World Health Organization (WHO)/French American British (FAB) classification that meets IPSS-R classification of very low, low, or intermediate risk disease o Ring sideroblast ≥ 15% of erythroid precursors in bone marrow OR ≥ 5% if the SF3B1 mutation is present o Less than 5% blasts in the bone marrow HMO HMO HMO J0896 Reblozyl luspatercept-aamt o Must be refractory, intolerant, or ineligible to receive erythropoietin stimulating agents (ESA) defined PPO PPO PPO as at least one of the following: 1. Documentation of non-response or response that is no longer maintained to prior ESAcontaining regimen of either recombinant human erythropoietin > 40,000 IU/week for at least 8 doses or equivalent OR darbepoetin alpha > 500 μg every 3 weeks for at least 4 doses or equivalent 2. Documentation of discontinuation of prior ESA-containing regimen at any time after introduction due to intolerance or an adverse event 3. A low chance of response to an ESA based on endogenous serum erythropoietin level > 200 U/L for subjects not previously treated with ESA’s o Must not have used any prior therapy with disease-modifying agents for underlying MDS disease (examples: immune-modulatory drug, hypomethylating agents, or immunosuppressive therapy) o Must not have MDS associated with del 5q cytogenetic abnormality o Must not have secondary MDS known to have arisen as the result of chemical injury or treatment with chemotherapy and/or radiation for other diseases • Prescribed by or in consultation with a hematologist or oncologist • Additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In/Out network

HCPCS Limit: 5 units J3489 Reclast zoledronic acid NDC NDC Limit

N/A N/A

Affected providers: In/Out network

HCPCS Limit: 1 unit

REGEN-COV casirivimab/ NDC NDC Limit Q0243 (EUA) imdevimab 61755-0035-02 22.2 ML 61755-0036-08 20.0 ML 61755-0037-05 21.1 ML

61755-0038-05 21.1 ML

Affected providers: In network

J3490/C HCPCS Limit: 9999 units Remdesivir remdesivir 9399 NDC NDC Limit

61958-2902-01 40 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indications Affected providers: In network Ankylosing spondylitis • FDA approved age • 10mg/kg every 6 weeks • Diagnosis of Crohn’s disease HCPCS Limit: 200 units Crohn's disease (pediatric) o Active Crohn’s disease: - Treatment with an adequate course of conventional therapy (such as steroids for 7 days, NDC NDC Limit • Psoriasis / psoriatic arthritis • immunomodulators such as azathioprine for at least 2 months) has been ineffective or is 57894-0030-01 20 UN Ulcerative colitis contraindicated or not tolerated • 10mg/kg every 8 weeks o Fistulizing Crohn’s disease • Diagnosis of ulcerative colitis: Rheumatoid Arthritis o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, • 10 mg/kg every 4 weeks immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated Crohn's Disease (adult) • Diagnosis of rheumatoid arthritis: • 10 mg/kg every 8 weeks o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include methotrexate, hydroxychloroquine, leflunomide, HMO HMO J1745 Remicade infliximab sulfasalazine PPO PPO o Administered in combination with methotrexate • Diagnosis of psoriatic arthritis o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine. • Diagnosis of plaque psoriasis o Trial and failure, contraindication, or intolerance to light therapy o Trial and failure of at least 3 months of one generic oral systemic agent unless contraindicated or not tolerated. Examples include cyclosporine, methotrexate, acitretin • Diagnosis of ankylosing spondylitis • Not to be used in combination with other biologics or targeted DMARDs • Trial and failure of Inflectra • A credible explanation must be provided as to why the requested product is expected to work when the preferred product did not • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indications Affected providers: In network Ankylosing spondylitis • FDA approved age • 10mg/kg every 6 weeks • Diagnosis of Crohn’s disease HCPCS Limit: 200 units Crohn's disease (pediatric) o Active Crohn’s disease: - Treatment with an adequate course of conventional therapy (such as steroids for 7 days, NDC NDC Limit • Psoriasis / psoriatic arthritis immunomodulators such as azathioprine for at least 2 months) has been ineffective or is 00006-4305-01 20 UN • Ulcerative colitis • contraindicated or not tolerated 00006-4305-02 20 UN 10mg/kg every 8 weeks o Fistulizing Crohn’s disease • Diagnosis of ulcerative colitis: Rheumatoid Arthritis o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, • 10 mg/kg every 4 weeks immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated Crohn's Disease (adult) • Diagnosis of rheumatoid arthritis: • 10 mg/kg every 8 weeks o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include methotrexate, hydroxychloroquine, leflunomide, HMO HMO Q5104 Renflexis infliximab-abda sulfasalazine PPO PPO o Administered in combination with methotrexate • Diagnosis of psoriatic arthritis o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine. • Diagnosis of plaque psoriasis o Trial and failure, contraindication, or intolerance to light therapy o Trial and failure of at least 3 months of one generic oral systemic agent unless contraindicated or not tolerated. Examples include cyclosporine, methotrexate, acitretin • Diagnosis of ankylosing spondylitis • Not to be used in combination with other biologics or targeted DMARDs • Trial and failure of Inflectra • A credible explanation must be provided as to why the requested product is expected to work when the preferred product did not • Any additional pertinent medical information Affected providers: In network

fluocinolone acetonide HCPCS Limit: 2 units Retisert J7311 intravitreal implant NDC NDC Limit

24208-0416-01 2 UN • Pref erred rituximab product(s): RUXIENCE and RIABNI Affected providers: In network

HCPCS Limit: 200 units Q5123 Riabni rituximab-arrx NDC NDC Limit 55513-0224-01 200 ML

55513-0326-01 200 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO •Non-preferred rituximab product Affected providers: In network Chronic Lymphocytic Leukemia •Pref erred rituximab product(s): RUXIENCE and RIABNI (CLL) HCPCS Limit: 200 units • 1st cycle: 375 mg/m2 500 mg/m2, then 500 mg/m2 cycle NDC NDC Limit 2-6 every 28 days 50242-0051-10 200 ML 50242-0051-21 200 ML Non-Hodgkin's Lymphoma (NHL) • 375 mg/m2 per dose 50242-0053-06 200 ML

Rheumatoid arthritis (RA) HMO HMO J9312 Rituxan rituximab • 1,000 mg per dose every 2 PPO PPO weeks for 2 doses, repeated every 24 weeks • Maximum of 2,000 mg per month

Wegener's granulomatosis / microscopic polyangiitis • 375 mg/m2 weekly for 4 weeks Maximum of 1,500 mg/m2 per month • Oncology Management Program Affected providers: In network

HCPCS Limit: 160 units rituximab and HMO HMO Rituxan Hycela J9311 hyaluronidase PPO PPO NDC NDC Limit 50242-0108-01 13.4 ML

50242-0109-01 13.4 ML Affected providers: In network

HCPCS Limit: 20 units

J0696 Rocephin ceftriaxone sodium NDC NDC Limit 00004-1965-02 3 UN 54569-1377-00 10 UN 54569-3207-00 3 UN

00143-9678-01 5 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

J9315 HCPCS Limit: 60 units J9315/ J9314 HCPCS Limit: 600 units Romidepsin romidepsin J9314 NDC NDC Limit 00703-4004-01 12 ML

00703-3125-08 6 UN • Non-preferred Hereditary Angioedema product Affected providers: In network Hereditary Angioedema • Diagnosis of Type I or Type II hereditary angioedema (HAE) • 8400 units • Documentation supporting absence of laryngeal spasms HCPCS Limit: 840 units • Laboratory results confirming diagnosis (Include all of the following: C1q, C4, and C1INH levels) c1 inhibitor HMO HMO J0596 Ruconest • FDA approved age NDC NDC Limit recombinant PPO PPO • Diagnosed by an immunologist, allergist, or hematologist 68012-0350-01 4 UN • Will not be authorized for use in laryngeal attacks 68012-0350-02 4 UN • Any additional pertinent medical information 71274-0350-01 4 UN

71274-0350-02 4 UN • Pref erred rituximab product(s): RUXIENCE and RIABNI Affected providers: In network

HCPCS Limit: 200 units Q5119 Ruxience rituximab-pvvr NDC NDC Limit 00069-0238-01 200 ML

00069-0249-01 200 ML • Oncology Management Program Affected providers: In network

HCPCS Limit: 9999 units HMO J9999 Rybrevant amivantamab-vmjw PPO NDC NDC Limit 57894-0501-00 28 ML

57894-0501-01 28 ML Affected providers: In network J9999

HCPCS Limit: 9999 units asparaginase Erwinia- Rylaze rywn NDC NDC Limit 68727-0900-01 2.5 ML

68727-0900-03 2.5 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Oncology Management Program Affected providers: In network

HCPCS Limit: 999 units J3490/ plasminogen, human- PPO Ryplazim J3590 tvmh HMO NDC NDC Limit 70573-0099-01 12.5 ML

70573-0099-02 12.5 ML Affected providers: In network

HCPCS Limit: 90 units

Sajazir icatibant acetate J1744 NDC NDC Limit 70709-0013-01 9 ML 70709-0013-03 9 ML

71225-0114-01 9 ML Affected providers: In network

HCPCS Limit: 54 units

Sandimmune cyclosporine J7502 NDC NDC Limit 00078-0110-22 54 ML 00078-0241-15 54 UN

00078-0241-61 54 UN Affected providers: In network

HCPCS Limit: 216 units J7515 Sandimmune cyclosporine NDC NDC Limit 00078-0240-15 216 UN

00078-0240-61 216 UN Affected providers: In network

HCPCS Limit: 8 units

NDC NDC Limit J7516 Sandimmune cyclosporine parental 00574-0866-01 40 ML 00078-0109-01 40 ML 00078-0109-61 40 ML 00574-0866-10 40 ML 00517-0866-01 40 ML

00517-0866-10 40 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 60 units

NDC NDC Limit 00078-0180-01 90 ML J2354 Sandostatin Octreotide, nondepot 00078-0180-61 90 ML 00078-0181-01 45 ML 00078-0181-61 45 ML 00078-0182-01 9 ML 00078-0182-61 9 ML 00078-0183-25 23 ML

00078-0184-25 5 ML Affected providers: In network

HCPCS Limit: 60 units

Sandostatin LAR J2353 octreotide acetate NDC NDC Limit Depot 00078-0646-61 4 UN 00078-0646-81 4 UN 00078-0818-81 3 UN

00078-0825-81 2 UN Affected providers: In network

HCPCS Limit: 9999 units Saphnelo anifrolumab-fnia J3590 NDC NDC Limit

00310-3040-00 2 ML • Oncology Management Program Affected providers: In network

HCPCS Limit: 150 units HMO HMO J9227 Sarclisa isatuximab-irf c PPO PPO NDC NDC Limit 00024-0654-01 75 ML

00024-0656-01 75 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In/Out of • FDA approved age network • Documentation of elevated erythrocyte metal-free protoporphyrin greater than or equal to 85% of the total erythrocyte protoporphyrin as determined by an accredited laboratory HCPCS Limit: 16 units OR HMO HMO • Documentation of a total erythrocyte protoporphyrin 50 – 100 times the upper limit of normal of the NDC NDC Limit J7352 Scenesse afamelanotide PPO PPO laboratory reference range as determined by an accredited laboratory 73372-0116-01 1 UN OR • Documentation of two mutations in the ferrochelatase (FECH) gene as determined by an accredited Max number of injections laboratory determined during PA process • Patient has documented symptoms of erythropoietic protoporphyria phototoxicity • No personal history of melanoma or other cancerous or precancerous skin lesions

• Prescribed by an endocrinologist, gastroenterologist, or oncologist. Affected providers: In network Acromegaly and Cushing Disease • 60 mg every 4 weeks • FDA approved age recommendation. HCPCS Limit: 60 units • Diagnosis of one of the following: o Acromegaly in patients who have had an inadequate response to surgery and/or for whom NDC NDC Limit surgery is not an option, and supported by an elevated Insulin-like Growth Factor-1 (IGF-1) level 00078-0641-61 3 UN o Cushing’s Disease for whom pituitary surgery is not an option or has not been curative and the 00078-0641-81 3 UN following: 00078-0642-61 2 UN - Treatment failure to ketoconazole, mitotane or cabergoline, unless contraindicated or not 00078-0642-81 2 UN tolerated 00078-0643-61 1 UN - Treatment failure with Signifor. Please provide a credible explanation why Signifor LAR is 00078-0643-81 1 UN Signifor HMO pasireotide expected to work if Signifor has not 00078-0741-81 2 UN J2502 LAR PPO 00078-0748-81 6 UN 55292-0134-01 6 UN 55292-0135-01 3 UN 55292-0136-01 2 UN 55292-0137-01 1.5 UN 55292-0138-01 1 UN 55292-0139-01 6 UN 55292-0140-01 3 UN 55292-0141-01 2 UN 55292-0142-01 1.5 UN

55292-0143-01 1 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network Rheumatoid arthritis, Psoriatic • FDA approved age Arthritis, Ankylosing Spondylitis • Diagnosis of rheumatoid arthritis (RA): HCPCS Limit: 600 units • 2 mg/kg at week 0 and 4, then every 8 weeks thereafter o Trial and failure of at least a 3-month trial of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, hydroxychloroquine, NDC NDC Limit

leflunomide, sulfasalazine 57894-0350-01 48 ML o Used in combination with methotrexate (unless contraindicated) HMO HMO • Diagnosis of psoriatic arthritis (PsA) J1602 Simponi Aria golimumab PPO PPO o Trial and failure of at least a 3-month trial of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine • Diagnosis of ankylosing spondylitis (AS) • Diagnosis of polyarticular juvenile idiopathic arthritis (pJIA) o Trial and failure of at least a 3-month trial of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include methotrexate and leflunomide • Not to be used in combination with other biologics or targeted DMARDs Affected providers: In network

HCPCS Limit: 200 units J3090 Sivextro tedizolid phosphate NDC NDC Limit

67919-0040-01 1 UN

o Must not be used in combination with Ultomiris or other medications to treat aHUS • Diagnosis of refractory generalized myasthenia gravis (MG) o Prescribed by or in consultation with a neurologist o Documented diagnosis of refractory, anti-acetylcholine receptor (AChR) antibody positive MG identified by: - Lab record or chart notes identifying the patient is positive for anti-AChR antibodies AND - One of the following confirmatory tests: . Positive edrophonium test . History of clinical response to oral cholinesterase inhibitors (for example: pyridostigmine) . Electrophysiological evidence of abnormal neuromuscular transmission by repetitive nerve stimulation (RNS) or single-fiber electromyography (SFEMG) o Patients must NOT have a history of: - Thymectomy within 12 months - Current thymoma - Other neoplasms of the thymus o Must demonstrate profound muscle weakness throughout the body resulting in one or more of the following: - Slurred speech - Impaired swallowing and choking - Double vision

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO - Upper and lower extremity weakness - Disabling fatigue - Shortness of breath due to respiratory muscle weakness - Episodes of respiratory failure o Failure of corticosteroids and at least 2 or more immunosuppressive agents (for example: azathioprine, cyclosporine, mycophenolate mofetil, methotrexate, and tacrolimus) o Trial and failure of 3 of the following: - Cyclophosphamide - Rituximab or a rituximab biosimilar - Chronic intravenous immunoglobulin (IVIG) - Chronic plasma exchange (PLEX) • Diagnosis of aquaporin-4 (AQP4) antibody positive neuromyelitis optica spectrum disorder (NMOSD) o FDA approved age Prescribed by or in consultation with a neurologist o TM TM o Must not be used in combination with Uplizna , Enspryng , or other medications to treat neuromyelitis optica spectrum disorder (NMOSD) o Adequate trial and failure of an adequate trial of, contraindication, or intolerance to rituximab/rituximab biosimilar, Uplizna, and Enspryng • Any additional pertinent medical information • Types 1, 2, or 3 Spinal Muscular Atrophy (SMA) confirmed by genetic testing o FDA approved age o Prescribed by or in consultation with a neurologist specializing in pediatric neuromuscular disorders o Patient is not fully ventilator dependent o Patient is not currently taking SMN2-targeting antisense oligonucleotide or SMN2 splicing modifier AND patient has not received prior treatment with any gene therapy (such as Zolgensma) or is not being considered for treatment with any other gene therapy for spinal muscle atrophy o Submission of a baseline, age-appropriate exam to establish baseline motor function and ability. Examples of baseline motor ability assessments include: - Hammersmith Infant Neurological Exam (HINE) HMO HMO J2326 Spinraza nusinersen - Hammersmith Functional Motor Scale Expanded (HFMSE) PPO PPO - Upper Limb Module (ULM) Test (nonambulatory patients) - Six-Minute Walk Test (6MWT) (ambulatory patients only) - Children’s Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND) Trial and failure, contraindication, or intolerance to the preferred drugs as listed in BCBSM/BCN's prior authorization and step therapy documents • Renewal Criteria: Continuation of coverage requires submission of repeat motor ability assessment and documentation of response to therapy defined as a clinically significant improvement in SMA-associated motor milestones and motor function (for example, progression, stabilization, or decreased functional motor decline) compared to predicted natural history and progression. • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of depressive symptoms in adults with Major Depressive Disorder with acute suicidal ideation Affected providers: In network o Must receive standard of care treatment for acute suicidal ideation, including a comprehensive treatment plan that involves cognitive behavioral therapy or interpersonal psychotherapy and HCPCS Limit: 84 unit optimization or initiation of oral antidepressant therapy. OR NDC NDC Limit • Diagnosis of treatment resistant depression 50458-0028-02 2 UN Trial and failure of at least two different oral antidepressants AND two augmentation therapies for at o 50458-0028-03 3 UN least 6 weeks. Each oral antidepressant and augmentation therapy must be used in combination with each other (augmentation therapies include but not limited to lithium, buspirone, and HMO HMO S0013 Spravato esketamine olanzapine). PPO PPO o Pharmacotherapy must be in combination with cognitive behavioral therapy or interpersonal psychotherapy weekly for at least 8 weeks of treatment to yield at least moderate improvement (20% diminution in symptoms). If no improvement, the clinician should review and reappraise the treatment plan. o Must be used in combination with one of the following oral antidepressants – duloxetine, sertraline, escitalopram, venlafaxine AND must not have experienced prior non-response to listed therapies. • Prescribed by or in consultation with a psychiatrist • Must not be used in combination with intravenous ketamine • FDA approved age • FDA approved indications Affected providers: In network Psoriasis/Psoriatic Arthritis: • FDA approved age • 90 mg every 12 weeks • Diagnosis of psoriasis (PsO) Max daily limit to be determined in Novologix through Prior Crohn’s Disease: o Trial and failure, contraindication, or intolerance to light therapy Authorization process • o Trial and failure of at least 3 months of one generic oral systemic agent unless contraindicated or not 90 mg every 8 weeks tolerated. Examples include cyclosporine, methotrexate, acitretin • Diagnosis of psoriatic arthritis (PsA) o Trial and failure of at least 3 months of one disease-modifying anti-rheumatic agent (DMARD) unless contraindicated or not tolerated. Examples include: methotrexate, cyclosporine, leflunomide, sulfasalazine HMO HMO • Diagnosis of Crohn’s disease J3357 Stelara subq ustekinumab PPO PPO o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated o Must start with appropriate Stelara IV dose • Diagnosis of ulcerative colitis o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated o Must start with appropriate Stelara IV dose • Not be used in combination with other biologic agents or targeted DMARDs • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of Crohn’s disease Affected providers: In network Crohn's Disease • o Treatment with an adequate course of conventional therapy (such as steroids for 7 days, 520 mg for one dose immunomodulators such as azathioprine for at least 2 months) has been ineffective or is Max daily limit to be determined in contraindicated or not tolerated Novologix through Prior • Diagnosis of ulcerative colitis Authorization process HMO HMO J3358 Stelara IV ustekinumab Treatment with an adequate course of conventional therapy (such as steroids for 7 days, PPO PPO o immunomodulators such as azathioprine for at least 2 months) has been ineffective or is contraindicated or not tolerated • Start of therapy with an appropriate dose of intravenous Stelara based on body weight • Not be used in combination with other biologic agents or targeted DMARDs • Any additional pertinent medical information Affected providers: In network

HCPCS Limit: 12 units J3000 Streptomycin sulfate streptomycin injection NDC NDC Limit

39822-0706-02 12 UN Affected providers: In network

HCPCS Limit: 100 units

fentanyl citrate NDC NDC Limit Sublimaze J3010 injection 17478-0030-02 200 ML 17478-0030-05 200 ML 17478-0030-20 200 ML 17478-0030-25 200 ML

17478-0030-55 200 ML Affected providers: In network

HCPCS Limit: 1 unit Q9991 Sublocade buprenorphine NDC NDC Limit 12496-0100-01 0.5 ML

12496-0100-05 0.5 ML Affected providers: In network

HCPCS Limit: 3 units buprenorphine Sublocade Q9992 extended-release NDC NDC Limit 12496-0300-01 1.5 ML

12496-0300-05 3 ML J7321 Supartz hyaluronate sodium Covered/preferred hyaluronic acid product

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Central precocious puberty • 50 mg per dose once every 12 Supprelin LA histrelin acetate months in males < 9 years of J9226 Implant age and females < 8 years of age Affected providers: In network

injection, granisetron, HCPCS Limit: 100 units Sustol extended-release, 0.1 J1627 mg NDC NDC Limit

47426-0101-06 0.4 ML • Oncology Management Program Affected providers: In/Out network

HCPCS Limit: 330 units injection, siltuximab, HMO HMO J2860 Sylvant 10 mg PPO PPO NDC NDC Limit 57894-0420-01 33 UN 57894-0421-01 9 UN 73090-0420-01 33 UN

73090-0421-01 9 UN • Indication of respiratory syncytial virus (RSV) prophylaxis Affected providers: In/Out Respiratory Syncytial Virus (RSV) • Coverage is based on the recommendations from the American Academy of Pediatrics (AAP) Policy network prophylaxis Statement Any additional pertinent medical information 15 mg/kg monthly in HMO HMO o **90378 Synagis palivizumab members < 24 months of PPO PPO Max number of injections age determined during Prior o Maximum of 5 doses Authorization process Given through RSV season 1% sodium Not covered hyaluronic acid product J7331 Synojoynt hyaluronate J7325 Synvisc hylan GF-20 Not covered hyaluronic acid product J7325 Synvisc-One hylan GF-20 Not covered hyaluronic acid product

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Breast cancer o Locally advanced/metastatic: 100 mg/m2 per dose every 3 weeks o Adjuvant: 75 mg/m2 every per dose every 3 weeks up Taxotere docetaxel J9171 to 6 cycles Non-small cell lung cancer (NSCLC)/prostate cancer/gastric adenocarcinoma/ head and neck cancer o 75 mg/m2 per dose every 3 weeks Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00007-5083-76 10 UN 00007-5085-76 5 UN 00409-5082-16 10 UN J0713 Tazicef ceftazidime injection 00409-5082-52 10 UN 00409-5084-11 5 UN 00409-5086-51 2 UN 00409-5092-52 10 UN 00409-5093-51 5 UN 00409-5084-51 6 UN 00409-5084-13 5 UN

00409-5092-11 10 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indications only Affected providers: In network AND • Have not received prior treatment with any CAR-T therapy despite indication or any other genetically- Q2053 HCPCS Limit: 1 unit modified T-cell therapy or are being considered for treatment with any other genetically-modified T-cell C9073 HCPCS Limit: 1 unit therapy AND NDC NDC Limit • Only to be administered at certified bone marrow/stem cell transplant centers 71287-0219-01 1 UN

• FDA approved age 71287-0219-02 1 UN • Prescribed by on in consultation with an oncologist • Treatment of adult patients with relapsed or refractory mantle cell lymphoma • Subjects must have received adequate prior therapy including at a minimum: o An anthracycline or bendamustine-containing chemotherapy o An anti-CD20 monoclonal antibody therapy o A Bruton's tyrosine kinase (BTK) inhibitor Q2053/ brexucabtagene HMO • Must have 1 measurable lesion Tecartus C9073 autoleucel PPO • Do not have any of the following: o ECOG performance status of 2 or greater o Absolute neutrophil count < 1,000/µL o Platelet count < 75,000/µL o Serum alanine aminotransferase/aspartate aminotransferase ≥ 2.5 upper limit of normal o Creatinine clearance < 60 mL/min o Cardiac ejection fraction < 50% o Active infection including hepatitis B, hepatitis C, HIV, or systemic fungal, bacterial, or viral infection o Prior allogeneic HSCT o Active central nervous system malignancy as determined by appropriate testing. Examples include: MRI and/or CSF analysis (including cytology plus molecular analysis, for example FISH) • The prescriber needs to submit documentation of response to Tecartus within 3 months following therapy as a follow-up to the prior approval request. • If new diagnoses are FDA approved, coverage will be determined based on the FDA approved indication on a case by case basis until fully evaluated by the BCBSM Pharmacy and Therapeutics Committee. HMO HMO • Oncology Management Program J9022 Tecentriq atezolizumab PPO PPO Affected providers: In network

HCPCS Limit: 240 units

J0712 Teflaro ceftaroline fosamil NDC NDC Limit 00456-0400-01 6 UN 00456-0400-10 6 UN 00456-0600-01 4 UN

00456-0600-10 4 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network Renal cell carcinoma (RCC) o 25 mg weekly HCPCS Limit: 50 units Maximum of 100 mg per month

NDC NDC Limit J9330 Temsirolimus temsirolimus 16729-0223-61 2 ML 65219-0200-05 5 ML 65219-0205-05 5 ML 72611-0780-01 2 ML

72611-0785-02 2 ML Affected providers: In network

HCPCS Limit: 80 units

J9340 Tepadina thiotepa injection NDC NDC Limit 53964-0001-01 80 UN 53964-0002-02 12 UN 70121-1630-01 80 UN

70121-1631-01 12 UN • FDA approved indication Affected providers: In network • FDA approved age • Prescribed by or in consultation with an endocrinologist or ophthalmologist HCPCS Limit: 300 units • Clinical activity score (CAS) greater than or equal to 4 in the most severely affected eye OR NDC NDC Limit

• Moderate to severe active thyroid eye disease defined as one or more of the following: 75987-0130-15 6 UN o Decrease in color vision o Moderate or severe soft tissue involvement o Exophthalmos greater than or equal to 3 mm above normal for race and gender Inconstant or constant diplopia HMO HMO HMO o J3241 Tepezza teprotumumab-trbw • Must have treated thyroid disease defined as: PPO PPO PPO o Euthyroid function with free triiodothyronine (T3) and thyroxine (T4) within the normal limits for the range of the laboratory OR o Thyroid function is normalizing with both T3 and T4 levels being less than 50% above or 50% below the normal limits for the range of the laboratory • Treatment with an adequate course of oral or intravenous (IV) corticosteroids (for example 30 mg/day prednisone for 4 weeks) has been ineffective, not tolerated, or is contraindicated • Physician attestation a discussion has been had with the member to stop smoking if they are a current smoker

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 400 units J1071 Testone CIK testosterone cypionate

NDC NDC Limit

76420-0650-01 2 UN • FDA approved age Affected providers: In/Out • Diagnosis of male hypogonadism network • Documentation of at least TWO signs/symptoms of testosterone deficiency HCPCS Limit: 400 units • Aveed or Testopel: Requires trial and failure, contraindication or intolerance to either generic Depo- HMO S0189 Testopel testosterone pellets testosterone or generic Delatestryl PPO NDC NDC Limit • Testosterone replacement products are not to be used in combination. N/A N/A • Exceptions to the coverage criteria will be made when necessary for female to male (FTM) transgender members. Max Quantity determined during PA process

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 400 units

NDC NDC Limit 00143-9659-01 2 ML 00143-9726-01 2 ML 00409-6557-01 4 ML 00409-6562-01 2 ML 00409-6562-02 2 ML 00409-6562-20 2 ML 00409-6562-22 2 ML 00574-0820-01 2 ML 00574-0820-10 2 ML Testosterone 00574-0827-01 2 ML testosterone cypionate J1071 cypionate 00574-0827-10 2 ML 00591-4128-79 2 ML 00781-3073-70 4 ML 00781-3074-70 2 ML 00781-3074-71 2 ML 54868-3618-00 2 ML 54868-3618-01 2 ML 62756-0015-40 2 ML 62756-0016-40 2 ML 62756-0017-40 4 ML 64980-0467-99 2 ML 69097-0802-32 2 ML 69097-0802-37 2 ML 72627-2101-03 8 ML

00517-1830-01 2 ML Affected providers: In network

HCPCS Limit: 400 units

Testosterone J3121 testosterone enanthate NDC NDC Limit enanthate 00591-3221-26 2 ML 00574-0821-05 2 ML 00143-9750-01 2 ML

72627-2105-03 2 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 80 units

NDC NDC Limit 00143-9565-01 80 UN J9340 Thiotepa thiotepa injection 55390-0030-10 80 UN 54879-0014-13 80 UN 25021-0246-02 80 UN 43598-0650-11 80 UN 72205-0045-01 80 UN 72205-0046-01 12 UN

00143-9309-01 80 UN Affected providers: In network

HCPCS Limit: 500 units

NDC NDC Limit 00781-3481-70 10 UN 00781-3481-92 10 UN J3243 Tigecycline tigecycline 16729-0364-03 10 UN 16729-0364-68 10 UN 60505-6098-00 10 UN 60505-6098-01 10 UN 63323-0960-10 10 UN 70594-0035-01 10 UN

70594-0035-02 10 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 17 units

NDC NDC Limit 00409-3469-13 1134 ML 00409-3578-01 34 ML 00409-3590-02 34 ML 00703-9402-04 34 ML 00703-9416-01 34 ML 17478-0114-02 34 ML 17478-0114-30 34 ML 36000-0242-01 34 ML 36000-0244-01 34 ML 36000-0244-25 34 ML 39822-0409-01 1 UN J3260 Tobramycin sulfate tobramycin sulfate 39822-0409-06 1 UN 39822-0412-01 1 UN 39822-0412-06 1 UN 54868-4106-00 34 ML 63323-0303-51 1 UN 63323-0303-55 1 UN 63323-0305-02 136 ML 63323-0306-02 34 ML 63323-0306-26 34 ML 63323-0306-30 34 ML 63323-0307-51 34 ML 67457-0428-00 34 ML 67457-0428-30 34 ML 67457-0473-00 34 ML 67457-0473-22 34 ML

70700-0173-22 2 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 8 units

NDC NDC Limit 00004-6920-06 8 ML ketorolac Toradol 00004-6921-06 8 ML J1885 tromethamine 00004-6922-06 4 ML 54868-1763-00 4 ML 54868-3843-00 4 ML 54868-4133-00 4 ML 76045-0209-00 4 ML

76045-0209-10 4 ML Affected providers: In network Renal cell carcinoma (RCC) • 25 mg weekly HCPCS Limit: 50 units Maximum of 100 mg per month J9330 To risel temsirolimus NDC NDC Limit

00008-1179-01 2 ML • Oncology Management Program Affected providers: In network • Pref erred trastuzumab product(s): KANJITI and TRAZIMERA HCPCS Limit: 120 units HMO HMO Q5116 Trazimera trastuzumab-gyyp PPO PPO NDC NDC Limit 00069-0305-01 3 UN

00069-0306-01 3 UN HMO HMO • Oncology Management Program J9033 Treanda bendamustine PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 20 units

NDC NDC Limit 00003-0315-05 5 ML 00003-0315-20 5 ML 16714-0130-01 5 ML 16714-0130-25 5 ML 16714-0140-01 5 ML 16714-0150-01 5 ML 70121-1049-01 5 ML Triamcinolone triamcinolone 70121-1049-02 5 ML J3301 acetonide acetonide 70121-1049-05 5 ML 70121-1168-01 5 ML 70121-1169-01 5 ML 70121-1651-01 5 ML 70121-1651-05 5 ML 70121-1652-01 5 ML 70121-1653-01 5 ML 70121-1654-01 5 ML 70121-1655-01 5 ML 70121-1657-01 5 ML 72603-0108-01 5 ML 72603-0202-01 5 ML

72603-0401-01 5 ML hyaluronan or Not covered hyaluronic acid product derivative, triluron, for Triluron J7332 intra-articular injection, 1 mg J7239 TriVisc sodium hyaluronate Not covered hyaluronic acid product • Oncology Management Program Affected providers: In network

sacituzumab HMO HMO J9317 HCPCS Limit: 600 units J9317 Trodelvy govitecan-hziy PPO PPO NDC NDC Limit

55135-0132-01 9 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age. • Must be prescribed or in consultation with an infectious disease specialist or a physician who specialized in the treatment of HIV • Used in combination with other anti-retroviral therapy for the treatment of human immunodeficiency virus type 1 (HIV-1) • Patient is heavily treatment-experienced with multidrug resistant HIV-1 infection based on the following: HMO HMO HMO J1746 Trogarzo Ibalizumab-uiyk Documented resistance (lab results may be requested) to at least one antiretroviral medication PPO PPO PPO o from each of the three following classes: nucleoside reverse transcriptase inhibitor (NRTI), non- nucleoside reverse transcriptase inhibitor (NNRTI) and protease inhibitor (PI) o Patients must have been treated for at least 6 months with antiretroviral therapies with recent treatment failure (within 8 weeks) • Failing their current antiretroviral regimen o Patient has a RNA viral load greater than 200 copies/mL •Non-preferred rituximab product Affected providers: In network •Pref erred rituximab product(s): RUXIENCE and RIABNI HCPCS Limit: 200 units HMO HMO Q5115 Truxima rituximab-abbs PPO PPO NDC NDC Limit 63459-0103-10 200 ML

63459-0104-50 200 ML Affected providers: In network

HCPCS Limit: 500 units

NDC NDC Limit J3243 Tygacil tigecycline 00008-4990-01 10 UN 00008-4990-02 10 UN 00008-4990-19 10 UN 00008-4990-20 10 UN 00008-4994-19 10 UN

00008-4994-20 10 UN • Diagnosis of a relapsing form of multiple sclerosis Affected providers: In network Crohn's Disease, Multiple • Diagnosis of Crohn’s disease Sclerosis • HCPCS Limit: 300 units • 300 mg every 4 weeks PPO PPO Lemtrada/Tysabri Site of Care program – FAQ document J2323 Tysabri natalizumab HMO HMO NDC NDC Limit 64406-0008-01 15 ML

59075-0730-15 15 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Non-preferred pegfilgrastim product Affected providers: In network • Pref erred pegfilgrastim product(s): NEULASTA, NEULASTA ONPRO & NYVEPRIA HMO HMO HCPCS Limit: 12 units Q5111 Udenyca pegfilgrastim-cbqv PPO PPO NDC NDC Limit

70114-0101-01 0.6 ML • FDA approved age Affected providers: In network Paroxysmal nocturnal • Documented diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) hemoglobinuria: Max daily limit to be determined in • 3,600 mg every 8 weeks o Prescribed by or in consultation with a hematologist o Flow cytometric confirmation of at least 5% PNH type III red cells Novologix through Prior Authorization process o Platelets ≥ 30,000 prior to ravulizumab therapy Atypical Hemolytic Uremic o Had at least 1 transfusion in 24 months preceding ravulizumab Syndrome: OR • 3,600 mg every 8 weeks o Documented history of major adverse thrombotic vascular events from thromboembolism OR o Patient has high disease activity defined as a lactic dehydrogenase (LDH) level ≥ 1.5 times the upper limit of normal with one of the following symptoms - Weakness - Fatigue - Hemoglobinuria - Abdominal pain HMO HMO HMO - Dyspnea J1303 Ultomiris ravulizumab PPO PPO PPO - Hemoglobin < 10 g/dL - A major vascular event - Dysphagia - Erectile dysfunction ® o Must not be used in combination with Soliris or other medications to treat PNH • Documentation diagnosis of atypical hemolytic uremic syndrome (aHUS) o Prescribed by or in consultation with a hematologist or nephrologist o Common causes of typical hemolytic uremic syndrome have been ruled out, including infectious causes of HUS and thrombotic thrombocytopenic purpura (TTP) o Must present with the following symptoms: - Hemoglobin < 10 g/dL - Platelets < 150,000/mm3 - Documented evidence of hemolysis, such as, elevated lactate dehydrogenase levels, decreased haptoglobin level, or schistocytosis - Increased serum creatinine OR currently undergoing dialysis o Must not be used in combination with Soliris or other medications to treat aHUS C9399/ • Oncology Management Program HMO HMO J3490/ Unituxin dinutuximab PPO PPO J9999

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved indication Affected providers: In network • FDA approved age • Prescribed by or in consultation with a neurologist HCPCS Limit: 300 units HMO HMO HMO • Must not be used in combination with Soliris®, EnspryngTM, or other medications to treat neuromyelitis J1823 Uplizna Inebilizumab - cdon PPO PPO PPO optica spectrum disorder (NMOSD) NDC NDC Limit • Adequate trial and failure of an adequate trial of, contraindication, or intolerance to rituximab/rituximab 72677-0551-01 300 ML biosimilar and Enspryng

Affected providers: In network

HCPCS Limit: 600 units meropenem/ Vabomere 2 J2186 vaborbactam NDC NDC Limit 70842-0120-01 6 UN

70842-0120-06 6 UN Affected providers: In network

HCPCS Limit: 4 units J9357 Valstar valrubicin NDC NDC Limit

67979-0001-01 20 ML Affected providers: In network

HCPCS Limit: 180 units J8680 Varubi rolapitant NDC NDC Limit

69656-0101-02 2 UN Affected providers: In network

HCPCS Limit: 333 units J2797 Varubi IV rolapitant NDC NDC Limit

69656-0102-10 96 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 1 unit

dip,pert(a)tet/hepB/pol/ Vaxelis NDC NDC Limit 90697 Hib/PF 63361-0243-10 0.5 ML 63361-0243-15 0.5 ML 63361-0243-58 0.5 ML

63361-0243-88 0.5 ML • Oncology Management Program Affected providers: In network

HCPCS Limit: 180 units HMO HMO J9303 Vectibix panitumumab PPO PPO NDC NDC Limit 55513-0954-01 90 ML

55513-0956-01 90 ML Affected providers: In network

J3490 HCPCS Limit: 9999 units Veklury remdesivir /C9399 NDC NDC Limit

61958-2901-02 2 UN Affected providers: In network Mantle cell lymphoma (MCL) & multiple myeloma (MM) HCPCS Limit: 35 units o 1.3 mg/m2 per dose J9041 Velcade bortezomib NDC NDC Limit 43598-0865-60 1 un 63020-0049-04 1 un

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 500 units

NDC NDC Limit 00517-2310-01 25 ML 00517-2310-05 25 ML 00517-2325-10 25 ML J1756 Venofer iron sucrose 00517-2325-01 25 ML 00517-2340-10 25 ML 00517-2340-25 25 ML 00517-2340-99 25 ML 49230-0530-10 25 ML 49230-0530-25 25 ML 49230-0534-10 25 ML

49230-0534-25 25 ML Affected providers: In network

midazolam HCPCS Limit: 50 units Versed J2250 hydrochloride NDC NDC Limit

00004-1947-01 10 ML J1427/ • Coverage of Viltepso is considered investigational/experimental for all indications and will not be provided. Viltepso viltolarsen *I/E C9071 • Prescribed by or in consultation with a geneticist or metabolic specialist Affected providers: In network Mucopolysaccharidosis type IV A • FDA approved indication (MPS IV A; Morquio A HMO HMO HMO • FDA approved age HCPCS Limit: 600 units syndrome) J1322 Vimizim elosulfase alfa PPO PPO PPO • Confirmation of diagnosis by serum assay showing a decrease in N-acetly-galactosamine-6-sulfatase • 300mg followed by genetic testing showing a mutation in the GALNS gene NDC NDC Limit

68135-0100-01 600 ML Affected providers: In network

HCPCS Limit: 80 units J9360 Vinblastine sulfate vinblastine sulfate NDC NDC Limit 63323-0278-10 80 ML

55390-0091-10 8 UN J7333 Visco-3 sodium hyaluronate Not covered hyaluronic acid product

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 16 units

Vistaril hydroxyzine pamoate Q0177 NDC NDC Limit 00069-5410-66 16 UN 00069-5420-66 8 UN

00904-7065-61 16 UN • FDA approved indication Affected providers: In network Type 1 Gaucher Disease adults • FDA approved age • 60 units/kg every 2 weeks • Prescribed by or in consultation with a geneticist or metabolic specialist HCPCS Limit: 180 units HMO HMO HMO • Confirmation of diagnosis by biochemical assay showing decreased glucocerebrosidase activity in white J3385 Vpriv velaglucerase alfa PPO PPO PPO blood cells or skin fibroblasts AND genotyping revealing two pathogenic mutations of the NDC NDC Limit

glucocerebrosidase gene 54092-0701-04 45 UN • Two symptomatic manifestations of the disease are present, such as anemia, thrombocytopenia, bone disease, hepatomegaly, or splenomegaly • Migraine prevention: Affected providers: In network o FDA approved age Medication is being used for preventive treatment of migraine headaches HCPCS Limit: 300 units o o There is a persistent history of recurring debilitating headaches (4 or more headache days per month with migraine headache lasting for 4 hours per day or longer) NDC NDC Limit

Adequate trials (at least 2-month trial) of prophylactic therapy from at least TWO different therapy classes 67386-0130-51 3 ML HMO HMO HMO o J3032 Vyepti eptinezumab-jjmr that were not effective, contraindicated, or not tolerated PPO PPO PPO o An evaluation has been performed to rule out rebound headaches c aus ed by medication use and preventative steps have been taken. Medications that may be associated with rebound headache include, but are not limited to, narcotics, triptans exceeding more than 12 doses per month, caffeine, and NSAIDs • Prescribed by or in consultation with a neurologist • Not to be used in combination with other CGRP antagonists for migraine prevention *Coverage of Vyondys 53 is considered investigational/experimental for all indications and will not be Vyondys 53 golodirsen J1429 I/E* provided. Affected providers: In network

HCPCS Limit: 176 units daunorubicin/cytarabin Vyxeos J9153 e NDC NDC Limit 68727-0745-01 4 UN 68727-0745-02 4 UN 68727-0745-05 4 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

HCPCS Limit: 300 units J0691/ Xenleta lefamulin C9054 NDC NDC Limit 72000-0120-01 30 ML

72000-0120-06 30 ML • Diagnosis the medication is being used to treat Affected providers: In network Cervical Dystonia • Names of medications previously used to treat this condition, including dosages, dates of therapy and • 120 units every 12 weeks response HCPCS Limit: 500 units Blepharospasm • Any additional pertinent medical information • 35 units/eye (70 total for both HMO J0588 Xeomin incobotulinumtoxin a NDC NDC Limit eyes) every 12 weeks PPO 00259-1605-01 10 UN Upper Limb Spasticity 00259-1610-01 5 UN • 400 units every 12 weeks 00259-1620-01 2.5 UN

46783-0161-01 10 UN

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of bone metastases from solid tumors Affected providers: In network Prevention of Skeletal Related • Treatment failure with at least one intravenous bisphosphonate or as first line therapy when National Events in Multiple Myeloma or Comprehensive Cancer Network (NCCN) supported category 1 preferred agent for prevention of skeletal HCPCS Limit: 120 units Solid Tumors, Giant Cell Tumor of related events in patients with bone metastases for the specific oncological diagnosis the Bone, Hypercalcemia of • Any additional pertinent medical information NDC NDC Limit Malignancy • 120 mg every 4 weeks OR 55513-0730-01 1.7 ML • Diagnosis of multiple myeloma • Treatment failure with at least one intravenous bisphosphonate or as first line therapy when National Comprehensive Cancer Network (NCCN) supported category 1 preferred agent for prevention of skeletal related events in patients with bone metastases for the specific oncological diagnosis HMO HMO • Any additional pertinent medical information J0897 Xgeva denosumab PPO PPO OR • Diagnosis of giant cell tumor of the bone in adults and skeletally mature adolescents • Documentation of confirmed giant cell tumor of bone and radiologic evidence of measurable disease (i.e., CT scan or MRI) • Documentation supporting bone is unresectable or surgical resection is likely to result in severe morbidity • Any additional pertinent medical information OR • Diagnosis of hypercalcemia of malignancy (HCM) • Lab results supporting the corrected serum calcium (CSC) > 12 mg/dL (3.0 mmol/L) • Treatment failure with at least one intravenous bisphosphonate • Any additional pertinent medical information • FDA approved age Affected providers: In network Dupuytren’s Contracture: • Diagnosis of Dupuytren’s contracture: • 0.58 mg per joint (can do 2 HCPCS Limit: 900 units joints/hand at one time) every o A finger flexion contracture with a palpable cord of at least one finger (other than the thumb) involving the metacarpophalangeal (MP) joint or the proximal interphalangeal (PIP) joint 4 weeks up to 3 treatment Administering physician must be a surgeon who has experience and training in hand surgeries NDC NDC Limit cycles per cord o • Diagnosis of Peyronie’s disease: 66887-0003-01 10 UN Peyronie’s disease: Prescribed by or in consultation with a urologist o • 0.58 mg on day 1 followed by a collagenase HMO o Palpable plaque and curvature deformity of 30° or greater at start of therapy J0775 Xiaflex second dose 1-3 days later of clostridium histolyticum PPO o Treatment with intralesional verapamil was ineffective, contraindicated, or not tolerated OR the patient has any of the following: each 4 week treatment cycle - The plaque has calcified with up to 4 treatment cycles - There is a curvature of greater than 60⁰ per plaque - The plaque has been present for greater than 12 months

- The plaque is stable and has not changed over the last 6 months • Facility must be enrolled to receive Xiaflexthrough Xiaflex REMS™ • Collagenase clostridium histolyticum will not be covered for cellulite or other cosmetic indications • Any additional pertinent medical information

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • Diagnosis of uncontrolled moderate to severe allergic asthma: Affected providers: In network Allergic Asthma • o \ 375 mg every 2 weeks o Positive skin test or in-vitro reactivity to a perennial aeroallergen HCPCS Limit: 90 units o Chronic administration of systemic corticosteroids or high dose inhaled corticosteroids in combination Chronic Idiopathic Urticaria with: NDC NDC Limit • 300 mg every 4 weeks 1. Ilong acting inhaled β2 agonist or leukotriene modifier for at least 3 months fails to maintain 50242-0040-62 3 UN adequate control. 50242-0214-01 6 UN AND

50242-0215-01 3 UN 2. LAMA (long acting muscarinic antagonist) in adults and children ≥12 years for at least 3 months fails to maintain adequate control o IgE level > 30 but < 700 IU/ml for patients 12 years of age and older o IgE level > 30 but < 1300 IU/ml for patients between the ages of 6 to < 12 years • Diagnosis of chronic idiopathic urticaria o Must have occurrence of almost daily hives and itching for at least 6 weeks o Past trial and failure all of the following for at least 2 months: 1. Trial and failure of a second-generation antihistamine at the maximal tolerated dose AND HMO HMO HMO J2357 Xolair omalizumab 2. Trial and failure one of the following at maximal dosing: PPO PPO PPO a) Another second-generation antihistamine b) H2 antagonist c) Leukotriene receptor antagonist d) First generation antihistamine given at bed e) Hydroxyzine f) Doxepin o Other diagnoses have been ruled out. • Diagnosis of nasal polyps o Patient is currently receiving and will continue to receive standard of care regimen o Inadequate response to treatment with at least a 2-month trial of intranasal corticosteroids o Baseline serum total IgE level of 30 IU/mL to 1,500 IU/mL prior to initiating treatment with Xolair

• Any additional pertinent medical information • FDA approved age • Cannot be used in combination with other biologic agents indicated for any of the conditions listed in the policy Affected providers: In network

HCPCS Limit: 30 units contraceptive hormone Xulane J7304 patch NDC NDC Limit 00378-3340-16 30 UN

00378-3340-53 30 UN HMO HMO • Oncology Management Program J9228 Yervoy ipilimumab PPO PPO *Based on FDA approved guidelines **CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved. *** For drugs covered under your commercial pharmacy Blue Cross or BCN benefit, please see the Blue Cross and BCN Prior Authorization and Step Therapy Guidelines IN = limits apply to in-state providers; OUT= limits apply to out of state providers 170 Blue Cross and BCN utilization management medical drug list For Blue Cross PPO (commercial) and BCN HMOSM (commercial) members Note: All requests for pediatric patients require clinical documentation A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Revised September 2021 • FDA approved indications only Affected providers: In network AND • Have not received prior treatment with any CAR-T therapy despite indication or any other genetically- HCPCS Limit: 1 unit modified T-cell therapy or are being considered for treatment with any other genetically-modified T-cell therapy NDC NDC Limit AND 71287-0119-01 1 UN • Only to be administered at certified bone marrow/stem cell transplant centers • FDA approved age • Prescribed by or in consultation with an oncologist • Treatment of adult patients with relapsed or refractory large B-cell lymphoma after two or more lines of systemic therapy, including diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma (PMBCL), high grade B-cell lymphoma, and DLBCL arising from follicular lymphoma (TFL) • Subjects must have received adequate prior therapy including at a minimum: o Anti-CD20 monoclonal antibody unless investigator determines that tumor is CD20-negative and o An anthracycline containing chemotherapy regimen o For subjects with transformed FL must have received prior chemotherapy for follicular lymphoma and subsequently have chemo refractory disease after transformation to DLBCL • Do not have the following: o Prior allogeneic HSCT o Active central nervous system malignancy as determined by appropriate testing. Examples include: MRI and/or CSF analysis (including cytology plus molecular analysis, for example FISH) o ECOG performance status of 2 or greater axicabtagene HMO HMO Absolute lymphocyte count less than 100/µL Q2041 Yescarta o ciloleucel PPO PPO o Creatinine clearance less than 60 mL/min o Hepatic transaminases more than 2.5 times the upper limit of normal o Cardiac ejection fraction less than 50% o Active serious infection • Treatment of adult patients with relapsed or refractory follicular lymphoma (FL) o Subjects must have received at least 2 prior lines of therapy one of which is an anti-CD20 monoclonal antibody combined with an alkylating agent o Must have measureable disease o Do not have any of the following: - Prior allogeneic HSCT - Active central nervous system malignancy as determined by appropriate testing. Examples include: MRI and/or CSF analysis (including cytology plus molecular analysis, for example FISH) - ECOG performance status of 2 or greater - Transformed FL - Histological grade 3b FL - Creatinine clearance less than 60 mL/min - Hepatic transaminases more than 2.5 times the upper limit of normal - Cardiac ejection fraction less than 50% - Active serious infection • The prescriber needs to submit documentation of response to Yescarta within 3 months following therapy as a follow-up to the prior approval request • If new diagnoses are FDA approved, coverage will be determined based on the FDA approved indication on a case by case basis until fully evaluated by the BCBSM Pharmacy and Therapeutics Committee HMO HMO • Oncology Management Program J9352 Yondelis trabectedin PPO PPO

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

fluocinolone acetonide HCPCS Limit: 18 units J7314 Yutiq intravitreal implant NDC NDC Limit

71879-0136-01 1 UN HMO HMO • Oncology Management Program J9400 Zaltrap ziv-aflibercept PPO PPO Affected providers: In network

HCPCS Limit: 6 units J9320 Zanosar streptozocin NDC NDC Limit

00703-4636-01 6 UN Affected providers: In network

HCPCS Limit: 24 units

NDC NDC Limit 24987-0363-01 24 ML 24987-0362-10 24 ML ranitidine Zantac 24987-0364-01 24 ML J2780 hydrochloride 00173-0362-38 24 ML 00173-0363-00 24 ML 00173-0363-01 24 ML 52565-0096-01 24 ML 52565-0101-10 24 ML 52565-0102-01 24 ML

52565-0101-01 24 ML • Oncology Management Program Affected providers: In network • Preferred filgrastim product(s): NIVESTYM & ZARXIO HCPCS Limit: 2000 units

NDC NDC Limit HMO HMO Q5101 Zarxio filgrastim-sndz 61314-0318-05 3.5 ML PPO PPO 61314-0318-10 3.5 ML 61314-0318-01 3.5 ML 61314-0326-05 2.5 ML 61314-0326-10 2.5 ML

61314-0326-01 2.5 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In network Alpha1-proteinase inhibitor • Must be a nonsmoker deficiency • Member must have pre-treatment serum levels of alpha-1 antitrypsin (AAT) that are less than 11 HCPCS Limit: 900 units • 60 mg/kg once weekly micromol/L measured by ELISA (less than 80 mg/dL measured by radial immunodiffusion or less than 57 mg/dL measured by nephelometry)consistent with phenotypes PiZZ, PiZ (null), or Pi (null, null) of AAT NDC NDC Limit alpha 1 proteinase HMO HMO J0256 Zemaira Phenotype/genotype testing may be requested for additional support of alpha-1 antitrypsin deficiency 00053-7201-02 9 UN inhibitor PPO PPO o diagnosis • Member must have symptomatic emphysema • Member must have deteriorating pulmonary function, as demonstrated by a decline in the FEV1 (35-60% of predictive value)

• Oncology Management Program Affected providers: In network

HMO HMO HCPCS Limit: 80 units J9223 Zepzelca lurpinectedin PPO PPO NDC NDC Limit

68727-0712-01 2 UN Affected providers: In network

ceftolozane 50 mg and HCPCS Limit: 6 units Zerbaxa J0695 tazobactam 25 mg NDC NDC Limit

67919-0030-01 3 UN • Non-preferred pegfilgrastim product Affected providers: In network • Pref erred pegfilgrastim product(s): NEULASTA, NEULASTA ONPRO & NYVEPRIA HCPCS Limit C9058: 3 units HMO HMO Q5120 Ziextenzo pegfilgrastim-bmez HCPCS Limit Q5120: 3 units PPO PPO NDC NDC Limit

61314-0866-01 0.6 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In network • Diagnosis of osteoarthritis of the knee with a Kellgren-Lawrence grade of 2 or greater HCPCS Limit: 64 units o Coverage will not be provided for injections into any joint besides the knee • Prescribed by or in consultation with a rheumatologist or orthopedic surgeon • Required therapies: NDC NDC Limit

70801-0003-01 2 UN o Non-pharmacological . Inadequate response is required to TWO or more of the following: - Resistance exercise (such as structured weightlifting or resistance band program) or cardiovascular exercise (such as walking, biking, stationary bike, or aquatic exercises) - Weight reduction (in those that are overweight defined as a BMI of 25 or greater) by 5% from baseline - Utilizing durable medical equipment (such as: wearing medically-directed patellar taping, triamcinolone wearing wedged insoles, or using walking aids) acetonide, - Physical therapy or occupational therapy preservative- free, HMO Pharmacological J3304 Zilretta o extended-release, PPO . Trial and failure of ALL of the following unless contraindicated or clinically significant adverse microsphere events are experienced: formulation - Oral non-steroidal anti-inflammatory drug (NSAID) at maximal therapeutic dosage • Oral NSAID not required if the member is at least 65 years of age or under 65 years of age and unable to take an oral NSAID - Topical NSAID - Immediate-release intra-articular triamcinolone acetonide injection . Treatment failure is defined as any of the following: - Inadequate pain relief - Frequent need for continued rescue doses of NSAIDs - Inability to increase activity levels or need to decrease activity levels - Adequate pain relief but experienced steroid-induced hyperglycemia . Please provide a credible explanation why Zilretta is expected to work if triamcinolone acetonide has not . Must not have had a previous intra-articular corticosteroid injection within the past 3 months

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 10 units

NDC NDC Limit 24987-0400-00 1 UN 24987-0354-10 5 UN 24987-0437-00 5 UN 00001-4399-79 10 UN J0697 Zinacef sterile cefuroxime 24987-0352-10 10 UN 24987-0436-00 10 UN 24987-0425-00 250 ML 00173-0352-31 10 UN 00173-0354-35 5 UN 00338-2043-48 500 ML 00173-0436-00 10 UN 24987-0354-30 5 UN

00173-0425-00 250 ML • Diagnosis of clostridium dificile infection (CDI) and a positive stool test Affected providers: In network • Patient at high risk of CDI recurrence including: • Patients 65 years of age and older HCPCS Limit: 300 units • History of CDI in the past 6 months • Immunocompromised state NDC NDC Limit HMO J0565 Zinplava bezlotoxumab • Severe CDI at presentation 00006-3025-00 120 ML PPO • Clostridium dificile ribotype 027 00006-3025-01 120 ML • Prescribed by or in consultation with a gastroenterologist or infectious disease specialist • Patient 18 years of old or greater • Used in conjunction with standard of care antibacterial agents (i.e. metronidazole or vancomycin) Any additional pertinent medical information • Oncology Management Program • Preferred bevacizumab product(s): MVASI & ZIRABEV HMO HMO Q5118 Zirabev bevacizumab-bvzr PPO PPO • Please note: Zirabev does not require prior authorization for eye conditions

Affected providers: In network

HCPCS Limit: 50 units J2405 Zof ran ondansetron hcl NDC NDC Limit 00173-0442-00 25 ML

70860-0777-21 25 ML

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In network

HCPCS Limit: 12 units

NDC NDC Limit 00173-0447-00 12 UN 00173-0447-02 12 UN 33358-0370-02 24 UN S0119 Zof ran ondansetron hcl oral 35356-0524-30 24 UN 49999-0783-30 12 UN 00173-0570-00 12 UN 33358-0369-02 24 UN 00173-0447-04 48 UN 00173-0569-00 12 UN 00173-0446-00 12 UN 00078-0675-15 12 UN

00078-0676-15 6 UN Affected providers: In network

HCPCS Limit: 3 units

goserelin acetate NDC NDC Limit Zoladex J9202 implant 00310-0950-36 3 UN 00310-0951-30 1 UN 54569-3943-00 3 UN 70720-0950-36 3 UN

70720-0951-30 1 UN Affected providers: In/Out network

J3489 Zoledronic Acid zoledronic acid HCPCS Limit: 5 Units

NDC NDC Limit

N/A N/A

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO • FDA approved age Affected providers: In/Out • Prescribed by or in consultation with a neurologist or neuromuscular specialist with expertise in treating network spinal muscle atrophy • Diagnosis of spinal muscle atrophy with genetically-confirmed double-deletion of SMN1 exon 7 and less HCPCS Limit C9399: 9999 units 1 unit than or equal to three copies of SMN2 HCPCS Limit J3399:

• Must not have antibodies against the viral vector, AAV9 NDC NDC Limit • Must receive oral corticosteroids daily starting at least 24 hours prior to therapy and continuing 30 days 71894-0120-02 1 UN after therapy with Zolgensma 71894-0121-03 1 UN • The patient does not have advanced SMA (for example: complete paralysis of limbs, permanent ventilator 71894-0122-03 1 UN dependence) 71894-0123-03 1 UN • Must not be getting treatment with Spinraza or Evrysdi 71894-0124-04 1 UN • Any additional pertinent medical information 71894-0125-04 1 UN 71894-0126-04 1 UN J3399/ onasemnogene HMO HMO Zolgensma 71894-0127-05 1 UN C9399 abeparvovec-xioi PPO PPO 71894-0128-05 1 UN 71894-0129-05 1 UN 71894-0130-06 1 UN 71894-0131-06 1 UN 71894-0132-06 1 UN 71894-0133-07 1 UN 71894-0134-07 1 UN 71894-0135-07 1 UN 71894-0136-08 1 UN 71894-0137-08 1 UN 71894-0138-08 1 UN 71894-0139-09 1 UN 71894-0140-09 1 UN

71894-0141-09 1 UN Affected providers: In/Out network

J3489 Zometa zoledronic acid HCPCS Limit: 5 Units

NDC NDC Limit

N/A N/A

Quantity Limit Summary Brand Name Generic Name Authorization Summary Code Required Required Procedure Site of of Site Care Authorization

Documentation PPO HMO Affected providers: In/Out network

HCPCS Limit: 1 Unit **90736 Zostavax zoster vaccine live/pf NDC NDC Limit N/A N/A

1 dose/lifetime Affected providers: In

HCPCS Limit: 12 Units

NDC NDC Limit 43288-0104-10 24 UN S0119 Zuplenz ondansetron 57881-0444-01 24 UN 57881-0444-10 24 UN 57881-0448-01 12 UN 57881-0448-10 12 UN 43288-0108-10 48 UN 89141-0444-30 12 UN

89141-0448-30 6 UN • Oncology Management Program Affected providers: In/Out network

loncastuximab tesirine- HMO HMO J3590 Zynlonta HCPCS Limit: 9999 Units lpyl PPO PPO NDC NDC Limit

79952-0110-01 3 UN Affected providers: In network

HCPCS Limit: 30 units

NDC NDC Limit 00009-4992-01 3000 ML J2020 Zyvox linezolid injection 00009-4992-02 3000 ML 00009-5137-01 3000 ML 00009-5137-04 3000 ML 00009-5140-01 3000 ML 00009-5140-04 3000 ML 00009-7807-01 3000 ML

00009-7807-02 3000 ML