Health Net Health Plan of Oregon, Inc. 13221 SW 68th Parkway, Ste. 200 Tigard, Oregon 97223 Phone 1-888-802-7001 www.healthnetoregon.com

Pharmacy Drug List Changes THIRD QUARTER 2020 – COMMERCIAL PRODUCTS

OUTPATIENT PHARMACEUTICALS SUBMITTED UNDER THE MEDICAL BENEFIT See the list below for all HCPCS codes affected by changes as of 07/01/2020. “New” indicates new requirements, “Existing” indicates current requirements, “Step Therapy” indicates step therapy requirements added to existing criteria. For Health Net Health Plan of Oregon, Inc. Commercial, newly approved medications may require prior authorization. For Medicare please refer to the Health Net Pre-Authorization check tool on our website at https://or.healthnetadvantage.com/for-providers/medicare-pre-auth.html. Simply enter the CPT code and the pre-authorization check tool will advise you whether the service requires prior authorization.

Commercial (EPO, POS, Brand (Generic Name) HCPC Code PPO, Community Care)

Third Quarter 2020 Changes

Adakveo® (crizanlizumab-tmca) C9053/C9399/J3490/J3590 New

Bynfezia Pen™ (octreotide acetate) J2354 New

Darzalex Faspro™ (daratumumab- J3590 New hyaluroidase-fihj)

Durysta™ (bimatoprost intracameral J3490/C9399 New implant)

Eylea® (afibercept) Q0178 Updated

Givlaari® (givosiran) C9056 New

Jelmyto™ (mitomycin for pyelocalcaeal J3490/J999/C9399 New solution)

Ontruzant® (trastuzumab-dttb) Q5112 New

Romidepsin (romidepsin) J9315 New

Retacrit® (epoetin alfa-epbx) Q5106 Updated

Rituxan® (rituximab) J9312 Updated

Ruxience® (rituximab-pvvr) J999 Updated

Sarclisa® (isatuximab-irfc) C9399/J3490/J3590/J9999 New Pharmacy Drug List Changes Third Quarter 2020 Continued

Truxima® (rituximab-abbs) Q5115 Updated

Zarxio® (filgrastim-sndz)** Q5101 Updated

Ziextenzo® (pegfilgrastim-bmez)** C9058 New

PHARMACEUTICALS COVERED UNDER THE PHARMACY BENEFIT Drug Name (generic name) Change

TIER 1 ADDITIONS AND CHANGES – NO CHANGES FOR JULY 1, 2020

TIER 2 ADDITIONS AND CHANGES

Cimduo® (Lamivudine-Tenofovir Step Therapy Disoproxil Fumarate) Treatment for HIV (human immunodeficiency virus)

Descovy® (Lamivudine-Tenofovir Prior Authorization Disoproxil Fumarate) Treatment for HIV (human immunodeficiency virus)

Prior Authorization Xtampza ER® (Oxycodone) Opioid analgesic for severe, chronic pain. TIER 3 ADDITIONS AND CHANGES

Caplyta™ (Lumateperone) Prior Authorization Quantity Limit of 1 tablet per day An antipsychotic to treat Schizophrenia Hysingla ER® (Hydrocodone Prior Authorization Bitartrate) Opioid analgesic for severe, chronic pain Secuado® (Asenapine) Prior Authorization Quantity Limit of 1 tablet per day An antipsychotic to treat Schizophrenia Skyrizi™ (Risankizumab-rzaa) Prior Authorization Tier 3 on OR ADL and OR EDL Treatment for moderate-to-severe plaque psoriasis Oxycontin® (Oxycodone Prior Authorization Hydrochloride) Opioid analgesic for severe, chronic pain Rinvoq™ (Upadacitinib) Prior Authorization Tier 3 on OR ADL Treatment for rheumatoid arthritis Valtoco® (Diazepam) Tier 3 on OR ADL Quantity Limit of 10 nasal spray devices per 30 days Antiepileptic nasal spray Zohydro® ER (Hydrocodone) Prior Authorization Opioid analgesic for severe, chronic pain 2

Pharmacy Drug List Changes Third Quarter 2020 Continued

SPECIALTY TIER AND OTHER ADDITIONS AND CHANGES

Ayvakit™ (Avapritinib) AC Prior Authorization Quantity Limit of 1 tablet per day Treatment of gastrointestinal stromal tumor (GIST) with certain mutations Brukinsa™ (Zanubrutinib) AC Prior Authorization Treatment of Mantle Cell Lymphoma Jelmyto™ (mitomycin for NF pyelocalcaeal solution) Prior Authorization Treatment of low-grade upper tract urothelial cell cancer (LG- UTUC); a type of bladder cancer Retevmo™ (Selpercatinib) NF Prior Authorization Treatment of certain types of lung cancer Reyvow™ (Lasmiditan NF succinate) Quantity Limit of 4 tablets per month of 50MG and 8 tablets per month of 100MG Treatment of acute migraine Rinvoq™ (Upadacitinib) Specialty Tier on OR and WA EDL Prior Authorization Treatment of rheumatoid arthritis Skyrizi™ (Risankizumab-rzaa) Specialty Tier on WA EDL Prior Authorization Treatment of moderate-to-severe plaque psoriasis Tabrecta™ (Capmatinib) NF Prior Authorization Treatment of certain types of lung cancer Valtoco® (Diazepam) Specialty Tier on OR and WA EDL Quantity Limit of 10 nasal spray devices per 30 days Antiepileptic nasal spray 1 Changes listed in the table apply to EDL and ADL unless a specific formulary is noted. 2 Tier 1*, Tier 2*, Tier 3*, PV - *These preventive medications are covered at $0 cost share if you have a Preventive Pharmacy benefit 3 **Self injectables, when used as chemotherapy adjunct, do not require prior authorization. Definitions ADL – AonActive Drug List EDL – Essential Rx Drug List NF – Non Formulary PV- Preventive Benefit SP – Specialty AC – Anti-cancer QL – Quantity Limit Step Therapy – Prior authorization is required if Step Therapy is not met.

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Pharmacy Drug List Changes Third Quarter 2020 Continued

DRUG LIST AT WWW.HEALTHNETOREGON.COM Please be sure to visit our website at www.healthnetoregon.com to view the most current version of our drug lists. ADDITIONAL INFORMATION For questions regarding the information contained in this update, please contact the Health Net Pharmacy Department at 1-888-802-7001

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