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1 Effective August 1, 2021

1 Effective August 1, 2021

Effective August 1, 2021 - PROVIDER COPY

THIS LIST APPLIES TO ALL MEDICARE MEMBERS

Certain drugs require prior authorization in order to be covered under your health plan. Prior authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment (including prescribed drug intervention) relative to approved criteria. Prior authorization is required to ensure that the drug is medically necessary and you will receive the benefits to which you are entitled.

Requests for prior authorization must be received before the services or drugs are provided/ administered. Failure of a network provider to contact SummaCare for required authorization of items covered under your benefit plan will relieve the health plan and you from any financial responsibility for the service if those services are rendered before notifying the plan.

NOTE: Network providers are responsible for obtaining authorization at least 48 hours before administering these prescription drugs. If the provider is not in the plan network, it is the member’s responsibility to verify that prior authorization has been obtained.

How to request prior authorization for drugs covered under the medical benefit: • Fax submission of requests for prior authorization should be used for non-urgent requests. • Routine requests: Fax 234-231-7082 • Urgent requests: Call 330-996-8710 or 888-996-8710 • Oncology requests: For all drugs marked with “*” Call 855-774-1315

SummaCare provides coverage under the medical benefit for many drugs that are administered in an office, home or outpatient setting. We require certain drugs to receive prior authorization before being administered. The following drugs may require prior authorization:

PROVIDER COPY

5FU (fluorouracil) * ALKERAN (melphalan) * ABRAXANE (paclitaxel) * ALOXI (palonosetron) * ACTEMRA (tocilizumab) * ALPHANATE (antihemophilic factor) ACTHAR GEL (corticotropin) ALPHANINE SD (antihemophilic factor) ACTIMMUNE (interferon gamma-1b) * ALPROLIX (factor product) ADAKVEO (crizanlizumab-tmca) AMONDYS (casimersen) ADCETRIS () * ANDEXXA (andexanet alfa) ADRIAMYCIN (doxorubicin) * ARA-C (cytarabine) * ADVATE (factor product) ARALAST (alpha proteinase inhibitor) ADYNOVATE (antihemophilic factor VIII) ARANESP (darbepoetin alfa) * AFSTYLA (factor product) AREDIA (pamidronate disodium) * AKYNZEO (fosnetupitant/palonosetron) * ARRANON (nelarabine) * ALIMTA (premetrexed disodium) * ARZERRA () * ALIQOPA (copsnlidib)* ASCENIV (immune globulin) 1

ASPARLAS (calaspargase pegol-mknl) * DANYELZA (-gqgk) * ATGAM (antithymocyte globulin) DARZALEX () * AVASTIN () * DARZALEX FASPRO (daratumumab-hyaluronidase) * AVONEX (interferon beta-1a) DEPOCYT (cytarabine-liposome) * AVSOLA (infliximab-axxq) DOJOLVI (triheptanoin) AZEDRA (iobenguane I 131) DOXIL (doxorubicin-liposome) * BAVENCIO () * DTIC-DOME (dacarbazine) * BCNU (carmustine) * DUROLANE (hyaluronate and derivatives) BEBULIN/BEBULIN VH (factor product) DYSPORT (abobotulinumtoxin A) BELEODAQ (belinostat) * ELELYSO (taliglucerase–alfa) BELRAPZO (bendamustine) * ELIGARD (leuprolide acetate) * BENDEKA (bendamustine) * ELLENCE (epirubicin) * BENEFIX (factor product) ELOCTATE (factor product) BENLYSTA IV (belimumab) ELOXATIN (oxaliplatin) * BERINERT (c1 esterase inhibitor) ELZONRIS (tagraxofusp-erzs) * BESPONSA () * EMPLICITI () * BIVIGAM (immune globulin) EMPAVELI (pegcetacoplan) BLENOXANE (bleomycin) * ENHERTU (fam- deruxtecan-nxki) * BLENREP (-blmf) * ENTYVIO (vedolizumab) BLINCYTO () * EPOGEN (epoetin alfa) * BOTOX (onabotulinumtoxin A) ERBITUX () * BRINEURA (cerliponase alfa) ERWINAZE (asparaginase) * CABLIVI (-yhdp) ESPEROCT (factor product) CAMPTOSAR (irinotecan) * EVENITY (-aqqg) CARIMUNE (immune globulin) EVKEEZA (-dgnb) CAYSTON (aztreonam for inhalation) EVOMELA (melphalan) * CERUBIDINE (daunorubicin) * EXONDYS 51 (eteplirsen) CIMZIA (certolizumab pegol) FASENRA (benralizumab) CINQAIR (reslizumab) FASLODEX (fulvestrant) * CINRYZE (c1 esterase inhibitor) FEIBA NF (factor product) CINVANTI (aprepitant) * FENSOLVI (leuprolide acetate) * CLOLAR (clofarabine) * FIRMAGON (degarelix) * COAGADEX (factor product) FLEBOGAMMA (immune globulin) CORIFACT (factor product) FLOLAN (epoprostenol sodium) COSELA () * FLUDARA (fludarabine) * COSMEGEN (dactinomycin) * FOLOTYN (pralatrexate) * CRYSVITA (-twza) FUDR (floxuridine) * CUVITRU (immune globulin) FULPHILA (-jmdb) * CYRAMZA () * FUSILEV (levoleucovorin) * CYTOGAM (cytomegalovirus immune globulin) GAMASTAN (immune globulin) CYTOXAN (cyclophosphamide) * GAMIFANT (emapalumab-lzsg) DACOGEN (decitabine) * GAMMAGARD (immune globulin)

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GAMMAPLEX (immune globulin) KADCYLA () * GAMMAKED (immune globulin) KANJINTI (trastuzumab-anns) * GAMUNEX-C (immune globulin) KANUMA (sebelipase alfa) GAZYVA () * KCENTRA (factor product) GEL-ONE (hyaluronate and derivatives) KEYTRUDA () * GELSYN (hyaluronate and derivatives) KHAPZORY (levoleucovorin) * GENVISC (hyaluronate and derivatives) KOATE (factor product) GEMZAR (gemcitabine) * KOGENATE FS (factor product) GIVLAARI (givosiran) KOVALTRY (factor product) GLASSIA (proteinase inhibitor) KRYSTEXXA (pegloticase) GRANIX (tbo-) * KYMRIAH (tisagenleceucel) HAEGARDA (c1 esterase inhibitor - human) KYPROLIS (carfilzomib) * HALAVEN (eribulin mesylate) * LARTRUVO () * HELIXATE FS (factor product) LEMTRADA () HEMLIBRA (emicizumab-kxwh) LEUCOVORIN * HEMOFIL M (antihemophilic factor) LEUKINE () * HERCEPTIN (trastuzumab) * LEUSTATIN (cladribine) * HERCEPTIN HYLECTA (trastuzumab, 10 mg and LIBTAYO (-rwic) * Hyaluronidase-oysk) * HERZUMA (trastuzumab-pkrb) * LUMIZYME (alglucosidase) HIZENTRA (immune globulin) LUMOXITI (moxetumomab psaudotox-tdfk) * HUMATE-P (factor product) LUPRON DEPOT (leuprolide acetate) * HYALGAN (hyaluronate and derivatives) LUTATHERA (lutetium lu177 dotatate) HYCAMTIN (topotecan) * LUXTURNA (voretigene neparvovec-rzyl) HYMOVIS (hyaluronate and derivatives) MARGENZA () HYQVIA (immune globulin) MARQIBO (vincristine sulfate liposome) * IDAMYCIN (idarubicin) * MEPSEVII (vestronidase alfa-vjbk) IDELVION (factor product) MESNEX (mesna) * IFEX (ifosfamide) * METHOTREXATE * ILARIS (canakinumab) MIRCERA (methoxy polyethylene glycol-epoetin beta) ILUMYA (tildrakizumab-asmn) MONJUVI (tafasitamb-cxix) * IMFINZI () * MONOCLATE-P (factor product) IMLYGIC (talimogene laherparepvec) * MONONINE (factor product) INFLECTRA (infliximab-dyyb) MONOVISC (hyaluronate and derivatives) INFUGEM (gemcitabine) * MUSTRAGEN (mechlorethamine) * INTRON A (interferon alfa-2b) * MUTAMYCIN (mitomycin) * ISTODAX (romidepsin) * MVASI (bevacizumab-awwb) * IXEMPRA (ixabepilone) * MYLOTARG () * IXINITY (factor product) MYOBLOC (rimabotulinumtoxin b) JELMYTO (mitomycin)* NAVELBINE (vinorelbine) * JEMPERLI (-gxly) * NEULASTA (pegfilgrastim) * JEVTANA (cabazitaxel) * NEUPOGEN (filgrastim) * JIVI (factor product) NIPENT (pentostatin) *

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NIVESTYM (filgrastim-aafi) * PROLASTIN C (alpha proteinase inhibitor) NOVANTRONE (mitoxantrone) * PROLEUKIN (aldesleukin) * NOVOEIGHT (factor product) PROVENGE (sipuleucel-T) * NOVOSEVEN RT (factor product) QUTENZA (capsaicin 8% patch) NPLATE (romiplostim) QUZYTTIR (cetirizine hcl) NUCALA (mepolizumab) RADICAVA (edaravone) NULOJIX (belatacept) REBINYN (factor product) NUWIQ (factor product) REBLOZYL (luspatercept-aamt) * NYVEPRIA (pegfilgrastim-apgf) * RECOMBINATE (factor product) OBIZUR (antihemophilic factor) RELISTOR (methylnaltrexone bromide) OCREVUS (ocrelizumab) REMICADE (infliximab) OCTAGAM (immune globulin) REMODULIN (treprostinil) OFIRMEV (acetaminophen injection) RENFLEXIS (infliximab-abda) OGIVRI (Trastuzumab-dkst) * REPATHA () ONCASPAR (pegaspargase) * RETACRIT (epoetin alfa) * ONCOVIN (vincristine sulfate) * RIABNI (-arrx) * ONIVYDE (irinotecan liposome) * RITUXAN (rituximab) * ONPATTRO (patisiran) RITUXIN HYCELA (rituximab-hyaluronidase human) * ONTRUZANT (trastuzumab-dttb) * RIXUBIS (factor product) OPDIVO () * RUCONEST (c1 esterase inhibitor) ORENCIA (abatacept) RUXIENCE (rituximab-pvvr) * ORTHOVISC (hyaluronate and derivatives) RYBREVANT (-vmjw) * OXLUMO (lumasiran) SANDOSTATIN (octreotide) * PADCEV (-ejfv) * SARCLISA (-irfc) * PANZYGA (immune globulin-ifas) SCENESSE (afamelanotide) PARAPLATIN (carboplatin) * SEVENFACT (factor product) PARSABIV (etelcalcetide) SIGNIFOR LAR (pasireotide pamoate) PEGASYS (peginterferon alfa-2a) * SIMPONI ARIA (golimumab) PEGINTRON (peginterferon alfa-2b) * SOLIRIS (eculizumab) PEPAXTO (melphalan flufenamide) * SOMATULINE DEPOT (lanreotide) * PERJETA () * SPINRAZA (nusinersen) PHESGO (pertuzumab, trastuzumab, hyaluronidase) * SPRAVATO (esketamine) PHOTOFRIN (porfimer) * STELARA (ustekinumab) PLATINOL (cisplatin) * STRENSIQ (asfotase alfa) POLIVY (-piiq) * SUPARTZ FX (hyaluronate and derivatives) PORTRAZZA () * SUSTOL (granisetron) * POTELIGEO (-kpkc) * SYLATRON (peginterferon, alfa-2b) * PRALUENT () SYLVANT () * PRIVIGEN (immune globulin) SYNAGIS (palivizumab) PROBUPHINE IMPLANT (buprenorphine) SYNRIBO (omacetaxine mepesuccinate) * PROCRIT (epoetin alfa) * SYNVISC (hyaluronate and derivatives) PROFILNINE SD (factor product) SYNVISC-ONE (hyaluronate and derivatives) 4

TAKHZYRO (lanadelumab-cwvz) VENTAVIS (iloprost) TAXOL (paclitaxel) * VIDAZA (azacitidine) * TAXOTERE (docetaxel) * VILTEPSO (viltolarsen) TECARTUS (brexucabtagene autoleucel) VIMIZIM (elosulfase alfa) TECENTRIQ () * VISCO-3 (hyaluronate and derivatives) TEMODAR (temozolomide) * VONDYS 53 (golodirsen) TEPEZZA (tazemetostat) VONVENDI (factor product) TESTOPEL ( pellets) VORAXAZE (glucarpidase) THERACYS (bcg) * VUMON (teniposide) * THIOPLEX (thiotepa) * VYEPTI (-jjmr) TICE (bcg) * VYXEOS (daunorubicin/cytarabine liposome) * TOPOSAR (etoposide) * WILATE (factor product) TORISEL () * XEMBIFY (immune globulin) TRAZIMERA (trastuzumab-qyyp) * XEOMIN (incobotulinumtoxin A) TREANDA (bendamustine hcl) * XGEVA () * TRELSTAR (triptorelin pamoate) * XIAFLEX (collagenase) TRETTEN (factor product) XOFIGO (radium Ra 223 dichloride) TRILURON (hyaluronate and derivatives) XOLAIR (omalizumab) XYNTHA/XYNTHA SOLOFUSE (antihemophiliac TRISENOX (arsenic trioxide) * factor) TRIVISC (hyaluronate and derivatives) YERVOY () * TRODELVY (-hziy) * YESCARTA (axicabtagene) TRUXIMA (rituximab-abbs) * YONDELIS (trabectedin) * TYSABRI (natalizumab) ZALTRAP (ziv-afilbercept) * TYVASO (treprostinil) ZANOSAR (streptozocin) * UDENYCA (pegfilgrastim-cbqv) * ZARXIO (filgrastim-sndz) * ULTOMIRIS (ravulizumab-cwvz) ZEMAIRA (alpha proteinase inhibitor) UNITUXIN () * ZEPZELCA (lurbinectedin) * UPLIZNA (inebilizumab-cdon) ZIEXTENZO (pegfilgrastim-bmez) * VALSTAR (valrubicin) * ZINPLAVA (bezlotoxumab) VANTAS (histrelin implant) * ZIRABEV (bevacizumab-bvzr) * VECTIBIX () * ZOLADEX (goserelin acetate) * VELBAN (vinblastine) * ZOLGENSMA (onasemnogene abeparvovec) VELCADE (bortezomib) * ZOMETA (zoledronic acid) *

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PROVIDER COPY

IMPORTANT INFORMATION:

1. This document is not intended to interfere with urgently needed care. Urgent care is any request for medical care or treatment in which the time periods for SummaCare to make non- urgent care determinations (within 14 days) could result in the following circumstances: • Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment; or • In the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.

If in the judgment of the rendering provider the care is of an emergency or urgent nature, the plan will review for medical necessity after the care has begun.

2. All services, even if authorized, are subject to your benefit plan contract coverage and exclusions, eligibility and network design. Approvals are not a guarantee of coverage, as your benefit plan contract may retroactively terminate at a future date.

3. Services not listed on this document may not be covered because they are listed as exclusions on your plan contract. Your benefit plan contract exclusions and current status of eligibility may be verified online at www.summacare.com/medicare. Call the customer service number on your member identification card to inquire about eligibility and coverage.

4. Providers may visit Plan Central at https://summacare.myplancentral.com to view eligibility and benefits or register for a user account. For additional questions, please email [email protected].

To find the most current list of services, surgeries, durable medical equipment or drugs covered under your medical benefit requiring prior authorization, please visit www.summacare.com/medicare or call the customer service number located on your member identification card. If you are unsure as to what requires prior authorization, please call customer service.

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