Drug Coverage Guidelines – Oxford Clinical Policy

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UnitedHealthcare® Oxford Clinical Policy Drug Coverage Guidelines

Policy Number: PHARMACY 098.215 T0 Effective Date: September 1, 2021  Instructions for Use

Table of Contents Page Related Policies Conditions of Coverage...... 1 Refer to Payment Guidelines below Description of Services ...... 1 Definitions ...... 4 Payment Guidelines ...... 4 Policy History/Revision Information ...... 249 Instructions for Use ...... 256

Conditions of Coverage

This policy applies to Oxford plan membership.

Note: Not all Oxford groups have selected the same pharmacy benefits. Refer to the group's pharmacy plan number for specific exclusions, exceptions, and dispensing limitations. New Jersey Small group plan members should refer to their Certificate of Coverage for prior authorization and quantity limit guidelines.

Description of Services

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

Overview Oxford's PBM provides a nationwide network of participating pharmacies that administers prescription drugs on a retail level. Groups that purchase the Pharmacy Rider and Medicare Members with a Pharmacy benefit will have their retail pharmacy benefit administered by the PBM. For information regarding medication coverage related to the Member's pharmacy benefit, providers may contact Oxford's PBM. For issues of medication coverage unrelated to the Member's pharmacy benefit (Intravenous infusions, intramuscular injections, etc), Oxford may be contacted directly.

Pharmacy Guideline Pharmacy Guideline Details New FDA-Approved New FDA-approved drug products may require prior authorization immediately upon launch of the medication. Drugs For information on coverage of recent FDA-approved drug products for which drug-specific criteria are unavailable, refer to Interim New Product Coverage Criteria. Also refer to the Clinical Policy titled Review at Launch for New to Market Medications. For oral chemotherapy, refer to Oral Chemotherapeutic Agents. New Jersey (NJ) Members who are enrolled in a New Jersey group Product with a 3-Tier Prescription Drug Benefit and for whom the NJ Formulary Regulations Formulary apply should refer to Prior Authorization/Notification Non-Formulary (i.e., Tier 3 or higher) Copay Adjustment – New Jersey. Regulations Opioid Overutilization The Center for Disease Control (CDC) recommends that clinicians should prescribe the lowest effective dosage when opioids are started. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine equivalent doses (MED) or more per day, and should avoid increasing dosage to 90 MED or more per day or carefully justify a decision to titrate dosage to 90 MED or more per day. • This includes all salt forms, single and combination ingredient products, all long- and short-acting formulations, and all brand and generic formulations, including but not limited to: codeine, buprenorphine (for pain), dihydrocodeine, fentanyl, methadone, meperidine, morphine, hydrocodone, hydromorphone, levorphanol, oxycodone, oxymorphone, pentazocine, tapentadol, tramadol. • For additional coverage criteria for the above drugs, refer to the Utilization Review Guideline titled Opioid Overutilization Cumulative Drug Utilization Review Criteria. Also refer to Short-Acting Opioid Review Criteria for Opioid Naïve Members and Supply Limits - Greater than 34 Day Supply for Opioids at Retail. Over-the-Counter • New Jersey (NJ) Plans: Prescription drugs for which there is a therapeutic over-the-counter (OTC) equivalent are not excluded from (OTC) Medications coverage. Refer to specific drug policies where applicable. • Connecticut (CT) and New York (NY) Plans: A prescription drug product that is therapeutically equivalent to an over-the-counter (OTC) drug may be covered if it is determined to be medically necessary. In order for a prescription drug to be deemed "medically necessary" when there is an equivalent OTC drug available, the physician must show that there is something about the prescription drug that is superior to the OTC drug, and likely to be more beneficial to the Member than the OTC drug. Documentation supporting medical necessity must be submitted by the provider. Pharmacy Benefit Oxford's PBM provides a nationwide network of participating pharmacies that administers prescription drugs on a retail level. Groups that Manager (PBM) purchase the Pharmacy Rider and Medicare Members with a Pharmacy benefit will have their retail pharmacy benefit administered by the PBM. • For information regarding medication coverage related to the Member's pharmacy benefit, providers may contact Oxford's PBM.

Pharmacy Guideline Pharmacy Guideline Details • For issues of medication coverage unrelated to the Member's pharmacy benefit (Intravenous infusions, intramuscular injections, etc), Oxford may be contacted directly. Quantity Duration Quantity duration (QD) and quantity level limitations (QLL) may be in place for certain medications. For information regarding QD or QLL (QD) and Quantity supply limits, refer to the following documents on UHCProvider.com > Drug Lists and Pharmacy > Supply Limits: Level Limitations • QD Supply Limits (defines the maximum quantity of medication that can be covered in a specified time period) (QLL) • QLL Supply Limits (defines the maximum quantity of medication that is covered for one prescription or copayment) Review at Launch The Review at Launch program provides Oxford the ability to review, evaluate, and implement programs for new to market medications. The medication may move to a covered status once the medication has been evaluated by the UnitedHealthcare Pharmacy and Therapeutics Committee and the appropriate system specifications have been implemented to ensure suitable utilization management strategies are in place. A medication will be subject to review at launch when the medication is listed on the Review at Launch Medication List. Refer to the Clinical Policy titled Review at Launch for New to Market Medications. Specialty Pharmacy Participating hospitals in CT, NJ and NY are required to obtain certain specialty medications from the Optum Specialty Pharmacy. The for Certain Specialty specialty medications included are: Medications • Actemra® (tocilizumab) injection for intravenous infusion Administered in an • Cimzia (certolizumab pegol) Outpatient Hospital • Entyvio® (vedolizumab) Setting • Infliximab (Avsola™, Inflectra®, Remicade®, Renflexis®) • Krystexxa® (Pegloticase) • Lemtrada (alemtuzumab) • Ocrevus® (ocrelizumab) • Orencia® (abatacept) injection for intravenous infusion • Simponi Aria® (golimumab) injection for intravenous infusion • Stelara® (ustekinumab) • Tysabri (natalizumab)

Participating hospitals located in CT, NJ and NY must obtain the above specialty medications from Optum when they are administered in an outpatient hospital. Optum will bill Oxford directly for these medications.

Outpatient Hospital is defined by the following CMS/AMA Place of Service codes: • 19 Off-Campus - Outpatient Hospital; and • 22 On-Campus - Outpatient Hospital

Exceptions: This does not apply to: • Hospitals that have contracted their separately reimbursable drugs at 165% of CMS or less.

Pharmacy Guideline Pharmacy Guideline Details • Hospitals whose aggregate reimbursement for the specialty drugs listed above are less than Oxford’s designated specialty pharmacy’s contracted rates for the same specialty drugs. • Hospitals that are located outside of CT, NJ and NY. • Oxford members that have Medicare or another health benefit plan as the primary payer and Oxford is the secondary payer.

Refer to the following documents for additional information: • Reimbursement Policy: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting • Administrative Protocol: Specialty Pharmacy Protocol for Certain Specialty Medications Administered in an Outpatient Hospital Setting for UnitedHealthcare Oxford Commercial Members available on UHCprovider.com/Protocols Topical Products for Topical medications are products that are applied locally to body surfaces such as the skin or mucous membranes. They include variety of New Jersey and New dosage forms, including but not limited to cream, lotions, ointments, foams and gels. A dollar threshold may be used to identify topical York Plans products which require prior authorization and must meet criteria in order to be covered. Refer to Prior Authorization/Notification Guidelines: Topical Products for New Jersey and New York Plans.

Definitions

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

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

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

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

Payment Guidelines

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

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Abilify (aripiprazole) IM Injection J0400 N/A N/A Medical N/A Tablet, Oral J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A Suspension Authorization Guidelines: New and Therapeutic Equivalent Medications Abilify MyCite Tablet with J8499 PBM • Prior Authorization/Medical Pharmacy N/A (aripiprazole tablet sensor Necessity Guidelines: Abilify with sensor) MyCite Abiraterone Acetate • Prior Authorization/ Notification 250 mg (generic Oral J8999 PBM Guidelines: Zytiga Pharmacy N/A Zytiga) Abiraterone Acetate Oral J8999 PBM Prior Authorization/Notification Pharmacy N/A 500 mg (generic Guidelines: Zytiga Zytiga) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Absorica Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (isotretinoin) Necessity Guidelines: Absorica Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Absorica LD Capsule J8499 PBM • Prior Authorization/Medical Pharmacy N/A (isotretinoin) Necessity Guidelines: Absorica LD • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Abstral (fentanyl) Tablet or J8499 PBM • Prior Authorization/Medical Pharmacy N/A Sublingual Necessity Guidelines: Abstral Tablet (Fentanyl) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Acanya Topical J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A (clindamycin Authorization Guidelines: New and phosphate 1.2% Therapeutic Equivalent and benzoyl Medications peroxide 2.5%) Accrufer (ferric Capsule J8499 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A maltol) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Acetaminophen/ Tablet J8499 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A Caffeine/ Drug Coverage Criteria - New and Dihydrocodeine Therapeutic Equivalent Bitartrate 325/30/16 Medications mg Aciphex Tablet J8499 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (rabeprazole) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Aciphex Sprinkle Capsule J8499 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (rabeprazole) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Acova (argatroban) Iv Injection J0883 and N/A N/A Medical N/A J0884 Actemra Sq Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (tocilizumab) Necessity Guidelines: Actemra Injection J3262 Oxford’s Medical Management Guidelines: Medical *Prior authorization Note: Prior Medical Maximum Dosage and Frequency authorization is required for the Management* Prior Authorization Guidelines: drug Actemra in all sites of service o Actemra (tocilizumab) through Oxford’s Medical Injection for Intravenous Management. Additional Prior Infusion authorization may be required for o Provider Administered Drugs the site of care of the injection. – Site of Care Hospital Outpatient Facility:

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Administration of Actemra in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Participating hospitals are required to purchase Actemra (tocilizumab) injection for intravenous infusion from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Acticlate Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (doxycycline Drug Coverage Criteria - New and hyclate) Therapeutic Equivalent Medications Actimmune Sq Injection J9216 PBM • Prior Authorization/Notification Pharmacy N/A (interferon gamma- Guidelines: Actimmune (interferon 1b) gamma-1b) Actiq (brand only) Lozenge J8499 PBM • Prior Authorization/Medical Pharmacy N/A (fentanyl citrate) Necessity Guidelines: Actiq (fentanyl citrate) Actonel (risedronate Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A sodium) (Brand Drug Coverage Criteria - New and Only) Therapeutic Equivalent Medications Actos (brand only) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (pioglitazone) Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Acuvail (ketorlac/ Ophthalmic J3490 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A tromethamine) Solution Drug Coverage Criteria - New and Therapeutic Equivalent Medications Aczone 7.5% Topical Gel J3490 N/A N/A Pharmacy N/A (dapsone) Adakveo Intravenous J0791 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (crizanlizumab- Medical Adakveo® (Crizanlizumab-Tmca) Administration of Adakveo in a tmca) Management Provider Administered Drugs - Site hospital outpatient facility of Care (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs - Site of Care Adapalene 0.1% Cream, Gel, J3490 N/A N/A N/A Note: Prescription drugs for which (generic Differin) Lotion there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Adapalene 0.1% Pad J3490 PBM Pharmacy Benefit/Prior Pharmacy Note: Prescription drugs for which Pad (generic Authorization Guidelines: New and there is a therapeutic over-the- Differin) Therapeutic Equivalent counter (OTC) equivalent are Medications excluded from coverage. Refer to the member specific benefit plan document as applicable. Adapalene 0.3% Gel J3490 N/A N/A N/A Note: Prescription drugs for which (generic Differin) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Adcirca (Brand Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A Only) (tadalafill) Necessity Guidelines: PAH Agents

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Adderall Tablet S0160 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (amphetamine/ Drug Coverage Criteria - New and dextroamphetamin) Therapeutic Equivalent (brand only) Medications Adderall XR Tablet S0160 N/A N/A Pharmacy N/A amphetamine/ dextroamphetamin [extended release]) Addyi (flibanserin) Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Addyi Adempas (riociguat) Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: PAH Agents Adhansia XR Extended- J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (methylphenidate release Drug Coverage Criteria - New and hydrochloride) Capsule Therapeutic Equivalent Medications Adlyxin (lixisenatide) Injection J3490 PBM • Prior Authorization/Notification Pharmacy The Prior Authorization/ Guidelines: Notification Guidelines: GLP-1 o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. • Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products. Adoxa (doxycycline Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A monohydrate) Drug Coverage Criteria - New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Adrenaclick Pen Injection J0171 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (epinephrine) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Adzenys XR-ODT Orally J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (amphetamine Disinter- Drug Coverage Criteria - New and extended-release) Grating Therapeutic Equivalent Tablet Medications Aemcolo (rifamycin) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Drug Coverage Criteria - New and Therapeutic Equivalent Medications Afinitor (everolimus) Oral J7527 PBM* • Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior J8999 Guidelines: Afinitor authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Afinitor (everolimus) Tablet J7527 PBM* • Prior Authorization/ Notification Pharmacy** *Prior authorization Note: Prior 2.5 mg, 5 mg, 7.5 J8999 Guidelines: Afinitor authorization through the PBM is mg tablet (Brand • Therapeutic Equivalent Guidelines: only required for those Oral Only) Drug Coverage Criteria - New and Oncology Drugs specifically listed Therapeutic Equivalent in a Coverage Criteria/Guideline Medications when the member is age 19 years or older. All other oral

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Afrezza (Insulin, Inhalation J3490 PBM • Prior Authorization/Medical Pharmacy N/A human) Powder Necessity Guidelines: Afrezza Aimovig (erenumab- Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A aooe) Necessity Guidelines: Aimovig AirDuo Digihaler Inhaler J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (fluticasone Drug Coverage Criteria - New and propionate and Therapeutic Equivalent salmeterol) Medications Airduo RespiClick Inhaler J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (Brand only) Drug Coverage Criteria - New and (fluticasone Therapeutic Equivalent propionate/ Medications salmeterol) Ajovy Injection J3031 PBM Prior Authorization/Medical Pharmacy N/A (fremanezumab- Necessity Guidelines: Ajovy vfrm) Aklief 0.005% cream Topical J3490 PBM • Prior Authorization/Notification Pharmacy N/A (trifarotene) cream Guideline: Aklief • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Aktipak gel Topical Gel J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (erythromycin and Drug Coverage Criteria - New and benzoyl peroxide) Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Akynzeo Capsule J8655 N/A N/A Pharmacy N/A (netupitant/ palonosetron) Akynzeo Injection J3490 Optum* • Prior Authorization Guidelines: Medical* *Prior Authorization Notes: (netupitant/ Antiemetics for Oncology* Prior authorization is required palonosetron) through Optum when Akynzeo is administered prior to chemotherapy infusion. Prior authorization is not required when self-administered outside of the infusion. Albenza Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A (albendazole) Necessity Guidelines: Albenza Albuterol HFA Inhaler J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A [Ventolin HFA Drug Coverage Criteria - New and authorized generic Therapeutic Equivalent (Prasco)] Medications Albuterol Tablets Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Albuterol Tablets Aldurazyme® Intravenous J1931 Oxford’s • Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (laronidase) Medical o Medical Therapies for Enzyme Administration of Aldurazyme in a Management Deficiencies hospital outpatient facility o Provider Administered Drugs (including any ambulatory infusion – Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Alecensa (alectinib) Capsule J8999 PBM • Prior Authorization/Notification Pharmacy N/A Guideline: Alecensa Alesse (ethinyl Pill S4993 N/A • Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members estradiol and with coverage for contraceptives levonorgestrel) through their prescription drug plan. If the member does not have contraceptive coverage through

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Aliskiren (Tekturna Tablets J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Authorized Generic) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Alkindi Sprinkle Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocortisone) granules Necessity Guidelines: Non-Solid Oral and Suppository Dosage Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Allegra D Tablet J8499 N/A N/A Pharmacy Note: Prescription drugs for which (fexofenadine & there is a therapeutic over-the- pseudoephedrine), counter (OTC) equivalent are Allegra suspension/ excluded from coverage. Refer to Allegra ODT the member specific benefit plan document as applicable. Allzital (allzital Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A butalbital/ Drug Coverage Criteria - New and acetaminophen) Therapeutic Equivalent Medications Almotriptan Tablet J8499 PBM* • Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: (generic) Supply Limits Prior authorization through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Alogliptin (Nesina Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Authorized Generic) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Alogliptin/ Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Metformin (Kazano Drug Coverage Criteria - New and Authorized Generic) Therapeutic Equivalent Medications Alogliptin/ Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Pioglitazone (Oseni Drug Coverage Criteria - New and Authorized Generic) Therapeutic Equivalent Medications Aloxi (palonosetron) Injection J2469 Optum* Prior Authorization Guidelines: Medical* *Prior Authorization Notes: Antiemetics for Oncology* Prior authorization is required through Optum when Aloxi is administered prior to chemotherapy infusion. Prior authorization is not required when self-administered outside of the infusion. Alpha Baclofen Injection And J0475 and N/A N/A Medical N/A (baclofen) Intrathecal J0476 Altoprev (lovastatin) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Drug Coverage Criteria - New and Therapeutic Equivalent Medications Altreno (tretinoin) Topical S0117, PBM Prior Authorization/Notification Pharmacy N/A lotion J3490 Guidelines: Altreno Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Alunbrig (brigatinib) Tablet J8499 PBM • Prior Authorization/Notification Pharmacy N/A Guidelines: Alunbrig Alvesco Inhalation J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (ciclesonide) aerosol Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ambien (zolpidem Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A tartrate) Authorization Guidelines: New and Therapeutic Equivalent Medications Ambien CR (Brand Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A Only) (zolpidem Authorization Guidelines: New and tartrate extended- Therapeutic Equivalent release[ER]) Medications Amerge Tablet J8499 PBM* • Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: (naratriptan) Supply Limits Prior authorization through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Amevive (alefacept) Injection, Sq J0215 N/A N/A Medical N/A Injection Amicar Tablet/Oral J8499 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (aminocaproic acid) Solution Drug Coverage Criteria - New and (Brand Only) Therapeutic Equivalent Medications Aminolevulinic acid Topical J7308 N/A N/A Medical N/A HCL

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Amitiza Capsule J8499 PBM • Prior Authorization/Medical Pharmacy N/A (lubiprostone) Necessity Guidelines: Amitiza (lubiprostone) Amlodipine/ Tablet J8499 N/A N/A Pharmacy N/A Atorvastatin (generic) Amlodipine/ Tablets J8499 PMB • Prior Authorization/Notification Pharmacy N/A Valsartan/ Guidelines: Generic Exforge HCT Hydrochlorothia- zide (generic Exforge HCT) Amnesteem Capsule J8499 N/A N/A Pharmacy N/A (isotretinoin) Amondys 45™ Injection C9075 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (Casimersen) J3490 Medical • Amondys 45™ (Casimersen) Administration of Amondys 45 in a J3590 Management Provider Administered Drugs – hospital outpatient facility Site of Care* (including any ambulatory infusion suite associated with the hospital) requires prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care. Amphetamine/ Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A dextro- Authorization Guidelines: New and amphetamine Therapeutic Equivalent extended-release Medications (generic Adderall XR) Ampyra Tablet J8499 PBM* Pharmacy Benefit/Prior Pharmacy** *Prior authorization Note: Prior (dalfampridine) Authorization Guidelines: New and authorization through the PBM is Therapeutic Equivalent required for Members age 19 and Medications older. Prior Authorization/Notification **Benefit Note: NJ Small Guidelines: Ampyra members should refer to their Certificate of Coverage for Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing authorization guidelines and quantity limit guidelines. Amrix/ Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A cyclobenzaprine Drug Coverage Criteria - New and extended release Therapeutic Equivalent Medications Amturnide Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (aliskiren, Drug Coverage Criteria - New and amlodipine, Therapeutic Equivalent hydrochloro- Medications thiazide) Amzeeq Topical foam J3490 PBM • Prior Authorization/Medical Pharmacy N/A (minocycline 4% Necessity Guidelines: Amzeeq topical foam) Anabolin Injection J2320 N/A N/A Medical N/A (nandrolone deconoate) Anadrol-50 Tablet J8499 N/A N/A Pharmacy N/A (oxymetholone) Anafranil Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (clomipramine) Drug Coverage Criteria - New and (brand) Therapeutic Equivalent Medications Analpram Advanced Cream J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Kit (hydrocortisone Drug Coverage Criteria - New and acetate/pramoxine) Therapeutic Equivalent Medications Anastrozole Tablet S0170 PBM* Prior Authorization/ Regulatory Pharmacy N/A (generic) Guideline: Anastrozole Androderm Gel J3490 PBM • Prior Authorization/Medical Pharmacy N/A (testosterone) Necessity Guidelines: Androderm Androgel Gel J3490 PBM • Prior Authorization/Medical Pharmacy N/A (testosterone) Necessity Guidelines: Androgel • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Android, Oreton, Tablet J8499 N/A N/A Pharmacy N/A Methyl, Virilon and Methitest (methyl- testosterone) Annovera Vaginal J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (segesterone Insert Drug Coverage Criteria - New and acetate and ethinyl Therapeutic Equivalent estradiol vaginal Medications system) Antagon (ganirelix) Injection S0132* and Prior • Prior Authorization Guidelines: Pharmacy/ *Prior authorization Notes: J3490 authorization Infertility Diagnosis and Treatment Medical** HCPCS code S0132 (ganirelix) through Optum requires Prior authorization may be through Optum in all sites of required* service when associated with an infertility diagnosis code. **Benefit Notes: Coverage is limited to members with coverage for fertility drugs through their prescription drug plan. If the member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Antara (fenofibrate) - Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A 30mg and 90mg Drug Coverage Criteria - New and strengths only Therapeutic Equivalent Medications Antara 43mg, Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A 130mg (fenofibrate) Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Anusol HC Suppository J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Suppository (brand) Drug Coverage Criteria - New and (hydrocortisone) Therapeutic Equivalent Medications Anzemet Injection J1260 N/A N/A Medical N/A (dolasetron) Tablet Q0180 N/A N/A Pharmacy N/A Apadaz (Brand Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Only) Drug Coverage Criteria - New and (benzhydrocodone/ Therapeutic Equivalent acetaminophen) Medications Aplenzin Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A (bupropion) Authorization Guidelines: New and Therapeutic Equivalent Medications Apokyn Prior Authorization/Medical Injection J0364 PBM Pharmacy N/A (apomorphine) Necessity Guidelines: Apokyn Apop 10% gel Topical Gel J3490 N/A N/A Pharmacy N/A (sulfacetamide) Apriso Capsule J8499 N/A N/A Pharmacy N/A (mesalamine) Aptensio XR Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Drug Coverage Criteria - New and Therapeutic Equivalent Medications Aptiom Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A (eslicarbazepine Necessity Guidelines: Single acetate) Source Brand Anticonvulsants Aqua Glycolic HC Topical J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (hydrocortisone) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Arakoda Tablets J8499 N/A N/A Pharmacy N/A (tafenoquine)

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

Aralast NP [Alpha1- Intravenous J0256 Oxford’s • Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: Proteinase Inhibitor Injection Medical o Alpha1-Proteinase Inhibitors Administration of Aralast NP in a (Human)] Management o Provider Administered Drugs hospital outpatient facility – Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Aranesp Injection, Sq J0882-ESRD Oxford’s Prior Authorization Guidelines: Medical**/ *No Prior authorization is required (Darbepoetin Alfa) Injection OR J0881- Medical Erythropoiesis-Stimulating Pharmacy* if dispensed by a retail pharmacy Non-ESRD Management** Agents** through the PBM. **Prior authorization is required if provided in a hospital, MD's office or home setting. Arazlo (tazarotene) Topical J3490 PBM • Prior Authorization/Notification Pharmacy N/A Lotion Guidelines: Arazlo • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Arcalyst (rilonacept) Injection, Sq J2793 PBM • Prior Authorization/Notification Pharmacy N/A Injection Guidelines: Rilonacept (Arcalyst) Aricept 23mg Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (donepezil Drug Coverage Criteria - New and hydrochloride) Therapeutic Equivalent Medications Arikayce (amikacin) Inhalation J3490 PBM • Prior Authorization/Medical Pharmacy N/A Solution Necessity Guidelines: Arikayce Arimidex (brand Tablet S0170 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A only) (anastrozole) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Arixtra Injection, Sq J1652 N/A* N/A Pharmacy *No Prior authorization is required (fondaparinux) Injection if dispensed by a retail pharmacy or mail order through PBM.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Armodafinil (generic Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Nuvigil) Guidelines: Nuvigil (armodafinil) ArmonAir Digihaler Inhaler J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (fluticasone Drug Coverage Criteria - New and propionate) Therapeutic Equivalent Medications ArmonAir Inhalation J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A RespiClick Powder Drug Coverage Criteria - New and (fluticasone Therapeutic Equivalent propionate) Medications Arnuity Ellipta Inhalation J3490 N/A N/A Pharmacy N/A (fluticasone furoate) Powder Aromasin Tablet S0155 PBM • Therapeutic Equivalent Guidelines: Pharmacy** *Prior Authorization Note: Prior (exemestane) Drug Coverage Criteria - New and authorization through the PBM is (Brand Only) Therapeutic Equivalent only required for those Oral Medications Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Arymo ER Extended J8499 N/A N/A Pharmacy N/A (morphine sulfate) Release Tablet Asacol HD Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A (mesalamine) Authorization Guidelines: New and Therapeutic Equivalent Medications AsmalPred and Tablet J8499 N/A N/A Pharmacy N/A AsmalPred Plus (Prednisolone)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Asmanex HFA Inhaler J3490 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (mometasone) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Asmanex Twisthaler Inhalation J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (mometasone Powder Drug Coverage Criteria - New and furoate) Therapeutic Equivalent Medications Astagraf XL Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (tacrolimus) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Astelin (brand) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (azelastine) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Astepro (azelastine) Nasal Spray J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Drug Coverage Criteria - New and Therapeutic Equivalent Medications Atacand Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (candesartan Drug Coverage Criteria - New and cilexetil) (Brand Therapeutic Equivalent Only) Medications Atelvia (risedronate Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A sodium) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ativan (brand only) Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A (lorazepam) Authorization Guidelines: New and Therapeutic Equivalent Medications Atorvastatin Tablet J8499 PBM • Prior Authorization/Notification Pharmacy N/A (generic Lipitor) Guidelines: Cardiovascular 10mg, 20mg Disease Prevention Zero Cost Share

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Atralin (tretinoin) Varies S0117 PBM* • Prior Authorization/Notification Pharmacy** *Prior authorization Notes: Prior (Brand and Generic) Guidelines: Atralin (tretinoin) authorization for NJ Small LOBs is • Therapeutic Equivalent Guidelines: based on the member's benefit. Drug Coverage Criteria - New and **Benefit Note: Not all groups Therapeutic Equivalent have selected the standard Medications pharmacy benefit. Refer to member's pharmacy plan, if applicable. Atripla (efavirenz/ Tablet J8499 PBM • Step Therapy Guidelines: Atripla Pharmacy N/A emtricitabine/ tenofovir disoproxil fumarate) (Brand and Generic) Aubagio Tablet J8499 PBM • Prior Authorization/Notification Pharmacy N/A (teriflunomide) Guidelines: Aubagio Augmentin Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (amoxicillin Drug Coverage Criteria - New and clavulanate) (brand) Therapeutic Equivalent Medications Augmentin ED-600 Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (amoxicillin Drug Coverage Criteria - New and clavulanate) (brand) Therapeutic Equivalent Medications Augmentin XR/ Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Amoxicillin- Drug Coverage Criteria - New and Clavulanate ER Therapeutic Equivalent (amoxicillin and Medications clavulanate potassium) Auralgan 5.5%/1.4% Drops, J3490 N/A N/A Pharmacy N/A (antipyrine, Solution benzocaine) Auryxia (ferric Tablet J8499 N/A N/A Pharmacy N/A citrate)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Austedo Tablet J8499 PBM • Prior Authorization/Medical Pharmacy N/A (deutetrabenazine) Necessity Guidelines: Austedo Auvi-Q (epinephrine) Injection J3490 PBM • Pharmacy Benefit/Prior Pharmacy N/A Authorization Guidelines: New and Therapeutic Equivalent Medications Avapro (irbesartan) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (Brand Only) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Avar Foam (9.5%- Topical J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A 5%), Avar, Avar LS Drug Coverage Criteria - New and (sodium Therapeutic Equivalent sulfacetamide/ Medications sulfur) Avastin Iv Infusion, J9035 N/A* • Medical Management Guidelines: Medical *Non-Oncology Indications: No (bevacizumab) Injection Maximum Dosage and Frequency Prior authorization required. Aveed (testosterone Injection J3145 N/A • Medical Management Guidelines: Medical N/A undecanoate) Maximum Dosage and Frequency Avelox tablet (Brand Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Only) (moxifloxacin Drug Coverage Criteria - New and hcl) Therapeutic Equivalent Medications Avinza (morphine Capsule J8499 N/A • N/A Pharmacy N/A sulfate controlled release) (Brand Only) Avinza (morphine Capsule J8499 PBM • Prior Authorization/Medical Pharmacy N/A sulfate controlled Necessity Guidelines: Avinza release) (Generic Only) Avita (tretinoin) Varies S0117 PBM • Prior Authorization/Notification Pharmacy N/A Guidelines: Avita (tretinoin) • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Avodart Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (dutasteride) Drug Coverage Criteria - New and (brand) Therapeutic Equivalent Medications Avonex (Interferon IM Injection J1826, PBM • Prior Authorization/Notification Pharmacy N/A Beta 1a) Or Injection Q3025 and Guidelines: Avonex Q3026 Avsola (infliximab- Injection Q5121 Oxford’s Medical Management Guidelines: Medical *Prior authorization Notes: Prior axxq) Medical Maximum Dosage and Frequency authorization is required in all sites Management Prior Authorization Guidelines: of service. ™ o Infliximab (Avsola , Hospital Outpatient Facility: ® ® Remicade , Inflectra , Administration of Avsola in a ® Renflexis ) hospital outpatient facility o Provider Administered Drugs (including any ambulatory infusion – Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Axiron Gel J3490 PBM • Prior Authorization/Medical Pharmacy N/A (testosterone) Necessity Guidelines: Axiron • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ayvakit (avapritinib) Tablet J8999 PBM • Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Ayvakit Azilect (Brand Only) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (rasagiline) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Azor (amlodipine Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A besylate and Authorization Guidelines: New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing olmesartan medoxomil) Bafiertam Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A (monomethyl Guidelines: Bafiertam fumarate) Balcoltra (ethinyl Tablets J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A estradiol/ Drug Coverage Criteria - New and levonorgestrel/ Therapeutic Equivalent ferrous bisglycinate) Medications Balversa Tablets J8999 PBM • Prior Authorization/Notification Pharmacy N/A (Erdafitinib) Guideline: Balversa Banzel (Rufinamide) Tablet J8499 PBM • Prior Authorization/Notification Pharmacy N/A Guidelines: Banzel (Rufinamide) Baqsimi (glucagon) Nasal J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A Powder Drug Coverage Criteria - New and Therapeutic Equivalent Medications Baraclude Tablets Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (Brand Only) Drug Coverage Criteria - New and (entecavir) Therapeutic Equivalent Medications Basaglar (insulin Injection J3490 PBM • Pharmacy Benefit/Prior Pharmacy N/A glargine) Authorization Guidelines: New and Therapeutic Equivalent Medications Baxdela Tablet J8499 N/A N/A Pharmacy N/A (delafloxacin) Beconase AQ Nasal Spray J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (beclomethasone Drug Coverage Criteria - New and dipropionate, Therapeutic Equivalent monohydrate) Medications Belbuca Buccal Film J8499 PBM • Prior Authorization/Medical Pharmacy N/A (buprenorphine) Necessity Guidelines: Belbuca Belsomra Tablet J8499 PBM • Step Therapy Guidelines: Pharmacy N/A (suvorexant) Belsomra

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Benicar Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (olmesartan) (brand Drug Coverage Criteria - New and only) Therapeutic Equivalent Medications Benicar HCT Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (olmesartan Drug Coverage Criteria - New and medoxomil- Therapeutic Equivalent hydrochloro- Medications thiazide)(brand only) Benlysta Subcutan- J0490 PBM* / • Prior Authorization/Notification Pharmacy*/ *Prior authorization Note: Prior (belimumab) eous Oxford’s Guidelines*: Benlysta Medical** authorization is required for the Injection* / Medical • Prior authorization Guidelines**: drug Benlysta in all sites of service. Injection** Manage- o Enzyme Replacement Additional Prior authorization may ment** Therapy be required for the site of care of o Provider Administered Drugs the injection. – Site of Care **Hospital Outpatient Facility: Administration of Benlysta in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Benzaclin Jar Topical J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (brand only) Drug Coverage Criteria - New and (benzoyl peroxide Therapeutic Equivalent and clindamycin) Medications Benzaclin Pump Topical J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (benzoyl peroxide Drug Coverage Criteria - New and and clindamycin) Therapeutic Equivalent Medications Benzaclin Kit (1%- Gel J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A 5%) (Clindamycin Drug Coverage Criteria - New and Phosphate-Benzoyl Therapeutic Equivalent Peroxide) Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Benzefoam Aerosol/ J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A BenzeFoam Ultra Foam Drug Coverage Criteria - New and Therapeutic Equivalent Medications Benznidazole Tablets J8499 PBM • Prior Authorization/Notification Pharmacy N/A Guidelines: Benznidazole Beovu Injection J0179 N/A • Medical Management Guidelines: Medical N/A (brolucizumab-dbll) Maximum Dosage and Frequency Bepreve Ophthalmic J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (bepotastine) Drops Drug Coverage Criteria - New and Therapeutic Equivalent Medications Berinert (C1 Injection J0597 PBM*/ Prior Authorization Guidelines: Pharmacy*/ *Self-administered: Berinert esterase inhibitor Oxford’s Hereditary Angioedema (HAE), Medical** requires Prior authorization human) Medical Treatment and Prophylaxis** through the PBM and is covered Management** • Prior Authorization/Medical under the pharmacy benefit when Necessity Guidelines*: Berinert obtained at a pharmacy. **Provider administered: Berinert requires Prior authorization through Oxford’s Medical Management and is covered under the medical benefit. Betamethasone Topical J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A valerate foam Drug Coverage Criteria - New and (generic Luxiq) Therapeutic Equivalent Medications Betapace (sotalol) Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (brand) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Betaseron Injection J1830 or PBM • Prior Authorization/Notification Pharmacy N/A (Interferon Beta 1b) J3490 Guidelines: Betaseron Bethkis Inhalation J3490 PBM • Prior Authorization/Notification Pharmacy N/A (tobramycin) Solution Guidelines: Bethkis

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Bethkis Inhalation J3490 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (tobramycin) (Brand Solution Drug Coverage Criteria - New and Only) Therapeutic Equivalent Medications Bevespi Aerosphere Inhalation J3490 N/A N/A Pharmacy N/A (glycopyrrolate/ Aerosol formoterol fumarate) Bevyxxa Capsule J8499 N/A N/A Pharmacy N/A (betrixaban) Bexarotene caps Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (generic Targretin) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Bexxar Injection J3490 N/A N/A Medical N/A (tositumomab) Beyaz Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (drospirenone/ Drug Coverage Criteria - New and ethinyl estradiol/ Therapeutic Equivalent levomefolate) Medications Bijuva (estradiol and Capsule J8499 N/A N/A Pharmacy N/A progesterone) Biktarvy Tablets J8499 N/A N/A Pharmacy N/A (bictegravir/ emtricitabine/ tenofovir alafenamide) bimatoprost 0.03% Eye Drops J3490 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (generic Lumigan) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Binosto Tablet J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (alendronate) Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Boniva (ibandronate Injection J1740 N/A N/A Medical N/A sodium) Boniva Tablet Tablet J8499 N/A N/A Pharmacy N/A (ibandronate sodium) Bonjesta Tablets J8499 PBM • Prior Authorization/Medical Pharmacy N/A (doxylamine/ Necessity Guidelines: Bonjesta pyridoxine) Bosulif (bosutinib) Tablet J8999 PBM • Prior Authorization/Notification Pharmacy N/A Guidelines: Bosutinib (Bosulif) • Step Therapy Guidelines: Bosutinib (Bosulif) Botox, Botulinum Injection J0585 Oxford’s • Prior Authorization Guidelines: Medical N/A Toxin Type Medical Botulinum Toxins A and B (onabotulinumtoxin Management A) Department Braftovi Capsule J8999 PBM • Prior Authorization/Notification Pharmacy N/A (encorafenib) Guidelines: Braftovi • Step Therapy Guidelines: Braftovi Brexafemme Tablet J8499 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (ibrexafungerp) Drug Coverage Criteria - New and Therapeutic Equivalent Medications Breztri Aerosphere Inhaler J3490 PBM Therapeutic Equivalent Guidelines: Pharmacy N/A (budesonide/ Drug Coverage Criteria - New and glycopyrrolate/ Therapeutic Equivalent formoterol Medications fumarate) Brilinta (Ticagrelor) Tablet J8499 N/A N/A Pharmacy N/A Brineura Injection J0567 Oxford’s Prior Authorization Guidelines: Medical N/A (cerliponase alfa) Medical Brineura (cerliponase alfa) Management Brisdelle Capsule J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A (paroxetine) Drug Coverage Criteria - New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Briviact Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (brivaracetam) Necessity Guidelines: Single Source Brand Anticonvulsants Bromday Ophthalmic J3490 N/A N/A Pharmacy N/A (bromfenac) Drops Brompheniramine/ Oral syrup J8499 PBM • Therapeutic Equivalent Pharmacy N/A Pseudoephedrine/ Guidelines: Drug Coverage Dextromethorphan Criteria - New and Therapeutic Equivalent Medications Bromsite Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (bromfenac) Ophthalmic Guidelines: Drug Coverage Solution Criteria - New and Therapeutic Equivalent Medications Bronchitol Inhalation J3490 PBM • Prior Authorization/ Notification Pharmacy N/A (mannitol) Powder Guidelines: Bronchitol • Step Therapy Guidelines: Bronchitol Brukinsa Capsule J8999 PBM • Prior Authorization/Notification Pharmacy N/A (zanubrutini) Guideline: Brukinsa • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Bryhali 0.01% Topical J3490 PBM • Step Therapy Guidelines: Bryhali Pharmacy N/A (halobetasol Lotion propionate) Budesonide/ Inhalation J3490 PBM • Therapeutic Equivalent Pharmacy N/A Formoterol Powder Guidelines: Drug Coverage (Symbicort Criteria - New and Therapeutic Authorized Generic) Equivalent Medications Budesonide nasal Nasal Spray J3490 PBM • Therapeutic Equivalent Pharmacy N/A spray (generic Guidelines: Drug Coverage Rhinocort Aqua) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Bunavail Film Buccal Film J8499 PBM Prior Authorization/Medical Pharmacy N/A (buprenorphine and Necessity Guidelines: naloxone)(Brand Buprenorphine/Naloxone Only) Products Buphenyl (Sodium Tablets and J8499 PBM Prior Authorization/Notification Pharmacy N/A phenylbutyrate) Oral Powder Guidelines: Sodium phenylbutyrate Buprenorphine HCl Sublingual J8499 N/A N/A Pharmacy N/A Tablet Buprenorphine Tablet J8499 N/A N/A Pharmacy N/A (generic Subutex) Buprenorphine/ Tablet J8499 N/A N/A Pharmacy N/A naloxone (generic Suboxone) Bupropion (SR) Tablet J8499 N/A N/A Pharmacy Benefits for Smoking Cessation for (generic Zyban) Health Care Reform apply to all plans subject to health care reform. Butal/Apap 50/300 Tablet/ J8499 PBM • Therapeutic Equivalent Guidelines: Pharmacy N/A mg (butalbital- Capsule Drug Coverage Criteria - New and acetaminophen) Therapeutic Equivalent Medications Butalbital/ Capsule J8499 PBM • Therapeutic Equivalent Pharmacy N/A acetaminophen/ Guidelines: Drug Coverage caffeine/codeine Criteria - New and Therapeutic 50mg/300mg/ Equivalent Medications 40mg/30mg (generic Fioricet with Codeine) Butrans Patch J3490 PBM Prior Authorization/Medical Pharmacy Coverage Criteria does not apply (buprenorphine) Necessity Guidelines: Butrans to CT of business. Bydureon Extended J3490 PBM • Prior Authorization/Notification Pharmacy The Prior Authorization/ (exenatide) release Guidelines: Notification Guidelines: GLP-1 injection o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing o GLP-1 Receptor Agonists (NJ) policy applies to Connecticut and • Step Therapy Guidelines: GLP-1 New York plans and products. Receptor Agonists (NJ) The Prior Authorization/ Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products. Bydureon BCise Extended J3490 PBM • Prior Authorization/Notification Pharmacy The Prior Authorization/ (exenatide) release Guidelines: Notification Guidelines: GLP-1 injection o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. • Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products. Byetta (exenatide) Injection J3490 PBM • Prior Authorization/Notification Pharmacy The Prior Authorization/ Guidelines: Notification Guidelines: GLP-1 o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. • Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products. Bynfezia (octreotide Injectable J3490 PBM • Prior Authorization/Medical Pharmacy N/A acetate) pen Necessity Guidelines: Bynfezia • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Bystolic (nebivolol) Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cabenuva Injection C9077 N/A* Prior Authorization Guidelines: Medical *Prior Authorization Notes: (Cabotegravir; - J3490 Long-Acting Injectable Prior authorization is not required Rilpivirine) Antiretroviral Agents for HIV but is strongly recommended for Review at Launch for New to Cabenuva. While no penalty will be Market Medications* imposed for failure to request a pre-service review, if you do not request one, a medical necessity review will be conducted post- service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of Oct. 1, 2021, prior authorization will be required. Cablivi Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A (caplacizumab- Guidelines: Cablivi yhdp) Cabometyx Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (cabozantinib) Guidelines: Cabometyx

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Caduet and generic Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A Caduet (amlodipine Guidelines: Drug Coverage and atorvastatin) Criteria - New and Therapeutic Equivalent Medications Calcijex (Calcitriol) Injection J0636 N/A N/A Medical* *Injectable prescription vitamins administered under the direction of a physician as medically necessary are reimbursed under the Medical Benefit. Calcipotriene/ Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A Betamethasone Ointment Guidelines: Drug Coverage suspension Criteria - New and Therapeutic (Taclonex Equivalent Medications Authorized Generic) Calderol Capsule J8499 N/A N/A Pharmacy N/A (calcifediol) Calquence Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (acalabrutinib) Guidelines: Calquence Cambia (diclofenac Powder, J8499 PBM Therapeutic Equivalent Pharmacy N/A potassium) Tablet, Guidelines: Drug Coverage Capsule Criteria - New and Therapeutic Equivalent Medications Canasa (Brand only) Rectal J3490 PBM Therapeutic Equivalent Pharmacy N/A (mesalamine) Suppository Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Capecitabine Tablet J8999 N/A N/A Pharmacy N/A (generic Xeloda) Caplyta Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (Lumateperone) Necessity Guidelines: Caplyta Caprelsa Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: (vandetanib) Guidelines: Caprelsa Prior authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing when the member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Carafate (sucralfate) Oral J8499 PBM • Prior Authorization/Medical Pharmacy N/A Suspension Necessity Guidelines: Non-Solid Oral and Suppository Dosage Carafate (sucralfate) Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (Brand Only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Carbaglu (carglumic Tablet J8499 PBM • Prior Authorization/Notification Pharmacy N/A acid) Guidelines: Carbaglu Cardizem (diltiazem) Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cardizem CD Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (diltiazem) (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cardizem LA Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (diltiazem) (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Carnitor Tablet or J8499 N/A N/A Pharmacy* *Coverage is limited to Members (levocarnitine/ Solution with coverage for vitamins/ L-Carnitine) supplements through their prescription drug plan. If the member does not have vitamin/ supplement coverage through their prescription drug plan, then this is

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Injection J1955 N/A Medical Management Guidelines: Medical* *Benefit is State Specific. Medical Formula & Specialized Food Benefit/Pharmacy Benefit. Carospir Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A Suspension Suspension Necessity Guidelines: Carospir (spironolactone) [CAR-T (Chimeric Injection 0537T**, Prior Optum Guidelines: Oncology Transplant- *Chimeric Antigen Receptor Antigen Receptor) 0538T**, authorization Medication Clinical Coverage ation Services (CAR)-T Cell Therapy may be Cell Therapy] 0539T**, through Optum Transplant Review eligible for coverage as an Abecma (ide- 0540T**, Optum* Guidelines: Chimeric Antigen autologous stem cell therapy under Receptor T-cell Therapy cel) C9076, a member’s Transplantation Breyanzi C9399, Services benefit. (lisocabtagene C9999, maraleucel) J3490, Coverage determinations are Kymriah J9999, based on the Optum Transplant (tisagenlecleuc Q2041, Review Guidelines: Chimeric el) Q2042, Antigen Receptor T-cell Therapy Tecartus criteria for covered transplants. Q2053, (brexucabtagen S2107 e autoleucel) Prior authorization through Optum Yescarta is required in all sites of service. (axicabtagene

ciloleucel) **Codes 0537T, 0538T, 0539T, and 0540T are part of the CAR-T process; refer to the Optum Transplant Review Guidelines: Chimeric Antigen Receptor T-cell Therapy Cataflam Tablet J3490 PBM Therapeutic Equivalent Pharmacy N/A (diclofenac Guidelines: Drug Coverage potassium Criteria - New and Therapeutic immediate-release) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Caverject Vial J0270 N/A N/A Pharmacy N/A (alprostadil) Cayston (Aztreonam Inhalation J3490 PBM* Prior Authorization/Notification Pharmacy* *NJ Small members should refer for Inhalation Solution Guidelines: Cayston to their Certificate of Coverage for Solution) Step Therapy Guidelines: Cayston Prior authorization guidelines. Celebrex (brand Capsule J8499 PBM • Therapeutic Equivalent Pharmacy N/A only) (celecoxib) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Celexa (citalopram) Tablet J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and Therapeutic Equivalent Medications Cellcept Tablet/ J8499 PBM • Therapeutic Equivalent Pharmacy N/A (mycophenolate Capsule/ Guidelines: Drug Coverage mofetil) (brand only) Suspension Criteria - New and Therapeutic Equivalent Medications Cenestin Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (conjugated Guidelines: Drug Coverage estrogens) (brand Criteria - New and Therapeutic only) Equivalent Medications Centany AT Kit Ointment J3490 PBM • Therapeutic Equivalent Pharmacy N/A (mupirocin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cequa Ophthalmic J3490 PBM • Prior Authorization/Medical Pharmacy N/A (cyclosporine) solution Necessity Guidelines: Cequa • Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cerdelga (eliglustat) Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Cerdelga Ceredase® IV Infusion, J0205 N/A N/A Medical N/A (algucerase) Injection

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Cerezyme® IV Infusion, J1786 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (imiglucerase) Injection Medical Intravenous Enzyme Replacement Administration of Cerezyme in a Management Therapy (ERT) for Gaucher hospital outpatient facility Disease (including any ambulatory infusion Prior Authorization Guidelines*: suite associated with the hospital) Provider Administered Drugs – requires Prior authorization with Site of Care review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Cesamet (nabilone) Capsule J8650 N/A N/A Pharmacy N/A Cetirizine Solution Oral Solution J8499 N/A N/A N/A Note: Prescription drugs for which (generic Zyrtec) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Cetrotide (cetrorelix Injection J3490 Optum* Prior Authorization/Medical Pharmacy* *Benefit Note: Coverage is limited acetate) Necessity Guidelines: Cetrotide to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Cetylev Tablet J8499 N/A N/A Pharmacy N/A (acetylcysteine) Chantix (varenicline Tablet J8499 PBM** Prior Authorization/Medical Pharmacy* *Benefits for Smoking Cessation tartrate) Necessity Guidelines**: Tobacco for Health Care Reform apply to all Cessation for Health Care Reform plans subject to health care Supply Limit Guidelines: HCR reform. Tobacco Cessation - Supply Limits Override - NJ Fully Insured **Prior authorization is not required for New York plans

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Chelation Therapy IV Infusion J3490 Oxford’s Prior Authorization Guidelines: Medical N/A M0300 and Medical Chelation Therapy for Non- S9355 Management Overload Conditions Chemotherapy Injection Varies Optum* Optum Guidelines: Oncology Medical *Prior Authorization Notes: (Injectable) Drugs Medication Clinical Coverage Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after. Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021.

For prior authorization requirements for chemotherapy and related cancer therapies, refer to: https://www.uhcprovider.com/en/ prior-auth-advance-notification/ oncology-prior-auth/oncology- injectable-chemo-prior-auth.html Chlorzoxazone 250 Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A mg Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cholbam (cholic Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A acid) Guidelines: Cholbam Choline Fenofibrate Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (generic Trilipix) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Chorionic Injection J0725* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS Gonadatropin J3490 authorization Infertility Diagnosis and Treatment Medical** code J0725 (chorionic through Optum gonadatropin) requires Prior may be authorization through Optum in all required* sites of service when associated with an infertility diagnosis code.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Cialis (tadalafil) Tablet J8499 N/A N/A Pharmacy N/A Ciclodan Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A Combination Guidelines: Drug Coverage Package (ciclopirox) Criteria - New and Therapeutic Equivalent Medications Ciclodan Kit Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (ciclopirox) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cimduo (lamivudine Tablet J8499 N/A N/A Pharmacy N/A / tenofovir DF) Cimzia Sq Injection J3490*, PBM*/ Medical Management Pharmacy*/ *Self-administered: Cimzia (certolizumab J0717** Oxford’s Guidelines**: Maximum Dosage Medical** requires Prior authorization pegol) Medical and Frequency through the PBM and is covered Management** Prior authorization Guidelines**: under the pharmacy benefit. ® o Cimzia (Certolizumab Pegol) **Provider administered: Cimzia o Provider Administered Drugs requires Prior authorization – Site of Care through Oxford’s Medical Prior Authorization/Medical Management and is covered under Necessity Guidelines*: Cimzia the medical benefit. **Hospital Outpatient Facility: • Administration of Cimzia in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care • Participating hospitals are required to purchase Cimzia (certolizumab pegol) from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Cinqair (reslizumab) Intravenous J3490, Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: Infusion J3590, and Medical o Provider Administered Drugs Administration of Cinqair in a J2786 Management – Site of Care hospital outpatient facility o Respiratory Interleukins (including any ambulatory infusion (Cinqair®, Fasenra®, and suite associated with the hospital) Nucala®) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Cinryze (C1 Injection J0598 PBM*/ Prior Authorization Guidelines**: Pharmacy*/ *Self-administered: Cinryze esterase inhibitor Oxford’s Hereditary Angioedema (HAE), Medical** requires Prior authorization (human)) Medical Treatment and Prophylaxis through the PBM and is covered Management** Prior Authorization/Medical under the pharmacy benefit when Necessity Guidelines*: Cinryze obtained at a pharmacy. Therapeutic Equivalent **Provider administered: Cinryze Guidelines*: Drug Coverage requires Prior authorization Criteria - New and Therapeutic through Oxford’s Medical Equivalent Medications Management and is covered under the medical benefit.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Cinvanti Injectable J0185 Optum* Prior Authorization Guidelines: Medical *Prior Authorization Notes: (aprepitant) emulsion Antiemetics for Oncology* Prior authorization is required through Optum when Cinvanti is administered prior to chemotherapy infusion. Prior authorization is not required when self-administered outside of the infusion. Cipro (ciprofloxacin) Tablet J8499 N/A N/A Pharmacy N/A Injection J0744 N/A N/A Medical N/A Cipro suspension Oral J8499 N/A N/A Pharmacy N/A (Brand Only) Suspension (ciprofloxacin) Cipro XR Tablet J8499 N/A N/A Pharmacy N/A (ciprofloxacin extended-release) Ciprodex Tablet J8499 N/A N/A Pharmacy N/A (ciprofloxacin HCL/ dexamethasone) Claforan Iv Infusion J0698 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is only (cefotaxime sodium) Medical Lyme Disease required only when used in the Management* treatment of Lyme disease. Exception: Prior authorization is not required for Connecticut Members. Claravis Capsule J8499 N/A N/A Pharmacy N/A (isotretinoin) Clarifoam EF Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (sulfacetamide/ Foam Guidelines: Drug Coverage sulfur) (brand) Criteria - New and Therapeutic Equivalent Medications Clarinex Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (desloratadine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Clarinex D Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (desloratadine and Guidelines: Drug Coverage pseudoephedrine) Criteria - New and Therapeutic Equivalent Medications Clarinex Reditab Tablet J8499 N/A N/A Pharmacy N/A (desloratadine orally disintegrating tablet) Clenpiq (sodium Oral Solution J8499 N/A N/A Pharmacy N/A picosulfate) Climara (Brand only) Transdermal J3490 PBM • Therapeutic Equivalent Pharmacy N/A (estradiol) Patch Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clindacin Pack Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (clindamycin Guidelines: Drug Coverage phosphate) Criteria - New and Therapeutic Equivalent Medications Clindagel Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (clindamycin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clindamycin Gel J3490 PBM • Therapeutic Equivalent Pharmacy N/A 1%/benzoyl Guidelines: Drug Coverage peroxide 5% Criteria - New and Therapeutic (generic BenzaClin) Equivalent Medications gel Clindamycin1.2%/b Topical J3490 N/A N/A Pharmacy N/A enzoyl peroxide 5% gel (Generic Duac) Clobazam Oral J8999 PBM • Prior Authorization / Notification Pharmacy N/A Guideline: Clobazam Clobeta (Clobetasol) Ointment J3490 and PBM • Therapeutic Equivalent Pharmacy N/A J8499 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Clobetasol Gel J3490 PBM • Therapeutic Equivalent Pharmacy N/A shampoo (generic Guidelines: Drug Coverage Clobex shampoo) Criteria - New and Therapeutic Equivalent Medications Clobex Lotion Lotion J3490 PBM • Therapeutic Equivalent Pharmacy N/A (clobetasol Guidelines: Drug Coverage propionate) Criteria - New and Therapeutic Equivalent Medications Clobex Shampoo Shampoo J3490 PBM • Therapeutic Equivalent Pharmacy N/A (clobetasol Guidelines: Drug Coverage propionate) Criteria - New and Therapeutic Equivalent Medications Clobex 0.05% spray Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (Brand only) Spray Guidelines: Drug Coverage (clobetasol Criteria - New and Therapeutic propionate) Equivalent Medications Clodan 0.05% Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (clobetasol Guidelines: Drug Coverage proprionate) Criteria - New and Therapeutic Equivalent Medications Clodan 0.05% kit Topical J3490 PBM • Therapeutic Equivalent Pharmacy N/A (clobetasol Guidelines: Drug Coverage proprionate) Criteria - New and Therapeutic Equivalent Medications Cloderm 0.1% Cream J3490 PBM Step Therapy Guidelines: Cloderm Pharmacy N/A cream (clocortolone) Cloderm cream Cream J3490 N/A N/A Pharmacy N/A (Brand Only (clocortolone) Cocet Plus Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (acetaminophen Guidelines: Drug Coverage and codeine Criteria - New and Therapeutic phosphate) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Codeine/ All Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A phenylephrine/ Forms Necessity Guidelines: Opioid promethazine Containing Cough Medicines Codeine/ All Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A promethazine Forms Necessity Guidelines: Opioid Containing Cough Medicines Colazal (balsalazide) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Colchicine Capsule Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (manufacturer: Guidelines: Drug Coverage West-Ward) Criteria - New and Therapeutic Equivalent Medications Colchicine Tablet Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (manufacturer: Guidelines: Colchicine Tablet Prasco) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Colcrys “authorized Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A generic” Guidelines: Colcrys (colchicine) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Colesevelam Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Welchol) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cometriq Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (cabozantinib) Guidelines: Cometriq authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Comfort Pac w/ Capsule J8499 PBM • Therapeutic Equivalent Pharmacy N/A Tizanidine Guidelines: Drug Coverage (tizanidine) Criteria - New and Therapeutic Equivalent Medications Compounds and Various J7999 PBM* Prior Authorization/Notification Pharmacy *NJ Small members should refer Bulk Powders: Guidelines: Compounds and Bulk to their Certificate of Coverage for various drugs Powders Prior authorization guidelines. Concerta Tablet J8499 N/A N/A Pharmacy N/A (methylphenidate) Conjupri Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (levamlodipine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Consensi Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (amlodipine and Guidelines: Drug Coverage celecoxib) Criteria - New and Therapeutic Equivalent Medications Continuous Glucose N/A S1030 Oxford’s • Prior Authorization Guidelines*: Medical*/ *Prior authorization is required Monitor Medical Continuous Glucose Monitoring Pharmacy** through Oxford if covered under Management*/ and Insulin Delivery for Managing the medical benefit. PBM** Diabetes **Prior authorization is required • Prior Authorization/Medical through the PBM if covered under Necessity Guideline**: Guardian the pharmacy benefit. Connect Sensor and Transmitter **Benefit Note: Not all groups for Continuous Glucose have selected the standard Monitoring pharmacy benefit. Refer to • Prior Authorization/Notification Member's pharmacy plan if Guidelines**: Continuous applicable. Glucose Monitors, sensors and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing transmitters (all brands except Guardian Connect) Conzip (tramadol) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Copaxone (brand Injection, Sq J1595 PBM Pharmacy Benefit/Prior Pharmacy N/A only)(glatiramer Injection Authorization Guidelines: New and acetate) Therapeutic Equivalent Medications Prior Authorization/Notification Guidelines: Copaxone Copegus (ribarivin) Tablet J8499 N/A N/A Pharmacy N/A Copiktra (duvelisib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Copiktra Cordran 0.025% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream cream Guidelines: Drug Coverage (flurandrenolide) Criteria - New and Therapeutic Equivalent Medications Cordran 0.05 % Cream J3490 PBM Step Therapy Guidelines: Cordran Pharmacy N/A cream Therapeutic Equivalent (clurandrenolide) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cordran 0.05% Lotion J3490 PBM Step Therapy Guidelines: Cordran Pharmacy N/A lotion Therapeutic Equivalent (flurandrenolide) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cordran 0.05% Topical J3490 PBM Step Therapy Guidelines: Cordran Pharmacy N/A Ointment Ointment Ointment (flurandrenolide) Coreg CR Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (carvedilol Guidelines: Drug Coverage phosphate) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Corgard (nadolol) Tablet J8499 N/A N/A Pharmacy N/A Corlanor Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (ivabradine) Guidelines: Corlanor Cosentyx Prefilled J3490 PBM Prior Authorization/Medical Pharmacy N/A (secukinumab) Syringe or Necessity Guidelines: Cosentyx Sensoready Pen Cosopt PF Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (dorzolamide hcl/ Solution Guidelines: Drug Coverage timolol maleate Criteria - New and Therapeutic Equivalent Medications Cotellic Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (cobimetinib) Guidelines: Cotellic Cotempla XR-ODT Oral J8499 PBM • Therapeutic Equivalent Pharmacy N/A (methylphenidate) Disintegrating Guidelines: Drug Coverage Tablet Criteria - New and Therapeutic Equivalent Medications Cozaar (losartan) Tablet or J8499 PBM Therapeutic Equivalent Pharmacy N/A (Brand Only) Oral Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cresemba Capsule J8499 N/A N/A Pharmacy N/A (isavuconazonium sulfate) Crestor Tablet J8499 PBM • Therapeutic Equivalent Pharmacy N/A (rosuvastatin Guidelines: Drug Coverage calcium) Criteria - New and Therapeutic Equivalent Medications Crinone Gel J3490 PBM Prior Authorization Guidelines: Pharmacy* *Benefit Note for Infertility Use: (progesterone gel) Infertility Diagnosis and Treatment Coverage is limited to Members Step Therapy Guidelines: Crinone with coverage for fertility drugs through their prescription drug plan. Members that do not have fertility drug coverage through their prescription drug plan should refer

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing to their Certificate of Coverage for coverage guidelines. Crinone 8% Injection J3490 Prior Prior Authorization Guidelines: Pharmacy/ *Benefit Note: Coverage is limited (progesterone) authorization Infertility Diagnosis and Treatment Medical* to Members with coverage for through Optum fertility drugs through their may be prescription drug plan. Members required that do not have fertility drug coverage through their prescription drug plan should refer to their Certificate of Coverage for coverage guidelines. Crofab (crotalidae Injection J0840 N/A N/A Medical N/A polyvalent immune fab (ovine) Crysvita Injection J0584 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (Burosumab-Twza) Medical o Crysvita (Burosumab-Twza) Administration of Crysvita in a Management o Provider Administered Drugs hospital outpatient facility – Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Cultivate Lotion J3490 PBM Step Therapy Guidelines: Cultivate Pharmacy N/A (fluticasone propionate 0.05%) Cuprimine Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (penicillamine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cyclobenzaprine 7.5 Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A mg (Fexmid) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Cyclophosphamide Oral J8530 N/A N/A Pharmacy N/A (Cytoxan)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Cyclophosph Capsule J8999 N/A N/A Pharmacy N/A Capsule (cyclophosphamide) Cymbalta Capsule J8499 PBM • Pharmacy Benefit/Prior Pharmacy N/A (duloxetine) (brand Authorization Guidelines: New and only) Therapeutic Equivalent Medications Cystadrops Ophthalmic J3490 PBM Prior Authorization/Notification Pharmacy N/A (cysteamine) solution Guidelines: Cystadrops Cystaran Ophthalmic J3490 PBM Prior Authorization/Notification Pharmacy N/A (cysteamine) Solution Guidelines: Cystaran (Cysteamine) Cytogam Injection 90291 or N/A N/A Medical N/A (cytomegalovirus J0850 immune globulin intravenous (human) Cytomel (Brand Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Only) (liothyronine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Daliresp Tablet J8499 PBM* Prior Authorization/Notification Pharmacy* *NJ Small members should refer (Roflumilast) Guidelines: Daliresp to their Certificate of Coverage for Prior authorization guidelines. Dapsone (aczone) Topical gel J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Daraprim Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (pyrimethamine) Necessity Guidelines: Daraprim Daurismo Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (glasdegib) Guidelines: Daurismo Daxbia (cephalexin) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Daytrana Patch J3490 PBM Therapeutic Equivalent Pharmacy N/A (methylphenidate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Dayvigo Tablet J8499 PBM Step Therapy Guidelines: Dayvigo Pharmacy N/A (lemborexant) Decadron Elixir Oral elixir J8499 PBM Therapeutic Equivalent Pharmacy N/A (Brand only) Guidelines: Drug Coverage (dexamethasone) Criteria - New and Therapeutic Equivalent Medications Decadron tablets Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage (dexamethasone) Criteria - New and Therapeutic Equivalent Medications Deca-Durabolin Injection J2320 N/A N/A Medical N/A (nandrolone) Delatestryl Injection J3490 N/A Medical Management Guidelines: Medical N/A (testosterone Maximum Dosage and Frequency enanthate) Delos Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A lotion/cleanser Guidelines: Drug Coverage (benzoyl peroxide) Criteria - New and Therapeutic Equivalent Medications Delstrigo Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (doravirine/ Guidelines: Drug Coverage lamivudine/tenofovir Criteria - New and Therapeutic disoproxil fumarate) Equivalent Medications Delzicol Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (mesalamine Authorization Guidelines: New and delayed release Therapeutic Equivalent Capsule) Medications Denavir (penciclovir) Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Desloratadine Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Clarinex) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Desonate 0.05% gel Gel J3490 PBM Step Therapy Guidelines: Pharmacy N/A (desonide) Desonate Desonil Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream/ointment Guidelines: Drug Coverage (Kit) (desonide) Criteria - New and Therapeutic Equivalent Medications Desoxyn (meth- Tablet J8499 N/A N/A Pharmacy N/A amphetamine) Desvenlafaxine Tablet J8499 N/A N/A Pharmacy N/A (desvenlafaxine) Desvenlafaxine ER Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (desvenlafaxine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Detrol (tolterodine) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Detrol LA Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (tolterodine tartrate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Devices: Various J3490 PBM Prior Authorization/Medical Pharmacy** ** The U.S. Food and Drug Aquoral, Necessity Guidelines: Devices Administration (FDA) classifies Atopaderm*, Therapeutic Equivalent devices as products that are Guidelines: Drug Coverage intended for use in the diagnosis, Caphosol, Criteria - New and Therapeutic cure, mitigation, treatment, or Eletone, Equivalent Medications* prevention of a disease that do not Entty Spray, achieve their purpose through EpiCeram, chemical action and are not Halucort, dependent on metabolism to HPRPlus, achieve their purpose. Devices are

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Hyclodex, typically benefit exclusions. This Hylaguard, program only applies when Hylatopic Plus, devices are covered by the KamDoy Rx, Member’s plan. Neocera, Neosalus, NeutraSal, Nutraseb, Penlen, Promiseb, Promiseb Complete Kit*, SalivaMax, Synerderm, Tetrix Dexedrine (dextro- Tablet Or S0160 N/A N/A Pharmacy N/A amphetamine) Capsule Dexilant (brand) Capsule J8499 N/A N/A Pharmacy N/A (dexlansoprazole) Dexmethylphen- Capsule J8499 N/A N/A Pharmacy N/A idate extended- release capsule (generic Focalin XR) Dextroamphet- Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A amine extended- Guidelines: Drug Coverage release (generic Criteria - New and Therapeutic Dexedrine) Equivalent Medications D.H.E. 45 (dihydro- Injection J3490 PBM Therapeutic Equivalent Pharmacy N/A ergotamine) (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Diabetic Supplies Varies A4206, N/A Prior Authorization Guidelines: N/A N/A A4210, Diabetes Supply Coverage for A4233- Commercial Plans (Including New A4236, Jersey Small Group Plans)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing A4244- A4245, A4250, A4253, A4256, A4258- A4259, A9275, E0607, E2100- E2101, E0784, K0601- K0605, A4230- A4232, A6257, J1610, J1815, J1817 and J3490 Diacomit Capsules, J8499 PBM Prior Authorization/Notification Pharmacy N/A (stiripentol) Powder for Guidelines: Diacomit Oral Suspension Dibenzyline Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (phenoxyl- Guidelines: Drug Coverage benzamine) (brand) Criteria - New and Therapeutic Equivalent Medications Diclegis Delayed- J8499 PBM Prior Authorization/Medical Pharmacy N/A (doxylamine Release Necessity Guidelines: Diclegis succinate and Tablet pyridoxine hydrochloride) Diclofenac 1% Topical Gel J3490 N/A N/A Pharmacy Note: Prescription drugs for which topical gel (generic there is a therapeutic over-the- Voltaren) counter (OTC) equivalent are excluded from coverage. Refer to

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing the member specific benefit plan document as applicable. Dicloxacillin Sodium Capsule J8499 N/A N/A Pharmacy N/A (Dycil, Dynapen) Differin 0.1% Varies J3490 N/A N/A N/A Note: Prescription drugs for which (adapalene) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Differin 0.3% Gel Topical Gel J3490 N/A N/A N/A Note: Prescription drugs for which (adapalene) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Diflorasone Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A diacetate 0.05% Ointment Guidelines: Drug Coverage ointment (generic Criteria - New and Therapeutic Psorcon) Equivalent Medications Diflucan Tablet J8499 N/A N/A Pharmacy N/A (fluconazole) Digital Applications: Digital Various PBM* Prior Authorization/Medical Pharmacy* *This program is for prescription EndeavorRx, reSET, Application Necessity Guidelines*: Digital digital applications (computer reSET-O, Somryst Applications: EndeavorRx, reSET, based treatment for cognitive reSET-O, Somryst behavioral therapy) including but not limited to EndeavorRx, reSET, reSET-O and Somryst. *Digital Application devices are typically excluded from coverage Dimethyl Fumarate Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A (generic Tecfidera) Guidelines: Dimethyl Fumarate Diovan (valsartan) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Diovan HCT Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (valsartan) (brand Authorization Guidelines: New and only) Therapeutic Equivalent Medications Disalcid (salsalate) Tablet And J8499 PBM Therapeutic Equivalent Pharmacy N/A Capsule Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Divigel 0.75 mg Topical Gel J3490 N/A N/A Pharmacy N/A (estradiol gel) Divigel 1.25g Topical Gel J3490 N/A N/A Pharmacy N/A (estradiol gel) Dojolvi Oral liquid J8499 PBM Prior Authorization/Medical Pharmacy N/A (triheptanoin) Necessity Guidelines: Dojolvi Dolophine Tablets S0109 PBM Prior Authorization/Medical Pharmacy N/A (methadone) Necessity Guidelines: Dolophine (Generic) Donepezil 5 or Oral Dis- J8499 N/A N/A N/A N/A 10mg (generic Intergrating Aricept) Tablet Donepezil 23mg Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Aricept Guidelines: Drug Coverage 23mg) Criteria - New and Therapeutic Equivalent Medications Doptelet Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (avatrombopag) Guidelines: Doptelet Step Therapy Guidelines: Doptelet Doral (quazepam) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Doribax Iv Infusion J1267 N/A N/A Medical N/A (doripenem)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Doryx (doxycycline Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hyclate) delayed Guidelines: Drug Coverage release tablet Criteria - New and Therapeutic Equivalent Medications Dovato (dolutegravir Tablet J8499 N/A N/A Pharmacy N/A and lamivudine) Doxepin Cream Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A Cream Guidelines: Doxepin Cream Doxorubicin Injection Q2049 and N/A N/A Medical N/A Hydrochloride Q2050 Liposomal Doxycycline 75mg Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A capsule (generic Guidelines: Drug Coverage Monodox) Criteria - New and Therapeutic Equivalent Medications Doxycycline 150mg Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A capsule (generic Guidelines: Drug Coverage Monodox) Criteria - New and Therapeutic Equivalent Medications Doxycycline Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Delayed-Release Guidelines: Drug Coverage Capsule 40mg Criteria - New and Therapeutic (Oracea authorized Equivalent Medications generic) D-Pennicillamine Oral Agent J8499 N/A* N/A Pharmacy *Oral chelation agents do not require Prior authorization. Drisdol Capsule, J8499 N/A N/A Pharmacy N/A (ergocalciferol) Liquid Drizalma Capsules J8499 PBM Prior Authorization/Medical Pharmacy N/A (Duloxetine) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Duac (Clindamycin Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A and Benzoyl Guidelines: Drug Coverage Peroxide) Criteria - New and Therapeutic Equivalent Medications Duac CS Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (Clindamycin and Guidelines: Drug Coverage Benzoyl Peroxide) Criteria - New and Therapeutic Equivalent Medications Duaklir (Aclidinium Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A Bromide/ Guidelines: Drug Coverage Formoterol Criteria - New and Therapeutic Fumarate) Equivalent Medications Duexis (famotidine Tablet J8499 N/A N/A Pharmacy Note: Prescription drugs for which and ibuprofen) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Dulera Inhaler J3490 PBM Step Therapy Guidelines: Dulera Pharmacy N/A (mometasone furoate/formoterol fumarate dihydrate) Duobrii (Halobetasol Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Propionate and Lotion Guidelines: Drug Coverage Tazarotene) Criteria - New and Therapeutic Equivalent Medications Duopa (carbidopa/ Enteral J8499 PBM Prior Authorization/Medical Pharmacy N/A levodopa) Suspension Necessity Guidelines: Duopa Dupixent Injection J3590 PBM Prior Authorization/Medical Pharmacy N/A (dupilumab) Necessity Guidelines: Dupixent Duragesic (Brand Transdermal J3490 PBM Prior Authorization/Medical Pharmacy N/A Only) (fentanyl) (12, Patch Necessity Guidelines: 25, 50, 75, 100 o Duragesic mcg/hr strengths o New and Therapeutic only) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Duragesic (generic) Transdermal J3490 PBM Prior Authorization/Medical Pharmacy N/A (fentanyl) (12, 25, Patch Necessity Guidelines: Duragesic 50, 75, 100 mcg/hr Therapeutic Equivalent strengths only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Durlaza (aspirin) Capsule J8499 N/A N/A N/A Note: Prescription drugs for which there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Dutoprol Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Duzallo (lesinurad/ Tablet J8499 N/A N/A Pharmacy N/A allopurinol) Dvorah Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (acetaminophen/ Guidelines: Drug Coverage caffeine/ Criteria - New and Therapeutic dihydrocodeine Equivalent Medications bitartrate) Dxevo-11 day pack Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (dexamethasone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Dyanavel XR Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (amphetamine Suspension Guidelines: Drug Coverage extended release) Criteria - New and Therapeutic Equivalent Medications Dymista (azelastine/ Nasal Spray J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A fluticasone) (Brand Authorization Guidelines: New and and Generic) Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Dysport Injection J0586 Oxford’s Prior Authorization Guidelines: Medical N/A (abobotulinumtoxin Medical Botulinum Toxins A and B A) Management Ecoza (econazole Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A nitrate topical foam Guidelines: Drug Coverage 1%) Criteria - New and Therapeutic Equivalent Medications Edex (alprostadil) Vial J0270 N/A N/A Pharmacy N/A Edluar (zolpidem) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications E.E.S. 400 Oral Liquid J8499 PBM Therapeutic Equivalent Pharmacy N/A (erythromycin Guidelines: Drug Coverage ethylsuccinate) Criteria - New and Therapeutic (brand) Equivalent Medications Effexor XR Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (venlafaxine) (brand Authorization Guidelines: New and only) Therapeutic Equivalent Medications Effient (prasugrel) Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Egrifta SV Injection J8999 PBM Prior Authorization/Notification Pharmacy N/A (tesamorelin) Guidelines: Egrifta (tesamorelin) Elaprase IV Infusion, J1743 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (idursulfase) Injection Medical o Medical Therapies for Enzyme Administration of Elaprase in a Management Deficiencies hospital outpatient facility o Provider Administered Drugs (including any ambulatory infusion – Site of Care* suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Elelyso Injection J3060 Oxford’s Medical Management Guidelines: Medical *Hospital Outpatient Facility: (taliglucerase alfa) Medical Intravenous Enzyme Replacement Administration of Elelyso in a Management Therapy (ERT) for Gaucher hospital outpatient facility Disease (including any ambulatory infusion Prior Authorization Guidelines*: suite associated with the hospital) Provider Administered Drugs – requires Prior authorization with Site of Care review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Elepsia XR Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (levetiracetam Guidelines: Drug Coverage extended-release) Criteria - New and Therapeutic Equivalent Medications Elestat (epinastine Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A HCL) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Elidel Topical J3490 PBM Step Therapy: Elidel Pharmacy N/A (pimecrolimus) Elidel Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A (pimecrolimus) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Eligard (leuprolide Sq Injection J1950, PBM Prior Authorization/Notification Pharmacy N/A acetate) J9217, J9218 Guidelines: Eligard (leuprolide and J9219 acetate) Elmiron (pentosan Capsule J8499 PBM Step Therapy Guidelines: Elmiron Pharmacy N/A polysulfate sodium) Emadine Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (emedastine Solution Guidelines: Drug Coverage difumarate) Criteria - New and Therapeutic Equivalent Medications Emend (aprepitant) Capsule Or J8501 N/A N/A Pharmacy N/A Trifold Pack Emend Injection J1453 Optum* Prior Authorization Guidelines: Medical *Prior Authorization Notes: (fosaprepitant) Antiemetics for Oncology* Prior authorization is required

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing through Optum when Emend is administered prior to chemotherapy infusion. Prior authorization is not required when self-administered outside of the infusion. Emflaza Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (deflazacort) Suspension Necessity Guidelines: Emflaza Emgality Injection J8499 PBM Prior Authorization/Medical Pharmacy N/A (galcanezumab- Necessity Guidelines: Emgality gnlm) Emgality (100mg Injection J8499 PBM Prior Authorization/Medical Pharmacy N/A only) Necessity Guidelines: Emgality (galcanezumab- gnlm) Empagliflozin/ Tablet J8499 N/A N/A Pharmacy N/A Metformin (Emtricitabine and Tablet J8499 PBM Prior Authorization/ Regulatory Pharmacy N/A Tenofovir Disoproxil Guidelines: HIV Pre-Exposure Fumarate) (generic) Prophylaxis 200/300mg Emverm Chewable J8499 PBM Prior Authorization/Medical Pharmacy N/A (mebendazole) Tablet Necessity Guidelines: Emverm Enablex Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (darifenacin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Enbrel (etanercept) Injection J1438 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Enbrel Endari (L-glutamine) Oral Powder J8499 PBM Prior Authorization/Medical Pharmacy N/A For Solution Necessity Guidelines: Endari

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Endometrin Vaginal J3490 N/A Prior Authorization Guidelines: Pharmacy* *Benefit Note for Infertility Use: (progesterone) Insert Infertility Diagnosis and Treatment Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Enspryng Subcutaneo J3490 PBM Prior Authorization/Medical Pharmacy N/A us Injection Necessity Guidelines: Enspryng Enstilar foam Topical J3490 N/A N/A Pharmacy N/A (calcipotriene/ Foam betamethasone) Entocort EC Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (budesonide) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Entresto (valsartan – Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A sacubitril) Necessity Guidelines: Entestro (valsartan-sacubitril) Entyvio Injection J3380 and Oxford’s Medical Management Guidelines: Medical *Prior authorization Note: Prior (vedolizumab) J3490 Medical Maximum Dosage and Frequency authorization is required for the Management* Prior Authorization Guidelines: drug Entyvio in all sites of service o Entyvio (vedolizumab) through Oxford’s Medical o Provider Administered Drugs Management. Additional Prior – Site of Care authorization may be required for the site of care of the injection.

Hospital Outpatient Facility: • Administration of Entyvio in a hospital outpatient facility (including any ambulatory

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. • Participating hospitals are required to purchase Entyvio (vedolizumab) from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Envarsus XR Tablet J7508 PBM Prior Authorization/Notification Pharmacy N/A (tacrolimus) Guidelines: Envarsus XR Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Epaned (enalapril) Powder For J8499 PBM Prior Authorization/Medical Pharmacy N/A Oral Solution Necessity Guidelines: Non-Solid Oral and Suppository Dosage Epclusa Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (sofosbuvir/ Necessity Guidelines: Epclusa velpatasfir) Epi Quinn Micro Varies J3490 N/A N/A Pharmacy* *Benefit Notes: Not covered for (hydroquinone) cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Epidiolex Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (cannabidiol) Necessity Guidelines: Single Source Brand Anticonvulsants

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Epiduo (adapalene Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A and benzoyl Guidelines: Drug Coverage peroxide) Criteria - New and Therapeutic Equivalent Medications Epiduo Forte Topical Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (adapalene and Guidelines: Drug Coverage benzoyl peroxide) Criteria - New and Therapeutic Equivalent Medications Epinephrine Pen Pen Injection J0171 PBM Therapeutic Equivalent Pharmacy N/A Injection, 0.15mg Guidelines: Drug Coverage and 0.3mg (generic Criteria - New and Therapeutic Adrenaclick) Equivalent Medications EpiPen/EpiPen Jr. Injection J0171, J3490 PBM Therapeutic Equivalent Pharmacy N/A (epinephrine) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Epzicom (abacavir/ Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A lamivudine) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Ergomar Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (ergotamine tartrate) Necessity Guidelines: Ergomar Erivedge Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (vismodegib) Guidelines: Erivedge authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Erleada Tablets J8499 PBM Prior Authorization/Notification Pharmacy N/A (apalutamide) Guidelines: Erleada Ertaczo Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A (sertaconazole Guidelines: Drug Coverage nitrate) Criteria - New and Therapeutic Equivalent Medications Erythromycin 0.5% Ophthalmic J3490 PBM Prior Authorization/Notification Pharmacy N/A Ophthalmic Ointment Guidelines: Gonococcal Ointment Ophthalmia Neonatorum (GON) Prevention Zero Dollar Cost Share Erythropoetin (EPO, Injection, Sq Q4081-ESRD PBM*/Oxford’s Prior Authorization Guidelines: Pharmacy*/ *Prior authorization is required if Epoetin Alfa, Injection OR J0885- Medical Erythropoiesis-Stimulating Medical** dispensed by a retail pharmacy Epogen, Procrit) non-ESRD Management** Agents** through the PBM for Epogen and Therapeutic Equivalent Procrit. Prior authorization is not Guidelines: Drug Coverage required if dispensed by a retail Criteria - New and Therapeutic pharmacy through the PBM for Equivalent Medications* EPO or Epoetin Alfa. **Prior authorization is required if provided in a hospital, MD's office or home setting. Esbriet (pirfenidone) Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Esbriet (pirfenidone) Esomeprazole Capsule J8499 N/A* N/A N/A* *Note: Prescription drugs for Strontium which there is a therapeutic over- the-counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Estrace vaginal Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A cream (estradiol) Guidelines: Drug Coverage vaginal cream) Criteria - New and Therapeutic (Brand Only) Equivalent Medications Estradiol (generic Cream J3490 N/A N/A Pharmacy N/A Estrace cream 0.01%)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Estradiol TD twice Transdermal J3490 PBM Therapeutic Equivalent Pharmacy N/A weekly patch Patch Guidelines: Drug Coverage (generic Vivelle-Dot) Criteria - New and Therapeutic Equivalent Medications Estradiol vaginal Vaginal J3490 N/A N/A Pharmacy N/A tablet [Yuvafem Tablet (generic for Vagifem)] Estrostep FE Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (ethinyl estradiol with coverage for contraceptives and norethindrone) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Eucrisa Topical J3490 PBM Step Therapy Guidelines: Eucrisa Pharmacy N/A (crisaborole) Ointment Evekeo Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (amphetamine Guidelines: Drug Coverage sulfate) Criteria - New and Therapeutic Equivalent Medications Evekeo ODT Oral Disinte- J8499 PBM Therapeutic Equivalent Pharmacy N/A (amphetamine grating Guidelines: Drug Coverage sulfate) Tablet Criteria - New and Therapeutic Equivalent Medications Evenity Injection J3111 Oxford’s Prior Authorization Guidelines: Medical N/A (romosozumab- Medical Evenity® (Romosozumab-aqqg) aqqg) Management Evista (raloxifene) Oral J8999 PBM Therapeutic Equivalent Pharmacy N/A (Brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Evkeeza Injection C9079, N/A* Prior Authorization Guidelines: Medical *Prior authorization Notes: (evinacumab-dgnb) J3490 Evkeeza™ (evinacumab-dgnb) Prior authorization is not required Review at Launch for New to but is strongly recommended for Market Medications* Evkeeza. While no penalty will be imposed for failure to request a pre-service review, if you do not request one, a medical necessity review will be conducted post- service to determine coverage. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of Oct. 1, 2021, prior authorization will be required. Evotaz (atazanavir/ Tablet J8499 N/A N/A Pharmacy N/A cobicistat) Evrysdi (risdiplam) Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Evrysdi Evzio (nalozone Auto-Injector J3490 PBM Prior Authorization/Medical Pharmacy N/A HCL injection) Necessity Guidelines: Evzio Exalgo Tablet J8499 N/A N/A Pharmacy N/A (hydromorphone) (Brand Only) Exalgo Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydromorphone) Necessity Guidelines: Exalgo (Generic Only) Excelon Patch Transdermal J3490 PBM Therapeutic Equivalent Pharmacy N/A (rivastigmine) Patch Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Exemestane Tablet S0156 PBM Prior Authorization / Regulatory Pharmacy N/A (generic) Guideline: Exemestane Exforge (amlodipine Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A valsartan) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Exforge HCT Tablet J8499 PBM Non-Formulary Guidelines: Pharmacy N/A (amlodipine, Exforge hydrochlorothiazide Therapeutic Equivalent and valsartan) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Exjade (Brand only) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (Deferasirox) Guidelines: Iron Chelators Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Exondys 51 Intravenous J1428 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (eteplirsen) Medical Exondys 51® (Eteplirsen) Administration of Exondys 51 in a Management Provider Administered Drugs – hospital outpatient facility Site of Care (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Exservan (riluzole) Oral Film J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Extavia (interferon Injection J1830 or PBM Prior Authorization/Notification Pharmacy N/A B-1b) J3490 Guidelines: Extavia Step Therapy Guidelines: Extavia (interferon B-1b) Extina Topical J3490 PBM Step Therapy Guidelines: Extina Pharmacy N/A (ketoconazole) Foam Eylea (afibercept) Injection J0178 N/A Medical Management Guidelines: Medical N/A Maximum Dosage and Frequency

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Eysuvis (loteprednol Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A etabonate) Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ezallor Sprinkle Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (rosuvastatin) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Fabior (tazarotene) Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Fabior (tazarotene) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fabrazyme® IV Infusion, J0180 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (agalsidase beta) Injection Medical o Medical Therapies for Enzyme Administration of Fabrazyme in a Management Deficiencies hospital outpatient facility o Provider Administered Drugs (including any ambulatory infusion – Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Falessa Kit (birth Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A control plus vitamin Guidelines: Drug Coverage supplement) Criteria - New and Therapeutic Equivalent Medications Famvir (famciclovir) Tablet J8499 N/A N/A Pharmacy N/A Fanapt (iloperidone) Oral J8499 N/A N/A Pharmacy N/A Fareston Tablet J8999 PBM Therapeutic Equivalent Pharmacy** *Prior authorization Note: Prior (toremifene) (Brand Guidelines: Drug Coverage authorization through the PBM is Only) Criteria - New and Therapeutic only required for those Oral Equivalent Medications Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Farxiga Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (dapagliflozin) Guidelines: Diabetes Medications Notification Guidelines: Diabetes SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Farydak Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (panobinostat) Guidelines: Farydak Fasenra Subcutan- J0517 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (benralizumab) eous Medical Provider Administered Drugs – Administration of Fasenra in a Injection Management Site of Care hospital outpatient facility Respiratory Interleukins (Cinqair®, (including any ambulatory infusion Fasenra®, and Nucala®)* suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Fasenra Pen Prefilled J3490 PBM Prior Authorization/Medical Pharmacy N/A (Benralizumab) Syringe / Necessity Guidelines: Fasenra Auto- Therapeutic Equivalent Injector Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Felbatol (felbamate) Tablet And J8499 PBM Prior Authorization/Medical Pharmacy N/A Oral Necessity Guidelines: Felbatol Suspension Femara (letrozole) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fenofibrate 43mg, Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A 130mg (generic Guidelines: Drug Coverage Antara) capsule Criteria - New and Therapeutic Equivalent Medications Fenofibrate 48mg, Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 145mg (generic Guidelines: Drug Coverage Tricor) Criteria - New and Therapeutic Equivalent Medications Fenofibrate 50mg, Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A 150mg (generic Guidelines: Drug Coverage Lipofen) capsule Criteria - New and Therapeutic Equivalent Medications Fenoglide Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (fenofibrate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fenoprofen (generic Capsules J8499 PBM Therapeutic Equivalent Pharmacy N/A Nalfon) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fenortho Capsules J8499 PBM Therapeutic Equivalent Pharmacy N/A (fenoprofen Guidelines: Drug Coverage calcium) Criteria - New and Therapeutic Equivalent Medications Fensolvi (leuprolide Injection J1950 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for acetate) J1951 Medical Gonadotropin Releasing Hormone the diagnosis of Gender Dysphoria Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing applicable Gender Dysphoria ICD- 10 diagnosis codes Fentanyl Citrate Lozenge J8499 PBM Prior Authorization/Notification Pharmacy N/A (generic Actiq) Guidelines: Actiq (fentanyl citrate) Fentanyl Citrate Oral Powder J8499 PBM Prior Authorization/Medical Pharmacy N/A bulk powder Necessity Guidelines: Fentora (fentanyl) Fentanyl Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A transdermal patch Patch Necessity Guidelines: Fentanyl (37.5, 62.5 and 87.5 Transdermal Patch mcg/hr strengths Therapeutic Equivalent only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fentora (fentanyl Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A buccal) Necessity Guidelines: Fentora (fentanyl) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Feraheme Intravenous Q0138 Oxford’s Prior Authorization Guidelines: Medical N/A (ferumoxytol) Medical Intravenous Iron Replacement Management Therapy (Feraheme®, Injectafer®, & MonoferricTM) Ferriprox Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (Deferiprone) Guidelines: Iron Chelators Fertinex Injection J3355* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS (urofollitropin) J3490 authorization Infertility Diagnosis and Treatment Medical** code J3355 (urofollitropin) requires through Optum Prior authorization through Optum may be in all sites of service when required* associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Fetzima Capsule J8499 PBM Step Therapy Guidelines: Pharmacy N/A (Levomilnacipran) Antidepressants Fibricor 35mg, Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 105mg (fenofibric Guidelines: Drug Coverage acid) Criteria - New and Therapeutic Equivalent Medications Finacea 15% Foam Foam J3490 N/A N/A Pharmacy N/A (azelaic acid) Fintepla Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (fenfluramine) Necessity Guidelines: Fintepla Fioricet with Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Codeine capsule Guidelines: Drug Coverage 50mg/300mg/ Criteria - New and Therapeutic 40mg/30mg Equivalent Medications Fioricet with Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Codeine Guidelines: Drug Coverage 50mg/325mg/ Criteria - New and Therapeutic 40mg/30mg (Brand Equivalent Medications Only) Firazyr (icatibant) Injection J1744 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Firazyr Firdapse Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (amifampridine) Necessity Guidelines: Firdapse Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Firmagon Injection J9155 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for Medical Gonadotropin Releasing Hormone the diagnosis of Gender Dysphoria Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD- 10 diagnosis codes. First Progesterone Varies J3490 N/A Prior Authorization Guidelines: Pharmacy* *Benefit Note for Infertility Use: (progestin) Infertility Diagnosis and Treatment Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Firvanq Oral Solution J8499 N/A N/A Pharmacy N/A (vancomycin hydrochloride) Flector (diclofenac) Patch J3490, J8499 N/A N/A Pharmacy Note: Prescription drugs for which there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Flolipid (simvastatin Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A suspension) Suspension Necessity Guidelines: Flolipid Flomax (tamsulosin) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Flo-Pred Suspension J8499 PBM Therapeutic Equivalent Pharmacy N/A (prednisolone) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Flovent Diskus, Inhaler J3490 N/A N/A Pharmacy N/A Flovent HFA (fluticasone) FlowTuss Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocodone/ Necessity Guidelines: Opioid guaifenesin) Containing Cough Medicines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Floxin 0.3% Otic Otic Solution J3490 PBM Therapeutic Equivalent Pharmacy N/A (ofloxacin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Flublok (Influenza Intra- Q2033 N/A Prior Authorization Guidelines: Medical N/A Vaccine, Muscular Preventive Care Services Recombinant Injection Vaccines Hemagglutinin Antigens) FluMist (influenza Nasal Spray 90660 N/A N/A Medical N/A virus vaccine (nasal)) Fluocinonide 0.1% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream (generic Guidelines: Drug Coverage Vanos) Criteria - New and Therapeutic Equivalent Medications Fluorouracil 0.5% Topical J3490 N/A N/A Pharmacy N/A Cream Fluoxetine 60mg Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fluoxetine tablets Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Sarafem) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Fluticasone/ Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A Salmeterol Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fluticasone (topical) Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Compounds and Bulk Powders Focalin Capsule J8499 N/A N/A Pharmacy N/A (dexmethylphenidat e HCl) Focalin XR Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (dexmethylphenidat Authorization Guidelines: New and e HCl [extended Therapeutic Equivalent release]) Medications Folic Acid Tablet J8499 N/A N/A Pharmacy* *Coverage is limited to Members with coverage for vitamins/ supplements through their prescription drug plan. If the Member does not have vitamin/ supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Follistim AQ Injection S0128 Prior Prior Authorization Guidelines: See Notes* *CT Plans: Medical Benefit. (follitropin beta) authorization Follicle Stimulating Hormone *NJ Plans: Pharmacy Benefit. through (FSH) Gonadotropins Medical Benefit for Members Optum* without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit. *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Forfivo XL Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (bupropion HCL) Authorization Guidelines: New and Therapeutic Equivalent Medications Fortamet (metformin Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A extended-release) Necessity Guidelines: Fortamet (Brand and Generic) (metformin extended-release) Forteo (teriparatide) Injection, Sq J3110 PBM Prior Authorization/Notification Pharmacy N/A Injection Guidelines: Teriparatide (Forteo) Step Therapy Guidelines: Forteo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fortesta Gel J3490 PBM Prior Authorization/Medical Pharmacy N/A (testosterone) Necessity Guidelines: Fortesta Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Injection J3490 N/A N/A Medical N/A Fosrenol Chewable Chewable J8499 PBM Therapeutic Equivalent Pharmacy N/A Tablets (lanthanum Tablets Guidelines: Drug Coverage carbonate) (brand Criteria - New and Therapeutic only) Equivalent Medications Fotivda (Tivozanib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Fotivda Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Fragmin (dalteparin) Injection, Sq J1645 N/A* N/A Pharmacy *No Prior authorization is required Injection if dispensed by a retail pharmacy or Mail Order through PBM. Frova (frovatriptan) Tablet J8499 PBM** Supply Limit Guidelines: Triptans Pharmacy* **Prior authorization Note: Prior Supply Limits authorization through the PBM is

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Prior authorization. *Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Frova (frovatriptan Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A succinate) (Brand Guidelines: Drug Coverage Only) Criteria - New and Therapeutic Equivalent Medications Fulphila Injection Q5108 PBM*/ Medical Management See *Pharmacy Benefit: If dispensed (pegfilgrastim-jmdb) Optum**/ Guidelines**: Maximum Dosage Notes*,** by a retail pharmacy or mail order Oxford** and Frequency through PBM. Prior authorization Optum Guidelines**: White Blood through the PBM is required. Cell Colony Stimulating Factors **Medical Benefit: If provided in a Therapeutic Equivalent hospital, MD's office, or in the Guidelines*: Drug Coverage home setting: Criteria - New and Therapeutic For oncology indications: Equivalent Medications o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Fuzeon (enfuvirtide) Injection J3490 PBM Prior Authorization/Notification Medical N/A Guidelines: Fuzeon

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Fycompa Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (perampanel) Necessity Guidelines: Single Source Brand Anticonvulsants Galafold Capsules J8499 PBM Prior Authorization/Notification Pharmacy N/A (migalastat) Guidelines: Galafold Gamifant Injection J9210 Oxford’s Prior Authorization Guidelines: Medical N/A (emapalumab-lzsg) Medical Gamifant (Emapalumab-lzsg) Management Gattex (teduglutide Injection, Sq J3490 PBM Prior Authorization/Notification Pharmacy N/A [rDNA origin]) Injection Guidelines: Gattex Gavreto (pralsetinib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Gavreto Gelnique Topical Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (oxybutynin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Gemtesa (vibegron) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Genadur Kit Nail Laquer J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Generess FE Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (norethindrone/ Guidelines: Drug Coverage ethinyl estradiol) Criteria - New and Therapeutic Equivalent Medications Generic Tablet J8499 N/A N/A Pharmacy N/A Levetiracetam XR Genotropin Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: Genotropin (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Genotropin Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A MiniQuick Necessity Guidelines: Genotropin (somatropin) MiniQuick Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Genvoya Tablet J8499 N/A N/A Pharmacy N/A (elvitegravir/ cobicistat/ emtricitabine/ tenofovir alafenamide) Geodon Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (ziprasisdone) Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications Gialax Kit Orol Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A (polyethylene Guidelines: Drug Coverage glycol) Criteria - New and Therapeutic Equivalent Medications Giazo (balsalazide Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A disodium) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Gilenya (fingolimod) Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Gilenya Gilotrif (afatinib) Tablet J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Gilotrif (Afatinib) authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral

Glassia [Alpha1- Intravenous J0257 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: Proteinase Inhibitor Injection Medical o Alpha1-Proteinase Inhibitors Administration of Glassia in a (Human)] Management o Provider Administered Drugs hospital outpatient facility – Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs – Site of Care. Glatiramer acetate injection J3490 PBM Prior Authorization / Notification Pharmacy N/A Guidelines: Glatiramer Acetate Glatopa (Glatiramer Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A [generic Copaxone]) Guidelines: Glatopa

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Gleevec (imatinib Oral, Varies S0088 PBM* Pharmacy Benefit/Prior Pharmacy** *Prior authorization Note: Prior mesylate) Authorization Guidelines: New and authorization through the PBM is Therapeutic Equivalent only required for those Oral Medications Oncology Drugs specifically listed Prior Authorization/Notification in a Coverage Criteria/Guideline Guidelines: Gleevec when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. *Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Gloperba Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (colchicine) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Glucophage XR Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (metformin Necessity Guidelines: Glucophage extended-release XR (metformin extended-release [brand only]) [brand only]) Glumetza Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (metformin Necessity Guidelines: Glumetza extended-release) (metformin extended-release) (Brand and Generic) Glyxambi Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (empagliflozin/ Guidelines: Diabetes Medications Notification Guidelines: Diabetes linagliptin) SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Gocovri Extended J8499 PBM Therapeutic Equivalent Pharmacy N/A (amantadine) Release Guidelines: Drug Coverage Capsules Criteria - New and Therapeutic Equivalent Medications Gonal-F /Gonal-f IM Or SQ S0126 Prior Prior Authorization Guidelines: See Notes** *CT Plans: Medical Benefit. RFF (follitropin alfa) Injection authorization Follicle Stimulating Hormone *NJ Plans: Pharmacy Benefit. through (FSH) Gonadotropins Medical Benefit for Members Optum* without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit. *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Gonitro Sublingual J8499 PBM Therapeutic Equivalent Pharmacy N/A (nitroglycerin) Powder Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Gralise (gabapentin) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Granix Injection J1447 PBM*/ Optum Guidelines**: White Blood See *Pharmacy Benefit: If dispensed (tbo-filgrastiim) Optum**/ Cell Colony Stimulating Factors Notes*,** by a retail pharmacy or mail order Oxford** Therapeutic Equivalent through PBM. Prior authorization Guidelines*: Drug Coverage through the PBM is required. Criteria - New and Therapeutic **Medical Benefit: If provided in a Equivalent Medications hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Gvoke (Flucagon) Prefilled J3490 N/A N/A Pharmacy N/A Syringe / Auto- Injector Haegarda [C1 Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A Esterase Inhibitor Necessity Guidelines: Haegarda Subcutaneous (Human)] Halobetasol 0.5% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Foam (Lexette Foam Guidelines: Drug Coverage Authorized Generic) Criteria - New and Therapeutic Equivalent Medications Halog 0.1% cream Cream J3490 PBM Step Therapy Guidelines: Halog Pharmacy N/A (halcinonide) Halog 0.1% Ointment J3490 PBM Step Therapy Guidelines: Halog Pharmacy N/A ointment (halcinonide) Halog 0.1% solution Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (halcinonide) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Halog cream Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A (halcinonide cream) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Halotestin Tablet J8499 N/A N/A Pharmacy N/A (fluoxymesterone)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Harvoni™ Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (ledipasvir/ Necessity Guidelines: Harvoni sofosbuvir) HCG (chorionic Injection J0725* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS gonadotropin) J3490 authorization Infertility Diagnosis and Treatment Medical** code J0725 (chorionic through Optum gonadotropin) J0725 requires Prior may be authorization through Optum in all required* sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines. Hectorol Capsule J8499 N/A N/A Pharmacy N/A (doxercalciferol) Injection J1270 N/A N/A Medical N/A Helidac (bismuth Capsule/ J8499 PBM Therapeutic Equivalent Pharmacy N/A subsalicylate) Tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Hemady Tablet J3490 PBM Therapeutic Equivalent Pharmacy N/A (dexamethasone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Hemangeol Oral Oral Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A solution Guidelines: Drug Coverage (propranolol Criteria - New and Therapeutic hydrochloride) Equivalent Medications Hemophilia Drugs J7170 See Notes* Medical Management See Notes* *NY LOBs and NJ Large and Brand Names J7177 Guidelines****: Maximum Small Groups: Adynovate**,***, J7175 Dosage and Frequency Prior authorization: Prior Authorization Guidelines:

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Advate, J7178 o Assisted Administration of • Is required through Oxford for Afstyla**, J7179 Clotting Factors, Coagulant self-administered clotting Alphanate, J7180 Blood Products & Other factor drugs (including Alphanine SD, J7181 Hemostatics Eloctate) provided by a Clotting Factors, Coagulant Hemophilia Treatment Center Alprolix, J7182 o Blood Products & Other including (Medical benefit Bebulin, J7183 Hemostatics applies): Benefix, J7185 Eloctate™ (Antihemophilic o o NY Presbyterian Hospital- Coagadex, J7186 Factor (Recombinant), FC Weill Cornell Center Corifact, J7187 Fusion Protein) for o Mount Sinai Medical Eloctate**, J7188 Connecticut Lines of Business Center Esperoct**,***, J7189 (Medical Benefit) o Long Island Jewish Feiba NF, J7190 o Home Health Care Medical Center Prior Authorization/Medical Feiba VH, J7192 • Is required for self- Necessity Guidelines**: Fibryga, J7193 administered Eloctate when Adynovate o covered under the pharmacy Helixate FS***, J7194 Afstyla o benefit, with Prior authorization Hemlibra**,****, J7195 Eloctate Medical Necessity o through the PBM. Hemofil-M, J7198 Esperoct o • Is NOT required for all other Humate-P, J7199 Hemlibra o self-administered clotting Idelvion, J7200 Ixinity o factor drugs (except Eloctate) , Jivi Ixinity** ***, J7201 o obtained through any specialty Xyntha Jivi**,***, J7202 o designated pharmacy Therapeutic Equivalent Koate-DVI, J7204 Guidelines***: Drug Coverage (Pharmacy benefit applies). Kogenate FS, J7205 Criteria - New and Therapeutic • Is required if assisted Kovaltry , J7207 J7208 Equivalent Medications administration (provider’s Monoclate-P, J7209 office, clinic, home, etc). Mononine, J7210 Eloctate is covered under the Novoeight, J7211 medical benefit, Prior Novoseven RT, J7212 authorization obtained through Oxford. Nuwig, Obizur, *CT LOBs: Profilnine SD, • Self-administered clotting Rebinyn*** factor drugs (except Eloctate) Recombinate, do not require Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing RiaSTAP, authorization and are covered Rixubis, under the medical benefit. Sevenfact***, • Self-administered Eloctate Tretten, requires Prior authorization Vonvendi, through Oxford and is covered under the medical benefit. Wilate, • If the member requires Xyntha**, assisted administration of their Xyntha Solofuse clotting factor drugs, Prior authorization is required in all sites of service and is covered under the medical benefit. For assisted administration in the home, refer to Home Health Care.

*HMO Members: If drugs are requested or supplied through a non-par vendor and authorization is not approved, these services will not be reimbursed by Oxford. HepaGam B Injection J1571 and N/A N/A Medical N/A (hepatitis B immune J1573 globulin [human]) Heparin Injection J1642 or N/A N/A See Notes* *Pharmacy Benefit: If dispensed J1644 by a retail pharmacy or mail order through PBM. *Medical Benefit: If provided in a hospital, MD's office, or in conjunction with home health care. Herceptin Injection J9355 Optum*/ Medical Management Guidelines: Medical Prior Authorization Notes (trastuzumab) Oxford** Maximum Dosage and Frequency *For oncology indications: Optum Guidelines*: Oncology Prior authorization is required Medication Clinical Coverage through Optum for dates of service Aug. 1, 2021 and after;

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 **Prior authorization is required through Oxford for non-oncology indications. Herzuma Injection Q5113 N/A Medical Management Guidelines: Medical N/A (trastuzumab-pkrb) Maximum Dosage and Frequency Hetlioz (tasimelteon) Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Hetlioz Hetlioz LQ Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (tasimelteon) Necessity Guidelines: Hetlioz Hetlioz LQ Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (tasimelteon) Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Hidex 6-day pack Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (dexamethasone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Horizant Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (gabapentin, Guidelines: Drug Coverage enacarbil) Criteria - New and Therapeutic Equivalent Medications Humatin Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (paromomycin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Humatrope Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: Humatrope (Somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Humegon Injection S0122* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS (menotropins) J3490 authorization Infertility Diagnosis and Treatment Medical** code S0122 (menotropins) through Optum requires Prior authorization may be through Optum in all sites of required service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their certificate of for coverage guidelines. Humira Injection, Sq J0135 PBM Prior Authorization/Medical Pharmacy N/A (adalimumab) Injection Necessity Guidelines: Humira Humira Prefilled J3490 PBM Prior Authorization/Medical Pharmacy N/A (adalimumab) Syringe Necessity Guidelines: Humira 10 mg/0.1 mL, Therapeutic Equivalent 20 mg/0.2mL, Guidelines: Drug Coverage 40 mg/0.4 mL, Criteria - New and Therapeutic 80 mg/0.8 mL Equivalent Medications strengths only Hycamtin Oral J8705 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (topotecan Guidelines: Hycamtin authorization through the PBM is hydrochloride) only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing authorization guidelines and quantity limit guidelines. Hycodan Oral Syrup J8499 PBM Therapeutic Equivalent Pharmacy N/A (hydrocodone and Guidelines: Drug Coverage homatropine syrup) Criteria - New and Therapeutic Equivalent Medications Hycofenix Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocodone/ Necessity Guidelines: Opioid pseudoephedrine/ Containing Cough Medicines guaifenesin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Hydrocodone/ Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A Guaifenesin Necessity Guidelines: Opioid Solution 2.5/200 Containing Cough Medicines mg/5 mL Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Hydrocodone/ All Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A Homatropine Forms Necessity Guidelines: Opioid Containing Cough Medicines hydrocortisone 1% Ointment J3490 N/A N/A Pharmacy N/A ointment in absorbase Hydromorphone ER Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Hydromorphone ER Hydroxyproges- Injection J1729 Oxford’s Prior Authorization Guidelines: 17- Medical N/A terone caproate Medical Alpha-Hydroxyprogesterone Management Caproate (Makena and 17P) Hysingla ER Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocodone Necessity Guidelines: Hysingla ER bitartrate)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Hytakerol Capsule J8499 N/A N/A Pharmacy N/A (dihydrotachysterol) Ibrance (palbociclib) Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Ibrance Icatibant (generic Injection J1744 PBM Therapeutic Equivalent Pharmacy N/A Firazyr) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Iclusig (ponatinib) Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Iclusig authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Idhifa (enasidenib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Idhifa Ilaris (canakinumab) Injection J0638 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: Medical Ilaris® (Canakinumab) Administration of Ilaris in a hospital Management Provider Administered Drugs – outpatient facility (including any Site of Care ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Ilevro (nepafenac) Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A Suspension Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Ilumya Subcutan- J3245 PBM*/ Medical Management Guidelines: Pharmacy*/ *Self-administration of Ilumya is (tildrakizumab- eous Oxford’s Maximum Dosage and Frequency Medical** covered under the pharmacy asmn) injection Medical Prior authorization Guidelines**: benefit; Prior authorization through ™ Management** o Ilumya (Tildrakizumab) the PBM is required. o Provider Administered Drugs **Provider administration of – Site of Care Ilumya is covered under the Prior Authorization/Medical medical benefit. Prior authorization Necessity Guidelines*: Ilumya through Oxford’s Medical Therapeutic Equivalent Management is required. Guidelines*: Drug Coverage Hospital Outpatient Facility: Criteria - New and Therapeutic Administration of Ilumya in a Equivalent Medications hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Imatinib (generic Oral S0088 and N/A N/A Pharmacy Prior authorization Note: Prior Gleevec) J8999 authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Imbruvica (ibrutinib) Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Imbruvica

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Imitrex Nasal Spray J3490, J8499 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: (sumatriptan) and J3030 Supply Limits Prior authorization through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. **NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Imitrex Tablet J8499 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: (sumatriptan) (brand Supply Limits Prior authorization through the only) Therapeutic Equivalent PBM is only required for quantity Guidelines: Drug Coverage requests exceeding the Triptan Criteria - New and Therapeutic Ceiling Limit. Equivalent Medications **NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Imitrex Injection J3030 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: (sumatriptan) (brand Supply Limits Prior authorization through the only) Therapeutic Equivalent PBM is only required for quantity Guidelines: Drug Coverage requests exceeding the Triptan Criteria - New and Therapeutic Ceiling Limit. Equivalent Medications **NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Coverage as certain Triptan drugs are included in the select designated pharmacy program. Immune Globulin Iv Infusion 90283 Oxford’s Prior Authorization Guidelines: Medical N/A (IVIG and SCIG) 90284 Medical Immune Globulin (IVIG and SCIG)

J1459 Management Immune Globulin Site of Care IVIg: J1554 Asceniv™ J1555 Bivigam® J1556 Carimune NF® J1557 Gammaplex® J1558 Flebogamma® Flebogamma® DIF J1559 Gammagard® Liquid J1561 Gammagard® S/D J1566 Gammaked™ J1568 Gamunex®-C J1569 Octogam® J1572 Panzyga® J1575 Privigen® J1599

SCIG: Cutaquig® Cuvitru® Gammagard® Liquid Gammaked™ Gamunex®-C Hizentra® HyQvia® Xembify® Impavido Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (miltefosine) Guidelines: Impavido Impeklo 0.05% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A lotion (clobetasol Lotion Guidelines: Drug Coverage propionate)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Impoyz (clobetasol Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A propionate) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Imuran Tablet J7500, J8499 PBM Therapeutic Equivalent Pharmacy N/A (azathioprine) Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications Imvexxy Vaginal J3490 N/A N/A Pharmacy N/A (Prasterone) Insert Inbrija (levodopa Inhalation J3490 PBM Prior Authorization/Medical Pharmacy N/A inhalation powder) Powder Necessity Guidelines: Inbrija Increlex Sq Injection J2170 PBM Prior Authorization/Medical Pharmacy N/A (mecasermin) Necessity Guidelines: Increlex (Mecasermin) Incruse Ellipta Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A (umeclidinium) Powder Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Inderal LA (Brand Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A only) (propranolol) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Inderal XL Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (propranolol) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Indocin Rectal J3490 PBM Prior Authorization/Medical Pharmacy N/A (Indomethacin) Suppository Necessity Guidelines: Non-Solid Suppository Oral and Suppository Dosage Indocin Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (Indomethacin) Suspension Necessity Guidelines: Non-Solid Suspension Oral and Suppository Dosage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Inflectra (infliximab) Intravenous Q5103 Oxford’s Medical Management Guidelines: Medical *Prior authorization Note: Medical Maximum Dosage and Frequency Prior authorization is required for Management* Prior Authorization Guidelines: the drug Entyvio in all sites of ™ o Infliximab (Avsola , service through Oxford’s Medical Remicade®, Inflectra®, Management. Additional Prior Renflexis®) authorization may be required for o Provider Administered Drugs the site of care of the injection. – Site of Care Hospital Outpatient Facility: • Administration of Inflectra in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. • Participating hospitals are required to purchase Inflectra (infliximab) from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Ingrezza Capsules J8499 PBM Prior Authorization/Medical Pharmacy N/A (valbenazine) Necessity Guidelines: Ingrezza Injectafer (ferric Intravenous J1439 Oxford’s Prior Authorization Guidelines: Medical N/A carboxymaltose) Medical Intravenous Iron Replacement Management Therapy (Feraheme®, Injectafer®, & MonoferricTM) Inlyta (axitinib) Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Inlyta authorization through the PBM is only required for those Oral

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Innohep (tinzaparin) Injection, Sq J1655 N/A* N/A Pharmacy *No Prior authorization is required Injection if dispensed by a retail pharmacy or mail order through PBM InnoPran XL Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (propranolol Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Equivalent Medications Inqovi (decitabine Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A and cedazuridine) Guidelines: Inqovi Inrebic (Fedratinib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Inrebic Step Therapy Guidelines: Inrebic Insulins: Injection J1815 PBM Therapeutic Equivalent Pharmacy N/A Admelog, Admelog Guidelines: Drug Coverage Solostar Criteria - New and Therapeutic Apidra, Apidra Equivalent Medications Solostar Fiasp, Fiasp FlexTouch Novolin 70/30, Novolin 70/30 Relion Novolin FlexPen 70/30

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Novolin N, Novolin N Relion Novolin R, Novolin R Relion Novolog, Novolog FlexPen, Novolog Penfill Novolog Mix 70/30, Novolog Mix 70/30 Prefilled FlexPen Insulin Lispro Injection J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Intermezzo Sublingual J8499 PBM Therapeutic Equivalent Pharmacy N/A (zolpidem tartrate) Tablet Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Intrarosa Vaginal J3490 N/A N/A Pharmacy N/A (prasterone) Inserts Intron-A (interferon Injection J9212 PBM* Optum Guidelines: Oncology Pharmacy *For Oncology and Non- Alfa-2b) Medication Clinical Coverage Oncology use: Prior authorization Prior Authorization/Notification is required. Guidelines: Intron-A (interferon alpha-2b) Intuniv (guanfacine) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and Therapeutic Equivalent Medications Invega Sustenna Extended J2426 N/A N/A Medical N/A (paliperidone Release palmitate extended Injection release) Invega Trinza Extended J3490 N/A N/A Medical N/A (paliperidone Release Injection

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing palmitate extended release) Invega Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (paliperidone) Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Inveltys (oteprednol Ophthalmic J3490 N/A N/A Pharmacy N/A etabonate) Suspension Invokamet Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (canagliflozin/ Guidelines: Diabetes Medications Notification Guidelines: Diabetes metformin) SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Invokamet XR Extended J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (canaglifloxin/ release Guidelines: Diabetes Medications Notification Guidelines: Diabetes metformin tablet SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors extended-release) Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Invokana Tablet J8499 PBM Non-Formulary Guidelines: Pharmacy The Non-Formulary Guidelines: (canagliflozin) Invokana Invokana policy applies to Prior Authorization/Notification Connecticut, New York, and New Guidelines: Diabetes Medications Jersey plans and products. SGLT2 Inhibitors (CT/NY) The Prior Authorization/ Step Therapy Guidelines: Diabetes Notification Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) Medications SGLT2 Inhibitors (CT/NY) policy applies to New

Jadenu (defirasirox) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Iron Chelators Jadenu granule, Granule or J8499 PBM Therapeutic Equivalent Pharmacy N/A tablet (deferasirox) Tablet Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Jakafi (ruxolitinib) Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Jakafi authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Jalyn (dutasteride Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A and tamsulosin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Janumet (sitagliptin Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy The Prior Authorization/ and metformin Authorization Guidelines: New and Notification Guidelines: Diabetes hydrochloride) Therapeutic Equivalent Medications DPP4 Inhibitors Medications (CT/NY) policy applies to New Prior Authorization/Notification York and Connecticut plans and Guidelines: Diabetes Medications products. DPP4 Inhibitors (CT/NY) The Step Therapy Guidelines: Step Therapy Guidelines: Diabetes Diabetes Medications DPP4 Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Janumet XR Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy The Prior Authorization/ (sitagliptin and Authorization Guidelines: New and Notification Guidelines: Diabetes metformin Therapeutic Equivalent Medications DPP4 Inhibitors hydrochloride, Medications (CT/NY) policy applies to New extended release) Prior Authorization/Notification York and Connecticut plans and Guidelines: Diabetes Medications products. DPP4 Inhibitors (CT/NY) The Step Therapy Guidelines: Step Therapy Guidelines: Diabetes Diabetes Medications DPP4 Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Januvia (sitagliptin) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy The Prior Authorization/ Authorization Guidelines: New and Notification Guidelines: Diabetes Therapeutic Equivalent Medications DPP4 Inhibitors Medications (CT/NY) policy applies to New

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prior Authorization/Notification York and Connecticut plans and Guidelines: Diabetes Medications products. DPP4 Inhibitors (CT/NY) The Step Therapy Guidelines: Step Therapy Guidelines: Diabetes Diabetes Medications DPP4 Medications DPP4 Inhibitors (NJ) Inhibitors (NJ) policy applies to New Jersey plans and products. Jardiance Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (empagliflozin) Guidelines: Diabetes Medications Notification Guidelines: Diabetes SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Jatenzo Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (testosterone Necessity Guidelines: Jatenzo undecanoate) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Jentadueto XR Extended J8499 N/A N/A Pharmacy N/A (linagliptin/ Release metformin) Tablet Jornay PM Extended- J8499 PBM Therapeutic Equivalent Pharmacy N/A (methylphenidate release Guidelines: Drug Coverage hydrochloride) capsule Criteria - New and Therapeutic Equivalent Medications Jublia Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A (efinaconazole) Necessity Guidelines: Jublia Juluca (dolutegravir Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A /rilpivirine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Juxtapid Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (lomitapide) Necessity Guidelines: Juxtapid Jynarque (tolvaptan) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Jynarque Kadian (morphine Capsule J8499 N/A N/A Pharmacy N/A sulfate extended release) (Brand Only) Kadian (morphine Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A sulfate extended Necessity Guidelines: Kadian release) (Generic Only) Kalbitor IV Infusion J1290 Oxford’s Prior Authorization Guidelines: Medical N/A (ecallantide) Medical Hereditary Angioedema (HAE), Management Treatment and Prophylaxis Kalydeco (ivacaftor) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Kalydeco Kanjinti Injection Q5117 N/A Medical Management Guidelines: Medical N/A (Trastuzumab-Anns) Maximum Dosage and Frequency Kanuma (sebelipase Injection J2840 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: alfa) Medical Medical Therapies for Enzyme Administration of Kanuma in a Management Deficiencies hospital outpatient facility Provider Administered Drugs – (including any ambulatory infusion Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Kapspargo Capsule J8499 N/A N/A Pharmacy N/A (metoprolol succinate) Kapvay (clonidine Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Karbinal ER Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (carbinoxamine Suspension Guidelines: Drug Coverage maleate) Criteria - New and Therapeutic Equivalent Medications Katerzia (amlodipine Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A benzoate) suspension Necessity Guidelines: Katerzia Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Kenalog Spray Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (triamcinolone) Spray Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Keppra Injection J1953 N/A N/A Medical N/A (levatiricetam) Keppra Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (levetiracetam) Necessity Guidelines: Keppra Keppra XR Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (levetiracetam Necessity Guidelines: Keppra XR extended release[XR]) Keralac 47% cream Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (urea) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Keralyt Scalp Kit Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (salicylic acid) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Kerydin (tavaborole) Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Kerydin Kesimpta Subcutaneo J3490 PBM Prior Authorization/Notification Pharmacy N/A (ofatumumab) us Injection Guidelines: Kesimpta Ketocon Ointment J3490 and PBM Therapeutic Equivalent Pharmacy N/A (ketoconazole) J8499 Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Ketodan Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Combination Guidelines: Drug Coverage Package Criteria - New and Therapeutic (ketoconazole) Equivalent Medications Ketoprofen Capsule J8499 PBM Step Therapy Guideline: Pharmacy N/A Ketoprofen Ketoprofen XR Extended J8499 PBM Step Therapy Guideline: Pharmacy N/A release Ketoprofen XR capsule Keveyis Tablet J8499 N/A Prior Authorization/Notification Pharmacy N/A (dichlorphena-mide) Guidelines: Keveyis Kevzara (sarilumab) Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Kevzara Khedezla Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (desvenlafaxine Guidelines: Drug Coverage extended release) Criteria - New and Therapeutic Equivalent Medications Kineret (anakinra) Injection, Sq J3490 PBM Prior Authorization/Notification Pharmacy N/A Injection Guidelines: Kineret (Anakinra)

Kisqali (ribociclib) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Kisqali Step therapy Guidelines: Kisqali Kisqali Femara Co- Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Pak (ribociclib/ Guidelines: Kisqali Femara Co-Pak letrozole) Step Therapy Guidelines: Kisqali Femara Co- Pak Kitabis Pak Inhalation J3490 PBM Prior Authorization/Notification Pharmacy N/A (tobramycin) Solution Guidelines: Kitabis Pak Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Klisyri (tirbanibuli) Topical J3490 PBM Step Therapy Guidelines: Klisyri Pharmacy N/A Ointment Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Klonopin (Brand Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A only) (clonazepam) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Kloxxado (naloxone Intranasal J3490 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Spray Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Korlym Oral J8499 PBM Prior Authorization/Notification Pharmacy* *NJ Small Members should refer (mifepristone) Guidelines: Korlym to their Certificate of Coverage for Prior authorization and quantity limit guidelines. Koselugo Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (selumetinib) Guidelines: Koselugo Krintafel Tablet J8499 N/A N/A Pharmacy N/A (tafenoquine) Krystexxa Injection J2507 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: ® (pegloticase) Medical Krystexxa (Pegloticase) Participating hospitals are required Management to purchase Krystexxa (pegloticase) from the Optum Specialty Pharmacy. Refer to the Clinical Policy titled Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Kuvan (sapropterin Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A dihydrochloride) Guidelines: Kuvan (sapropterin dihydrochloride) Kuvan (sapropterin Tablet or J8499, J8999 PBM Therapeutic Equivalent Pharmacy N/A dihydrochloride) Powder for Guidelines: Drug Coverage (Brand Only) Oral Solution

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Kynamro Sq Injection J3490 N/A N/A Pharmacy N/A (Mipomersen Sodium) Kynmobi Sublingual J8499 PBM Prior Authorization/Medical Pharmacy N/A (apomorphine hcl) film Necessity Guidelines: Kynmobi Kytril (granisetron Injection J1626 N/A Prior Authorization Guidelines: Medical N/A hydrochloride) Antiemetics for Oncology Tablet, Oral Q0166 and N/A Prior Authorization Guidelines: Pharmacy N/A Solution J8499 Antiemetics for Oncology Lactulose Oral Crystals for J8499 PBM Therapeutic Equivalent Pharmacy N/A Crystal Packet Reconstitu- Guidelines: Drug Coverage (generic Kristalose) tion for Oral Criteria - New and Therapeutic Administra- Equivalent Medications tion Lamictal Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (lamotrigine) Necessity Guidelines: Lamictal Lamictal ODT Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (lamotrigine orally Necessity Guidelines: Lamictal disintegrating ODT Tablet) (brand and generic) Lamictal XR Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (lamotrigine Necessity Guidelines: Lamictal XR extended release) (brand and generic) Lamisil (terbinafine Tablet J8499 N/A N/A N/A N/A hydrochloride) Lamotrigine XR Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Lamotrigine XR Lampit (nifurtimox) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Lampit

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Lantus (insulin Injection J3490 N/A N/A Pharmacy N/A glargine) Lantus Solostar Pen J3490 N/A N/A Pharmacy N/A (insulin glargine) Lazanda (fentanyl Nasal Spray J3490 PBM Prior Authorization/Medical Pharmacy N/A nasal spray) Necessity Guidelines: Lazanda Latuda (lurasidone) Tablet J8499 N/A N/A Pharmacy N/A Lemtrada Infusion J0202 and Optum*/ Optum Guidelines*: Oncology Medical Prior Authorization Notes (alemtuzumab) J9999 Oxford’s Medication Clinical Coverage *For oncology indications: Medical Prior Authorization Guidelines**: o Prior authorization is Management** Lemtrada (Alemtuzumab) required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 **Prior authorization is required through Oxford for non-oncology indications. Hospital Outpatient Facility: Participating hospitals are required to purchase Lemtrada (alemtuzumab) from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Lenvima (lenvatinib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Lenvima Lescol XL Capsule J8499 PBM Step Therapy Guidelines: Lescol Pharmacy N/A (fluvastatin) (brand and generic) Letairis (Brand only) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (ambrisentan) Necessity Guidelines: PAH Agents

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Letrozole (generic) Tablet J8499 PBM* Prior Authorization/Regulatory Pharmacy N/A Guideline: Letrozole Leukine Injection, Sq J2820 Optum/Oxford Optum Guidelines**: White Blood See *Pharmacy Benefit: If dispensed (sargramostim) Injection Cell Colony Stimulating Factors Notes*,** by a retail pharmacy or mail order through PBM. Prior authorization is not required. **Medical Benefit: If provided in a hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Leuprolide Acetate Injection J9218 PBM* Prior Authorization/Notification Pharmacy *For Oncology and Non- (subcutaneous) Guidelines: Leuprolide Acetate Oncology Use: Prior authorization (Eligard), is required. 1mg/0.2mL

Levalbuterol nebs Inhalation J8499 N/A N/A Pharmacy N/A (generic Xopenex nebs) Levemir (insulin Injection J3490 PBM* Prior Authorization/Notification Pharmacy *Levemir may be excluded from detemir) Guidelines: Levemir coverage. Refer to the member

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing specific benefit plan document as applicable. Levitra (vardenafil Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A HCI) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Levorphanol Tablet J8499 PBM Step Therapy Guidelines: Pharmacy N/A Levorphanol Lexapro Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (escitalopram) Authorization Guidelines: New and (brand only) Therapeutic Equivalent Medications Lexette 0.05% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (Halobetasol Foam Guidelines: Drug Coverage Propionate) Criteria - New and Therapeutic Equivalent Medications Lexiscan Iv Infusion J2785 N/A N/A Medical N/A (regadenoson) Librax Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (chlordiazepoxide / Guidelines: Drug Coverage clidinium) (brand) Criteria - New and Therapeutic Equivalent Medications Licart (diclofenac Topical J3490 N/A N/A Pharmacy Note: Prescription drugs for which epolalmine) System there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Lidocaine Patch Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A (Lidoderm) Patch Guidelines: Lidocaine Patch (Generic) Lidoderm Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A (lidocaine) (Brand) Patch Guidelines: Lidocaine Patch Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Lidorx (lidocaine Topical Gel J3490 N/A N/A Pharmacy N/A hydrochloride) Lidovin 3.95% Topical J3490 N/A N/A Pharmacy N/A (lidocaine) Cream Linzess (linaclotide) Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Linzess (Linaclotide) Lipitor (brand only) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (atorvastatin) Authorization Guidelines: New and Therapeutic Equivalent Medications Lipofen (fenofibrate) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Liptruzet (ezetimibe Tablet J8499 N/A N/A Pharmacy N/A and atorvastatin) Lithobid (lithium Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A carbonate) Necessity Guidelines: Lithobid Livalo (pitavastatin) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Livalo Lo Minastrin FE Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (ethinyl estradiol / Guidelines: Drug Coverage norethindrone) Criteria - New and Therapeutic Equivalent Medications Lo/Ovral (ethinyl Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members estradiol and with coverage for contraceptives norgestrel) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then Loestrin/FE (ethinyl these are not covered. Members estradiol and should refer to their Certificate of norethindrone) Coverage or Prescription Drug

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Rider language for coverage guidelines. Locoid Lipocream & Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Locoid Lotion Guidelines: Drug Coverage (hydrocortisone Criteria - New and Therapeutic butyrate) Equivalent Medications LoCort Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (dexamethasone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lodine (Brand only) Tablets / J8499 PBM Therapeutic Equivalent Pharmacy N/A (Etodolac) Capsules Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lodosyn Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (carbidopa) (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lofibra 54mg, Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 160mg (Brand only) Guidelines: Drug Coverage (fenofibrate) Criteria - New and Therapeutic Equivalent Medications Lofibra 67, 134, Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 200mg (fenofibrate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lokelma (sodium Powder for J8499 PBM Prior Authorization/Medical Pharmacy N/A zirconium oral Necessity Guidelines: Lokelma cyclosilicate) suspension Lonhala Magnair Inhalation J3490 PBM Prior Authorization/Medical Pharmacy N/A (glycopyrrolate) Solution Necessity Guidelines: Lonhala Magnair Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Lonsurf (trifluridine/ Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A tipiracil) Guidelines: Lonsurf Loprox Shampoo Shampoo J3490 PBM Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Loprox Suspension Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (ciclopirox) Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Loprox 0.77% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream (ciclopirox) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lorbrena (lorlatinib) Tablets J8999 PBM Prior Authorization/Notification Pharmacy N/A Guideline: Lorbrana Lorzone Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (chlorzoxazone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lotemax Gel Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (loteprednol Gel Guidelines: Drug Coverage etabonate) Criteria - New and Therapeutic Equivalent Medications Lotemax SM gel Ophthalmic J3490 N/A N/A Pharmacy N/A (loteprednol Gel etabonate ophthalmic gel) Lotrel (amlodipine Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A besylate and Guidelines: Drug Coverage benazepril Criteria - New and Therapeutic hydrochloride) Equivalent Medications (Brand Only) Lotronex (alosetron) Tablet J8499 N/A Prior Authorization/Notification Pharmacy FDA approved only for use in (brand) Guidelines: Lotronex (Alosteron) women.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lovaza (Brand Only) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (omega-3-acid ethyl Guidelines: Drug Coverage esters) Criteria - New and Therapeutic Equivalent Medications Lovaza (Generic) Capsule J8499 N/A N/A Pharmacy N/A (omega-3-acid ethyl esters) Lovenox (Brand Injection, Sq J1650 PBM Therapeutic Equivalent Pharmacy N/A only) (enoxaparin) Injection Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lucemyra Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (lofexidine) Necessity Guidelines: Lucemyra Lucentis Injection J2778 N/A Medical Management Guidelines: Medical N/A (ranibizumab) Maximum Dosage and Frequency Lumizyme Injection J0221 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (alglucosidase alfa) Medical Medical Therapies for Enzyme Administration of Lumizyme in a Management Deficiencies hospital outpatient facility Provider Administered Drugs – (including any ambulatory infusion Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Lunesta Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (eszopicione) Authorization Guidelines: New and (brand only) Therapeutic Equivalent Medications Lupaneta Pack Injection and J3490 Oxford’s Prior Authorization Guidelines: Medical N/A (leuprolide acetate Tablets Medical Gonadotropin Releasing Hormone injection & Management Analogs

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing norethindrone acetate tablets) Lupkynis Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (voclosporin) Necessity Guidelines: Lupkynis Lupron, Injection J1950, Optum*/ Optum Guidelines*: Oncology Medical** *Prior Authorization Note: Lupron Depot, J9217, and Oxford Medication Clinical Coverage For oncology indications: Lupron Depot J9219 Prior Authorization Guidelines: Prior authorization is required Pediatric Gonadotropin Releasing Hormone through Optum for dates of Analogs Lupron Implant service Aug. 1, 2021 and after; (Leuprolide Prior authorization is required Acetate): through eviCore for dates of service prior to Aug. 1, 2021 Lupron Depot 3.75mg, For Non-Oncology Use Prior authorization through Oxford is 11.25 (3 month required for all indications for: supply of 3.75 dose) Lupron Depot Pediatric (all

dosages) and Lupron Depot Lupron Depot 3.75mg, 7.5mg 11.25mg 22.5 (3 month supply of 7.5mg Prior authorization is required for dose) all dosages of Lupron Depot for 30mg (4 month the diagnosis of gender dysphoria; dose of 7.5mg) refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for Lupron Depot- applicable Gender Dysphoria ICD- Pediatric: 10 diagnosis codes. 7.5mg, 11.25mg, New Jersey Small Members should 15mg refer to their Certificate of Coverage for Prior authorization guidelines.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing **Benefit Note: For Connecticut Large and Small Plans: Infertility drugs will be covered under the Pharmacy Benefit if the Member has pharmacy coverage. If the Member does not have pharmacy coverage, infertility drugs will be covered under the Medical Benefit. Luxiq foam Foam J3490 PBM Therapeutic Equivalent Pharmacy N/A (betamethasone Guidelines: Drug Coverage valerate) Criteria - New and Therapeutic Equivalent Medications Luxturna Injection J3398 Oxford’s Prior Authorization Guidelines: Medical N/A (voretigene Medical Luxturna™ (Voretigene neparvovecrzyl) Management Neparvovecrzyl) Luzu (luliconazole) Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Lynparza (olaparib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Lynparza Lyrica (pregabalin) Capsule, J8499 PBM Prior Authorization/Medical Pharmacy N/A (Brand only) Oral Solution Necessity Guidelines: Lyrica Lyrica CR Tablets J8499 PBM Step Therapy Guidelines: Lyrica Pharmacy N/A (pregabalin) CR Lyumjev (insulin Injection J3490 PBM Therapeutic Equivalent Pharmacy N/A lispro-aabc) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Macugen Injection J2503 N/A Medical Management Guidelines: Medical N/A (pegaptanib Maximum Dosage and Frequency sodium) Makena (17-alpha- Injection J1726 Oxford’s Prior Authorization Guidelines: 17- Medical N/A hydroxy- Medical Alpha-Hydroxyprogesterone progesterone Management Caproate (Makena and 17P) caproate or 17P)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Mavenclad Tablets J8499 PBM Prior Authorization/Notification Pharmacy N/A (cladribine) Guidelines: Mavenclad Step Therapy Guidelines: Mavenclad Mavyret (glecaprevir Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A and pibrentasvir) Necessity Guidelines: Mavyret Maxalt and Maxalt- Tablet J8499 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: MLT (brand only) Supply Limits Prior authorization through the Therapeutic Equivalent PBM is only required for quantity Guidelines: Drug Coverage requests exceeding the Triptan Criteria - New and Therapeutic Ceiling Limit. Equivalent Medications **NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Mayzent Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (siponimod) Guidelines: Mayzent Mekinist Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (Trametinib) Guidelines: Mekinist (Trametinib) Mektovi Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (binimetinib) Guidelines: Mektovi Step Therapy Guidelines: Mektovi Menopur Injection S0122* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS (Menotropins) J3490 authorization Human Menopausal Medical** code S0122 (menotropins) through Gonadotropins (hMG) requires Prior authorization Optum* through Optum in all sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Mepron suspension Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (Brand Only) Suspension Guidelines: Drug Coverage (atovaquone) Criteria - New and Therapeutic Equivalent Medications Mepsevii Injection J3397 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (vestronidase alfa- Medical Medical Therapies for Enzyme Administration of Mepsevii in a vjbk) Management Deficiencies hospital outpatient facility Provider Administered Drugs – (including any ambulatory infusion Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Mesalamine Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Lialda) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Mesalamine Rectal J3490 N/A N/A Pharmacy N/A Suppository suppository (generic Canasa) Mestinon 60 mg Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (pyridostigmine) Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications Metadate CD Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (methylphenidate Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic ([controlled release Equivalent Medications brand only) Metadate ER Tablet J8499 N/A N/A Pharmacy N/A

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Methitest (methyl- Tablet J8499 N/A N/A Pharmacy N/A testosterone) Methylin and Capsule J8499 N/A N/A Pharmacy N/A Methylin ER (methylphenidate) Methylphenidate Capsule J8499 PBM N/A Pharmacy N/A extended-release capsule (generic Metadate CD) Methylphenidate Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A extended-release Guidelines: Drug Coverage tablet (generic Criteria - New and Therapeutic Concerta) Equivalent Medications Metopirone Capsule J3490 PBM* Prior Authorization/Medical Pharmacy *Prior authorization/Benefit (metyrapone) Necessity Guidelines: Diagnostic Notes: Agents – Metopirone* New York and New Jersey Plans: o Covered under the pharmacy benefit. o Prior authorization through the PBM is required. CT plans: o Prior authorization is NOT required. o Covered under the medical benefit. Metoprolol 37.5mg, Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 75mg Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications metoprolol Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A extended release/ Guidelines: Drug Coverage hydrochloro-thiazide Criteria - New and Therapeutic (Dutoprol Equivalent Medications Authorized Generic)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Metozolv ODT Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (metoclopramide Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Equivalent Medications Metrodin Injection J3355* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS (urofollitropin) J3490 authorization Infertility Diagnosis and Treatment Medical** code J3355 (urofollitropin) requires through Optum Prior authorization through Optum may be in all sites of service when required* associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Metrogel 0.75% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Vaginal Guidelines: Drug Coverage (metronidazole) Criteria - New and Therapeutic (brand) Equivalent Medications Metrogel 1% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (metronidazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Metronidazole 1% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A gel (generic Guidelines: Drug Coverage Metrogel 1%) Criteria - New and Therapeutic Equivalent Medications Metvixia (Methyl Topical J7309 N/A N/A Medical N/A aminolevulinate) Micardis (Brand Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Only) (telmisartan) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Micardis HCT Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (Brand Only) Guidelines: Drug Coverage (telmisartan/ Criteria - New and Therapeutic hydrochlorothiazide) Equivalent Medications Micort-HC 2.5% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream Cream Guidelines: Drug Coverage (hydrocortisone Criteria - New and Therapeutic acetate) Equivalent Medications Micronor Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (norethidrone) with coverage for contraceptives through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Mifeprex Oral S0190 Oxford’s Prior Authorization Guidelines: Medical* *Certain groups may exclude (mifepristone) Medical Mifeprex® (Mifepristone) these services from coverage if Management such coverage would be contrary to the Group's bona fide religious tenets. Refer to the Member's Certificate of Coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit. Migranal (dihydro- Nasal Spray J3490 PBM Prior Authorization/Medical Pharmacy N/A ergotamine) (brand) Necessity Guidelines: Migranal Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Migranal (dihydro- Nasal Spray J3490 PBM Prior Authorization/Medical Pharmacy N/A ergotamine) Necessity Guidelines: Migranal (generic) Minastrin 24 FE Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (norethindrone Guidelines: Drug Coverage acetate and ethinyl Criteria - New and Therapeutic estradiol/ferrous Equivalent Medications fumarate) Minivelle (Brand Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Only) (estradiol Patch Guidelines: Drug Coverage patch) Criteria - New and Therapeutic Equivalent Medications Minocin Injection J2265 N/A N/A Medical N/A (minocycline) Minocin 50mg, Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A 75mg and 100mg Guidelines: Drug Coverage (minocycline hcl) Criteria - New and Therapeutic Equivalent Medications Minocycline Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Dynacin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Minocycline Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A extended-release Necessity Guidelines: Solodyn (generic Solodyn) Minolira Extended- J8499 PBM Prior Authorization/Medical Pharmacy N/A (minocycline) Release Necessity Guidelines: Minolira Tablets Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Mirapex ER Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (pramipexole Guidelines: Drug Coverage dihydrochloride) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Mircera (methoxy Injection J3490 Oxford’s Prior Authorization Guidelines: Medical**/ *No Prior authorization is required polyethylene glycol- Medical Erythropoiesis-Stimulating Pharmacy* if dispensed by a retail pharmacy epoetin beta) Management** Agents** through the PBM. **Prior authorization is required if provided in a hospital, MD's office or home setting. Mirvaso Topical gel J3490 PBM Prior Authorization/Notification Pharmacy N/A (brimonidine gel) Guidelines: Mirvaso Misoprostol Tablet S0191 Oxford’s Prior Authorization Guidelines: Medical* *Certain groups may exclude Medical Abortions (Therapeutic and these services from coverage if Management Elective) such coverage would be contrary to the Group's bona fide religious tenets. Refer to the Member's Certificate of Coverage/health benefits plan. Healthy NY Plans do not have an elective abortion benefit. Mitigare (colchicine) Capsule J8499 N/A N/A Pharmacy N/A Moderiba Tablet Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (ribavirin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Moderiba Pak Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (ribavirin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Modicon (ethinyl Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members estradiol and with coverage for contraceptives norethindrone) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Rider language for coverage guidelines. Molindone Tablet J8499 N/A N/A Pharmacy N/A Momexin Combo Cream J3490 N/A N/A Pharmacy N/A Package (mometasone furoate) Monodox Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (doxycycline) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Monoferric (ferric Intravenous 1437 Oxford’s Prior Authorization Guidelines: Medical N/A derisomaltose) Infusion Medical Intravenous Iron Replacement Management Therapy (Feraheme® & Injectafer®, & Monoferric®) Morgidox Capsule J8499 N/A N/A Pharmacy N/A (doxycycline) Morgidox Kit/ Capsule/ J8499 PBM Therapeutic Equivalent Pharmacy N/A Combo Pkg Topical Guidelines: Drug Coverage (doxycycline plus Criteria - New and Therapeutic cleanser) Equivalent Medications MorphaBond ER Extended- J8499 N/A N/A Pharmacy N/A (morphine sulfate) Release Tablet Morphine Sulfate Tablet J8499 N/A N/A Pharmacy N/A Extended Release Pellets (generic Kadian) Motegrity Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (prucalopride) Necessity Guidelines: Motegrity Motofen (difenoxin/ Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A atropine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Movantik Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (naloxegol) Necessity Guidelines: Movantik Mozobil (plerixafor) Injection J2562 N/A N/A Medical N/A MS Contin Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (Morphine Sulfate Necessity Guidelines: MS Contin Controlled-Release) (Brand and Generic) Mulpleta Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (lusutrombopag) Guidelines: Mulpleta Multaq Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (dronedarone) Guidelines: Multaq Muse (alprostadil) Pellet J0275 N/A N/A Pharmacy N/A Mvasi Injection Q5107 N/A Medical Management Guidelines: Medical N/A (bevacizumab- Maximum Dosage and Frequency awwb) Myalept Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (metreleptin) Necessity Guidelines: Myalept (metreleptin) Mycapssa Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (octreotide) Necessity Guidelines: Mycapssa Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Mydayis Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (dextroampheta- Guidelines: Drug Coverage mineamphetamine Criteria - New and Therapeutic mixed salts) Equivalent Medications Myfembree Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (relugolix) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Myfortic Tablet J7518, J8499 PBM Therapeutic Equivalent Pharmacy N/A (mycophenolic acid) Guidelines: Drug Coverage (brand only)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Myobloc Injection J0587 Oxford’s Prior Authorization Guidelines: Medical N/A (rimabotulinum-toxin Medical Botulinum Toxins A and B B) Management Myorisan Capsule J8499 N/A N/A Pharmacy N/A (isotretinoin) Myozyme Iv Infusion, J0220 N/A N/A Medical N/A (alglucosidase alfa) Injection Myrbetriq Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (mirabegron) Authorization Guidelines: New and Therapeutic Equivalent Medications Mysoline Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (primidone) Necessity Guidelines: Mysoline Mytesi (crofelemer) Oral J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Mytesi Naftin 1% (naftifine Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A hcl) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Naftin 2% gel Topical Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (naftifine Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Equivalent Medications Naglazyme Injection J1458 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (galsulfase) Medical Medical Therapies for Enzyme Administration of Naglazyme in a Management Deficiencies hospital outpatient facility Provider Administered Drugs – (including any ambulatory infusion Site of Care* suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Nalfon 600 mg Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (fenoprofen Guidelines: Drug Coverage calcium) Criteria - New and Therapeutic Equivalent Medications Nalocet (Oxycodone Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A and Guidelines: Drug Coverage Acetaminophen) Criteria - New and Therapeutic Equivalent Medications Namenda XR Capsule J8499 PBM Therapeutic Equivalent N/A N/A (Memantine Guidelines: Drug Coverage Hydrochloride) Criteria - New and Therapeutic Equivalent Medications Namzaric Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (memantine Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Equivalent Medications Naprelan (Naproxen Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Sodium) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Naprelan CR (Dose Tablet J8499 N/A N/A Pharmacy N/A Card) (Naproxen Sodium) Naprosyn Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (naproxen) suspension Necessity Guidelines: Non-Solid suspension Oral and Suppository Dosage Narcan Nasal Spray Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (naloxone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nasonex Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (mometasone Guidelines: Drug Coverage furoate Criteria - New and Therapeutic monohydrate) Equivalent Medications

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

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Neo-Synalar kit Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (neomycin sulfate Guidelines: Drug Coverage and fluocinolone) Criteria - New and Therapeutic Equivalent Medications Nerlynx (neratinib) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Nerlynx Neuac 1.2%-5% Topical J3490 N/A N/A Pharmacy N/A (clindamycin phosphate and benzoyl peroxide) Neuac 1.2%-5% kit Topical J3490 N/A N/A Pharmacy N/A (clindamycin phosphate and benzoyl peroxide) Neulasta Injection, Sq J2505 Optum**/ Medical Management See *Pharmacy Benefit: If dispensed (pegfilgrastim) Injection Oxford Guidelines**: Maximum Dosage Notes*,** by a retail pharmacy or mail order and Frequency through PBM. Prior authorization is Optum Guidelines**: White Blood not required. Cell Colony Stimulating Factors **Medical Benefit: If provided in a hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Neupogen Injection, J1442 PBM*/ Optum Guidelines**: White Blood See *Pharmacy Benefit: If dispensed (filgrastim) Sq Injection Optum**/ Cell Colony Stimulating Factors Notes*,** by a retail pharmacy or mail order Oxford**

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent through PBM. Prior authorization is Guidelines*: Drug Coverage required. Criteria - New and Therapeutic **Medical Benefit: If provided in a Equivalent Medications hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Neurontin Capsule, J8499 PBM Prior Authorization/Medical Pharmacy N/A (gabapentin) Tablet Or Necessity Guidelines: Neurontin Oral Solution Nevirapine Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A extended release Guidelines: Drug Coverage (nevirapine) Criteria - New and Therapeutic Equivalent Medications Nexavar (sorafenib Tablet J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior tosylate) Guidelines: Nexavar authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing authorization guidelines and quantity limit guidelines. Nexavir Injection J3490 N/A N/A Medical N/A (kutapressin) Nexiclon XR Tablet, J8499 N/A N/A Pharmacy N/A (clonidine extended Suspension release) Nexium Capsule J8499 N/A N/A N/A Note: Prescription drugs for which (esomeprazole) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Nexium Suspension Suspension J8499 PBM Prior Authorization/Medical Pharmacy N/A (esomeprazole) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Nexletol Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (bempedoic acid) Necessity Guidelines: Nexletol Nexlizet Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (bempedoic Necessity Guidelines: Nexlizet acid/ezetimibe) Nextstellis (estetrol/ Pill J8499 PBM Therapeutic Equivalent Pharmacy N/A drospirenone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Niacor (niacin) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nicazeldoxy 30 kit Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (Doxycycline plus Guidelines: Drug Coverage MVI) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Nicotine OTC Transdermal A9150 N/A N/A Pharmacy Benefits for Tobacco Cessation for products: Patch/Gum/ Health Care Reform apply to all nicotine gum (e.g., Lozenge plans subject to health care reform Nicorette), nicotine lozenge (e.g., Nicorette), nicotine patch (e.g., Nicoderm CQ) Nicotrol Inhaler Inhalation J3490 PBM** Prior Authorization/Medical Pharmacy* *Benefits for Tobacco Cessation (nicotine) System Necessity Guidelines**: Tobacco for Health Care Reform apply to all Cessation for Health Care Reform plans subject to health care reform Supply Limit Guidelines: HCR Tobacco Cessation - Supply Limits **Prior authorization is not Override - NJ Fully Insured required for New York plans Nicotrol NS Nasal Spray J3490 PBM** Prior Authorization/Medical Pharmacy* *Benefits for Tobacco Cessation (nicotine) Necessity Guidelines**: Tobacco for Health Care Reform apply to all Cessation for Health Care Reform plans subject to health care reform Supply Limit Guidelines: HCR Tobacco Cessation - Supply Limits **Prior authorization is not Override - NJ Fully Insured required for New York plans Niferex (iron Capsule A9152 and N/A N/A Pharmacy* *Coverage is limited to Members polysaccharide) or A9153 with coverage for vitamins/ Niferex 150 Forte supplements through their prescription drug plan. If the Member does not have vitamin/supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Ninlaro (ixazomib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Ninlaro

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Nitisinone Capsules Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A (generic Orfadin) Guideline: Orfadin Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nitroglycerin spray Spray J8499 PBM Therapeutic Equivalent Pharmacy N/A (generic Guidelines: Drug Coverage nitrolingual) Criteria - New and Therapeutic Equivalent Medications Nitrolingual Pump Spray J8499 PBM Therapeutic Equivalent Pharmacy N/A Spray (nitroglycerin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nityr (nitisinone) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Nityr Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nivestym (filgrastim- Injection Q5110 PBM*/ Optum Guidelines**: White Blood See *Pharmacy Benefit: If dispensed aafi) Optum**/ Cell Colony Stimulating Factors Notes*,** by a retail pharmacy or mail order Oxford** Therapeutic Equivalent through PBM. Prior authorization is Guidelines*: Drug Coverage required. Criteria - New and Therapeutic **Medical Benefit: If provided in a Equivalent Medications hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prior authorization is required through Oxford for non- oncology indications. Nocdurna Tablets J8499 PBM Prior Authorization/Medical Pharmacy N/A (desmopressin- Necessity Guidelines: Nocdurna acetate) Norco Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (hydrocodone Guidelines: Drug Coverage bitartrate and Criteria - New and Therapeutic acetaminophen) Equivalent Medications (Brand Only) Norditropin Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (Somatropin) Necessity Guidelines: Norditropin (Somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Norditropin FlexPro Pen Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: Norditropin FlexPro Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Norditropin Pen Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A NordiFlex Necessity Guidelines: NordiFlex (somatropin) (somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Norgesic Forte Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (aspirin/caffeine/ Guidelines: Drug Coverage orphenadrine) Criteria - New and Therapeutic Equivalent Medications

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

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Noxafil (Brand Only) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (posaconazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nubeqa Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (darolutamide) Guidelines: Nubeqa Nucala (Auto- Auto Injector J3490, J3590 PBM Prior Authorization/Medical Pharmacy N/A Injector & Prefilled & Prefilled Necessity Guidelines: Nucala Syringe) Syringe (mepolizumab) Nucala Sub- J3490, Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (mepolizumab) Cutaneous J3590, and Medical o Provider Administered Drugs Administration of Nucala in a Injection J2182 Management – Site of Care hospital outpatient facility o Respiratory Interleukins (including any ambulatory infusion (Cinqair®, Fasenra®, and suite associated with the hospital) Nucala®) requires Prior authorization with Prior Authorization/Medical review by a Medical Director or Necessity Guidelines: Nucala their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs – Site of Care. Nucynta ER Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (tapentadol Necessity Guidelines: Nucynta ER extended release) Nuedexta Capsules J8499 PBM Prior Authorization/Medical Pharmacy N/A (dextromethor- Necessity Guidelines: Nuedexta phan/quinidine) Nulibry Injection J3490 N/A* Prior authorization Guidelines: Medical *Prior Authorization Notes: (fosdenopterin) J3590 • Medical Therapies for Enzyme Prior authorization is not required C9399 Deficiency but is strongly recommended for Review at Launch for New to Nulibry. While no penalty will be Market Medications* imposed for failure to request a pre-service review, if you do not request one, a medical necessity review will be conducted post- service to determine coverage. It is the referring physician’s

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing responsibility to provide medical documentation to demonstrate clinical necessity for the medication. As of Oct. 1, 2021, prior authorization will be required. Nuplazid Tablet J8499 N/A Prior Authorization/Notification Pharmacy N/A (pimavanserin Guidelines: Nuplazid tartrate) Nurtec ODT Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (rimegepant) disintegratin Necessity Guidelines: Nurtec ODT g tablet Prior Authorization/Supply Limit Guidelines: Agents for Migraine Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nutritonal Therapy, Iv Infusion, Varies Oxford’s Medical Management Guidelines: See Notes* *Benefit is State Specific. Medical Formula and Oral Tube Medical Formula & Specialized Food Benefit/Pharmacy Benefit Specialized Foods, Feed Management Parenteral Nutrition Therapy Nutropin AQ NuSpin Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: NuSpin (Somatropin) Nutropin and Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A Nutropin AQ Necessity Guidelines: Nutropin (somatropin) and Nutropin AQ (somatropin) Nuvaring Vaginal Ring J7303 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (etonogestrel/ with coverage for contraceptives ethinyl estradiol) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Rider language for coverage guidelines. Nuvessa Vaginal Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (metronidazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nuvigil (armodafinil) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (brand only) Guidelines: Nuvigil (armodafinil) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Nuzyra Tablet J0121 N/A N/A Pharmacy N/A (omadacycline) Nymalize Oral Solution J8499 N/A N/A Pharmacy N/A (nimodipine) Nystatin/triamcinolo Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A ne (generic Mycolog Guidelines: Drug Coverage II) cream Criteria - New and Therapeutic Equivalent Medications Nystatin/ Ointment J3490 PBM Therapeutic Equivalent Pharmacy N/A triamcinolone Guidelines: Drug Coverage (generic Mycolog II) Criteria - New and Therapeutic ointment Equivalent Medications Nyvepria Subcutan- Q5122 PBM*/ • Optum Guidelines**: White Blood See *Pharmacy Benefit: If dispensed (pegfilgrastim-apgf) eous Optum**/ Cell Colony Stimulating Factors Notes*,** by a retail pharmacy or mail order Injection Oxford** • Therapeutic Equivalent through PBM. Prior authorization is Guidelines*: Drug Coverage required. Criteria - New and Therapeutic **Medical Benefit: If provided in a Equivalent Medications hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after;

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Obredon Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocodone Necessity Guidelines: Opioid bitartrate and Containing Cough Medicines guaifenesin) Ocaliva (obeticholic Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A acid) Necessity Guidelines: Ocaliva Ocrevus Injection J2350 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (Ocrelizumab) Medical Ocrevus (Ocrelizumab) Participating hospitals are required Management to purchase Ocrevus (Ocrelizumab) from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Odefsey Tablet J8499 N/A N/A Pharmacy N/A (emtricitabine/ rilpivirine/ tenofovir) Odomzo (sonidegib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Odomzo Ofev (nintedanib) Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Ofev (nintedanib) Oforta (fludarabine Oral J8562 N/A N/A Pharmacy N/A phosphate) Ogivri (trastuzumab- Injection Q5114 N/A Medical Management Guidelines: Medical N/A dkst) Maximum Dosage and Frequency

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Oleptro (trazodone Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Oleptro ER Tablet J8499 N/A N/A Pharmacy N/A (trazodone hydrochloride ER) Olmesartan (generic Tablet J8499 N/A N/A Pharmacy N/A Benicar) Olumiant Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (baricitinib) Necessity Guidelines: Olumiant Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Olux (clobetasol Foam J3490 PBM Therapeutic Equivalent Pharmacy N/A propionate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Olux-CP (clobetasol Foam J3490 N/A N/A Pharmacy N/A propionate) Olux-E (clobetasol Foam J3490 PBM Therapeutic Equivalent Pharmacy N/A propionate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Olysio (simeprevir) Capsule J8499 N/A N/A Pharmacy N/A Omeclamox-Pak Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (omeprazole, Guidelines: Drug Coverage clarithromycin, Criteria - New and Therapeutic amoxicillin) Equivalent Medications Omeprazole Capsule J8499 N/A N/A Pharmacy N/A (generic) Omeprazole/ Capsule J8499 N/A N/A N/A Note: Prescription drugs for which sodium bicarbonate there is a therapeutic over-the- (generic) counter (OTC) equivalent are

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing excluded from coverage. Refer to the member specific benefit plan document as applicable. Omesartan/ Tablet J8499 N/A N/A Pharmacy N/A hydrochloro-thiazide (generic Benicar HCT) Omnaris Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (ciclesonide) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Omnitrope Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: Omnitrope (Somatropin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Onexton 1.2-3.75% Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (clindamycin Guidelines: Drug Coverage phosphate and Criteria - New and Therapeutic benzoyl peroxide) Equivalent Medications Onfi (clobazam) Oral J8999 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Onfi Ongentys Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (opicapone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Onmel Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (itraconazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Onpattro (patisiran) Injection J0222 Oxford’s Medical Management Guidelines: Medical *Hospital Outpatient Facility: Medical Maximum Dosage and Frequency Administration of Onpattro in a Management Prior Authorization Guidelines: hospital outpatient facility o Onpattro (Patisiran) (including any ambulatory infusion

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing o Provider Administered Drugs suite associated with the hospital) – Site of Care* requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Onsolis (fentanyl Film J8499 N/A N/A Pharmacy N/A buccal soluble film) Ontruzant Injection Q5112 N/A Medical Management Guidelines: Medical N/A (trastuzumab-dttb) Maximum Dosage and Frequency Onureg (azacitidine) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Onureg Onzetra Xsail Nasal J3490 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: (sumatriptan) Powder Supply Limits Prior authorization through the Therapeutic Equivalent PBM is only required for quantity Guidelines: Drug Coverage requests exceeding the Triptan Criteria - New and Therapeutic Ceiling Limit. Equivalent Medications **NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Opana ER Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (oxymorphone Necessity Guidelines: Opana ER extended release) (Generic Only) Opdivo (nivolumab) Injection J3490 N/A Medical Management Guidelines: Medical N/A Maximum Dosage and Frequency Opsumit Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (macitentan) Necessity Guidelines: PAH Agents Optivar (brand only) Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (azelastine) Drops Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Oracea Capsules J8499 PBM Therapeutic Equivalent Pharmacy N/A (doxycycline) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Oramorph Oral Solution J8499 N/A N/A Pharmacy N/A (morphine) Orbivan (butalbital, Oral J8499 N/A N/A Pharmacy N/A acetaminophen, and caffeine) Orencia (abatacept) Intravenous J0129 Oxford’s Medical Management Guidelines: Medical Hospital Outpatient Facility: Medical Maximum Dosage and Frequency • Administration of Orencia in a Management Prior Authorization Guidelines: hospital outpatient facility ® o Orencia (Abatacept) Injection (including any ambulatory for Intravenous Infusion infusion suite associated with o Provider Administered Drugs the hospital) requires Prior – Site of Care authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. • Participating hospitals are required to purchase Orencia (abatacept) injection for intravenous infusion from the Optum Specialty Pharmacy. Refer to Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Orencia (abatacept) Sq Injection J3590 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Orencia Orenitram Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (treprostinil) Necessity Guidelines: PAH Agents Orfadin capsules Capsule/ J8499 PBM Prior Authorization/Notification Pharmacy N/A and suspension Suspension Guideline: Orfadin

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing (nitisinone) (Brand Only) Orgovyx (relugolix) Tablet J8999 N/A N/A Pharmacy N/A Oriahnn (elagolix/ Capsules J8499 PBM Prior Authorization/Medical Pharmacy N/A estradiol/ Necessity Guidelines: Oriahnn norethindrone Therapeutic Equivalent acetate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Orilissa (elagolix) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Orilissa Orkambi™ Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (lumacaftor/ Necessity Guidelines: Orkambi ivacaftor) Orkambi 100-125 Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A mg tablet only Guidelines: Drug Coverage (lumacaftor/ Criteria - New and Therapeutic ivacaftor) Equivalent Medications Orladeyo Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (berotralstat) Necessity Guidelines: Orladeyo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ortho Cept (ethinyl Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members estradiol and with coverage for contraceptives desogestrel) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

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

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Ortho-Evra (Brand Patch J7304 PBM Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members Only) (Ethinyl Therapeutic Equivalent with coverage for contraceptives estradiol and Guidelines: Drug Coverage through their prescription drug norelgestromin Criteria - New and Therapeutic plan. If the Member does not have transdermal) Equivalent Medications contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Ortho Tri-Cyclen/Lo Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (ethinyl estradiol Therapeutic Equivalent with coverage for contraceptives and norgestimate) Guidelines: Drug Coverage through their prescription drug Criteria - New and Therapeutic plan. If the Member does not have Equivalent Medications contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Ortikos Capsules J8499 PBM Therapeutic Equivalent Pharmacy N/A (budesonide) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Osmolex ER Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (amantadine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Osphena Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (ospemifene) Guidelines: Osphena Otezla (apremilast) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Otezla

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Otic Care Ophthalmic J3490 N/A N/A Pharmacy N/A (neomycin/ Drops polymyxin-B HC) Otovel Otic Solution J3490 PBM Therapeutic Equivalent Pharmacy N/A (ciprofloxacin and Guidelines: Drug Coverage fluocinolone Criteria - New and Therapeutic acetonide) Equivalent Medications Otrexup Injection J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A (methotrexate Authorization Guidelines: New and injection) Therapeutic Equivalent Medications Ovace Plus 9.8% Lotion J3490 PBM Therapeutic Equivalent Pharmacy N/A lotion (sodium Guidelines: Drug Coverage sulfacetamide) Criteria - New and Therapeutic Equivalent Medications Ovace Plus foam Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (sodium Foam Guidelines: Drug Coverage sulfacetamide) Criteria - New and Therapeutic Equivalent Medications Ovidrel (chorionic Injection J0725* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS gonadotropin) J3490 authorization Infertility Diagnosis and Treatment Medical** code J0725 (chorionic through Optum gonadotropin) requires Prior may be authorization through Optum in all required* sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Ovrette (Norgestrel) Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members with coverage for contraceptives

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Oxandrin Tablet J8499 N/A N/A Pharmacy N/A (oxandrolone) Oxaydo (oxycodone Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hcl) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Oxbryta (voxelotor) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Oxbryta Oxervate Ophthalmic J3490 PBM Prior Authorization/Medical Pharmacy N/A (cenegermin) solution Necessity Guidelines: Oxervate Oxistat (oxiconazole Cream J3490 PBM Prior Authorization/Medical Pharmacy N/A nitrate) Necessity Guidelines: Oxistat Oxistat (oxiconazole Lotion J3490 PBM Therapeutic Equivalent Pharmacy N/A nitrate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Oxlumo (lumasiran) Injection J0224 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: Medical Oxlumo™ (Lumasiran) Administration of Oxlumo in a Management Provider Administered Drugs – hospital outpatient facility Site of Care (including any ambulatory infusion suite associated with the hospital) requires prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Oxtellar XR Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (oxcarbazepine Authorization Guidelines: New and extended release) Therapeutic Equivalent Medications Oxycodone ER Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A 12HR Tablet Necessity Guidelines: Oxycodone ER Oxycontin Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (oxycodone Necessity Guidelines: Oxycontin extended release) (Brand and Generic) (includes authorized generic) Oxymorphone Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A extended release Necessity Guidelines: Oxymorphone Oxytrol (oxybutynin) Tablet J8499 N/A N/A N/A Note: Prescription drugs for which there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Ozempic Injection J3490 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (semaglutide) Guidelines: Notification Guidelines: GLP-1 o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Ozobax (Baclofen) Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Non-Solid Oral and Suppository Dosage Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ozurdex Intravitreal J7312 N/A N/A Medical N/A (dexamethasone) Implant Pacnex HP and Topical J3490 N/A N/A Pharmacy N/A Pacnex LP (benzoyl peroxide) Palforzia [Peanut Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (Arachis hypogaea) immunother Necessity Guideline: Palforzia Allergen Powder- apy dnfp] Palynziq Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (pegvaliase-pqpz) Necessity Guidelines: Palynziq Pancreaze Capsule J8499 PBM Step Therapy Guidelines: Pharmacy N/A (pancrelipase) Pancreaze Panlor Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (Hydrocodone- Guidelines: Drug Coverage Acetaminophen) Criteria - New and Therapeutic Equivalent Medications Pantoprazole Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (camber products) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pantoprazole Tablet J8499 N/A N/A Pharmacy N/A (generic) Parlodel Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (bromocriptine Guidelines: Drug Coverage mesylate) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Parsabiv Injection J0606 Oxford’s Prior Authorization Guidelines: Medical N/A (etelcalcetide) Medical Parsabiv (Etelcalcetide) Management Pataday Ophthalmic J3490 N/A N/A Pharmacy Note: Prescription drugs for which (olopatadine) Solution there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Patanol Ophthalmic J3490 N/A N/A Pharmacy Note: Prescription drugs for which (olopatadine HCL) Solution there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Paxil CR paroxetine Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Pazeo (olopatadine Ophthalmic J3490 N/A N/A Pharmacy Note: Prescription drugs for which hydrochloride) Solution there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pcp 100 Kit Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (magesium citrate, Guidelines: Drug Coverage bisacodyl, Criteria - New and Therapeutic petrolatum, Equivalent Medications polyethylene glycol 3350, metoclopramide) Pediaderm AF Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A (nystatin) and Guidelines: Drug Coverage Pediaderm TA Criteria - New and Therapeutic (triamcinolone) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Pediprox-4 Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (benzalkonium) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pegasys Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A (peginterferon Alfa- Guidelines: Pegasys 2a) (peginterferon alfa-2a) Peg-Intron Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A (peginterferon Alfa- Guidelines: PEG-Intron 2b) (peginterferon alfa-2b) Pemazyre Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (pemigatinib) Guidelines: Pemazyre

Penicillin G IV Infusion J2540 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization Note: Prior potassium Medical Lyme Disease authorization is only required only Management* when used in the treatment of Lyme disease. Exception: Prior authorization is not required for CT Members. Penicillin G IV Infusion J2510 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization Note: Prior procaine, Aqueous Medical Lyme Disease authorization is only required only Management* when used in the treatment of Lyme disease. Exception: Prior authorization is not required for CT Members. Penlac Nail Lacquer Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (ciclopirox) (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Pennsaid 1.5% Drops J8499 N/A N/A Pharmacy Note: Prescription drugs for which Drops (diclofenac there is a therapeutic over-the- sodium) counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Pennsaid 2% Topical J3490 N/A N/A Pharmacy Note: Prescription drugs for which (diclofenac sodium) Solution there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Pentasa Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (mesalamine) Authorization Guidelines: New and Therapeutic Equivalent Medications Percocet Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (acetaminophen Authorization Guidelines: New and and oxycodone) Therapeutic Equivalent (brand only) Medications Pergonal Injection S0122* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS (menotropins) J3490 authorization Infertility Diagnosis and Treatment Medical** code S0122 (menotropins) through Optum requires Prior authorization may be through Optum in all sites of required* service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Pertzye Capsule J8499 PBM Step Therapy Guidelines: Pertzye Pharmacy N/A (pancrelipase) Pexeva (paroxetine Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A mesylate) Authorization Guidelines: New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Phexxi Vaginal Gel Contracep- J3490 PBM Prior Authorization/Medical Pharmacy N/A (lactic acid, citric tive Gel Necessity Guidelines: Phexxi Gel acid and potassium Therapeutic Equivalent bitartrate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Phoslo (calcium Capsule J8499 N/A N/A Pharmacy* *Coverage is limited to Members acetate) with coverage for vitamins/supplements through their prescription drug plan. If the Member does not have vitamin/supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Pifeltro (doravirine) Tablet J8499 N/A N/A Pharmacy N/A Piqray (alpelisib) Tablets J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Piqray Planzapine, long Injection J2358 N/A N/A Medical N/A acting Plaquenil (Brand Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Only) Guidelines: Drug Coverage (hydroxychloro- Criteria - New and Therapeutic quine) Equivalent Medications Plavix (clopidogrel) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Plegridy Pen & Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A Prefilled Syringe Guidelines: Plegridy (peginterferon beta- 1a)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Plenvu Pouches for J8499 N/A N/A Pharmacy N/A (polyethylene glycol oral solution 3350, sodium ascorbate, sodium sulfate, ascorbic acid, sodium chloride and potassium chloride) Plexion 9.8-4.8% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream, liquid, lotion Guidelines: Drug Coverage (sulfacetamide/ Criteria - New and Therapeutic sulfur) Equivalent Medications Plexion Cloth 9.8%- Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A 4.8% pads Guidelines: Drug Coverage (sulfacetamide/ Criteria - New and Therapeutic sulfur) Equivalent Medications Poly-Vi-Flor/Iron, Tablet, Oral J8499 N/A N/A Pharmacy* *Coverage is limited to Members Polyvitamin Solution with coverage for fluoride vitamins w/Fluoride, Tri-Vi- through their prescription drug Flor/Iron, Trivitamin plan. If the Member does not have w/Fluoride, and Vi- fluoride vitamin coverage through Daylin their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Pomalyst Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (pomalidomide) Guidelines: Pomalyst authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines.

Ponvory Pill J8499 PBM Therapeutic Equivalent Pharmacy N/A (ponesimod) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Potiga (Ezogabine) Tablet J8499 PBM N/A Pharmacy N/A Potaba Capsule, J8499 N/A N/A Pharmacy* *Coverage is limited to Members (aminobenzoate Tablet or with coverage for potassium) Powder vitamins/supplements through their prescription drug plan. If the Member does not have vitamin/supplement coverage through their prescription drug plan, then this is not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Praluent Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (alirocumab) Necessity Guidelines: Praluent (Alirocumab)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Pramosone E Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (hydrocortisone and Guidelines: Drug Coverage pramoxine) Criteria - New and Therapeutic Equivalent Medications Pregnyl (chorionic Injection J0725* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS gonadotropin) J3490 authorization Infertility Diagnosis and Treatment Medical** code J0725 (chorionic through Optum gonadotropin) requires Prior may be authorization through Optum in all required* sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Prenatal Vitamins: Tablet S0197 PBM* Therapeutic Equivalent Pharmacy** *Prior authorization is required Materna, Natalcare, Guidelines*: Drug Coverage through the PBM for Pegenna and Natalins Rx, Criteria - New and Therapeutic Prenara only. Equivalent Medications Neonatal/DHA, **Coverage is limited to Members Neonatal 19, with coverage for prenatal vitamins through their prescription drug Neonatal FE, plan. If the Member does not have Niferex-PN, prenatal vitamin coverage through Pregenna*, their prescription drug plan then Prenara*, these are not covered. Members Prenate 90, Prenatal should refer to their Certificate of Plus, Prenatal Rx, Coverage or Prescription Drug Prenatrix, Rider language for coverage Stuartnatal Plus guidelines. Prescription Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Emollients/ Guidelines: Drug Coverage Mosturizers Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prestalia Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (perindopril) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prevacid Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (lansoprazole) Necessity Guidelines: Non-Solid Solutab Oral and Suppository Dosage Lansoprazole generic Prevacid Solutab Solutab J8499 PBM Therapeutic Equivalent Pharmacy N/A (lansoprazole) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Prevacid Capsule J8499 N/A N/A N/A Note: Prescription drugs for which (lansoprazole) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Prevpac Capsule/ J8499 PBM Therapeutic Equivalent Pharmacy N/A ((lansoprazole 30- Tablet Guidelines: Drug Coverage mg) (amoxicillin Criteria - New and Therapeutic 500-mg) , Equivalent Medications (clarithromycin 500- mg) Prevymis Tablets J8499 PBM Prior Authorization/Notification Pharmacy N/A (letermovir) Guidelines: Prevymis Prezcobix Tablet J8499 N/A N/A Pharmacy N/A (darunavir/ cobicistat) Prilosec Capsule J8499 N/A N/A Pharmacy Note: Prescription drugs for which (omeprazole) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prilosec Suspension Suspension J8499 PBM Therapeutic Equivalent Pharmacy N/A (omeprazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Primlev (Oxycodone Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A and Guidelines: Drug Coverage Acetaminophen) Criteria - New and Therapeutic Equivalent Medications Pristiq Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (desvenlafaxine Guidelines: Drug Coverage succinate) Criteria - New and Therapeutic Equivalent Medications ProAir Digihaler Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A (albuterol sulfate) Powder/ Guidelines: Drug Coverage Digital Criteria - New and Therapeutic Inhaler Equivalent Medications Proair HFA Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A (albuterol sulfate) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Proair RespiClick Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A (albuterol sulfate) Powder Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications ProAir Respimat Inhaler J3490 N/A N/A Pharmacy N/A (albuterol)

Probuphine Subdermal G0516, Oxford’s Prior Authorization Guidelines: Medical N/A ® (buprenorphine) Implant G0517, Medical Buprenorphine (Probuphine & G0518, Management Sublocade®) J3490, J0570, and 11981 Procentra (dextro- Oral Solution J8499 N/A N/A Pharmacy N/A amphetamine)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prochieve Gel J3490 N/A Prior Authorization Guidelines: Pharmacy* *Benefit Note for Infertility Use (progesterone gel) Infertility Diagnosis and Treatment Coverage is limited to Members with coverage for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Procort Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (hydrocortisone Guidelines: Drug Coverage acetate and Criteria - New and Therapeutic pramoxine HCl) Equivalent Medications Proctocort Rectal J3490 PBM Therapeutic Equivalent Pharmacy N/A (hydrocortisone) Cream Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Procysbi Capsule, J8499 PBM Prior Authorization/Notification Pharmacy N/A (cysteamine Delayed Guidelines: Procysbi (cysteamine bitartrate) Release bitartrate) Pellet Step Therapy: Procysbi Prodrin Caplet J8499 PBM Therapeutic Equivalent Pharmacy N/A (acetaminophen/ Guidelines: Drug Coverage caffeine/ Criteria - New and Therapeutic isometheptene) Equivalent Medications Profasi (chorionic Injection J0725* and Prior Prior Authorization Guidelines: Pharmacy/ *Prior authorization Note: HCPCS gonadotropin) J3490 authorization Infertility Diagnosis and Treatment Medical** code J0725 (chorionic through Optum gonadotropin) requires Prior may be authorization through Optum in all required** sites of service when associated with an infertility diagnosis code. **Benefit Note: Coverage is limited to Members with coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing for fertility drugs through their prescription drug plan. If the Member does not have fertility drug coverage through their prescription drug plan, refer to their Certificate of Coverage for coverage guidelines. Progesterone Injection J3490 N/A N/A Medical N/A Prograf (tacrolimus) Capsule J7503, PBM Therapeutic Equivalent Pharmacy N/A (brand only) J7507, J8499 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Prograf granules for Granules for J8499 PBM Prior Authorization/Medical Pharmacy N/A suspension oral Necessity Guidelines: Non-Solid (tacrolimus) suspension Oral and Suppository Dosage

Prolastin-C [Alpha1- Intravenous J0256 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: Administration of Prolastin-C in a Proteinase Inhibitor Injection Medical Alpha1-Proteinase Inhibitors [Human)] Management Provider Administered Drugs – hospital outpatient facility Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care Prolate 10/300 mg Oral solution J8499 PBM Therapeutic Equivalent Pharmacy N/A (oxycodone/acetam Guidelines: Drug Coverage inophen) solution Criteria - New and Therapeutic Equivalent Medications Prolensa Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (Bromfenac Solution Guidelines: Drug Coverage Ophthalmic) Criteria - New and Therapeutic Equivalent Medications Prolia, Xgeva Injection J0897 Optum*/ Medical Management Guidelines: Medical *For oncology indications: (denosumab) Oxford** Maximum Dosage and Frequency Prior authorization is required Optum Guidelines*: Oncology through Optum for dates of Medication Clinical Coverage service Aug. 1, 2021 and after;

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prior Authorization Guidelines**: Prior authorization is required Denosumab (Prolia® & Xgeva®) through eviCore for dates of service prior to Aug. 1, 2021 **Prior authorization is required through Oxford for all requests for Non-oncology indications. Promacta Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (Eltrombopag) Guidelines: Promacta Prometrium (Brand Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Only) Guidelines: Drug Coverage (progesterone) Criteria - New and Therapeutic Equivalent Medications Propecia Varies J3490 N/A N/A Pharmacy* *Benefit Notes: Not covered for (finasteride) cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Proscar (finasteride) Tablet J8499 and N/A N/A Pharmacy N/A S0138 Protein C [human] Iv Infusion J2724 N/A N/A Medical N/A concentrate Protonix Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (Pantoprazole) Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Protonix Granules Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A for Suspension Guidelines: Drug Coverage (pantoprazole) Criteria - New and Therapeutic Equivalent Medications Protopic Topical J8499 PBM Step Therapy Guidelines: Protopic Pharmacy N/A (tacrolimus) Cream Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Proventil HFA Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A (albuterol sulfate) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Provigil (modafinil) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (brand) Guidelines: Provigil (modafanil) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Provigil (modafinil) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (generic) Guidelines: Provigil (modafanil) Prozac (fluoxetine) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and Therapeutic Equivalent Medications Prozac Weekly Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage (fluoxetine) Criteria - New and Therapeutic Equivalent Medications Prozena 4% patch Topical J3490 N/A N/A Pharmacy N/A (lidocaine) Patch Prudoxin (doxepin) Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A Cream Necessity Guidelines: Prudoxin Pulmicort Flexhaler Inhalation J3490 N/A N/A Pharmacy N/A (budesonide) Powder

Pulmicort Inhalation Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A Suspension Suspension Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Pulmozyme® Inhalation J7639 PBM Prior Authorization/Notification Pharmacy N/A (Dornase Alfa) Solution Guidelines: Pulmozyme (dornase alfa)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Puregon (follitropin IM Or SQ S0128 Oxford’s Prior Authorization Guidelines: See Notes* *CT Plans: Medical Benefit. beta) Injection Medical Infertility Diagnosis and Treatment *NJ Plans: Pharmacy Benefit Management Medical Benefit for Members without a Pharmacy Benefit. *NY Plans: Pharmacy Benefit. *All Plans: Infertility drugs may be excluded from coverage. Refer to Member's benefit package for specific coverage information. Purixan 20mg/ml Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (mercaptopurine) Suspension Necessity Guidelines: Non-Solid Oral and Suppository Dosage Pyridostigmine Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A 30mg Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Qbrelis (lisinopril) Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Non-Solid Oral and Suppository Dosage Qdolo (tramadol Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A hydrochloride) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Qinlock (ripretinib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Qinlock Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Qmiiz ODT Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (meloxicam) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Qnasl Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (beclomethasone Guidelines: Drug Coverage dipropionate) Criteria - New and Therapeutic Equivalent Medications Qtern (dapagliflozin/ Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ saxagliptin) Guidelines: Diabetes Medications Notification Guidelines: Diabetes SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Quartette (ethinyl Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A estradiol/ Guidelines: Drug Coverage levonorgestrel) Criteria - New and Therapeutic Equivalent Medications Qudexy XR Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (topiramate) (brand Authorization Guidelines: New and and authorized Therapeutic Equivalent generic) Medications Quelbree Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (Viloxazine Guidelines: Drug Coverage extended-release) Criteria - New and Therapeutic Equivalent Medications Quillichew ER Chewable J8499 PBM Therapeutic Equivalent Pharmacy N/A (methylphenidate Tablet Guidelines: Drug Coverage hcl) extended Criteria - New and Therapeutic release Equivalent Medications Quillivant XR Liquid J8499 PBM Therapeutic Equivalent Pharmacy N/A (methylphenidate Guidelines: Drug Coverage HCL) Criteria - New and Therapeutic Equivalent Medications Qutenza (capsaicin Patch J3490 N/A N/A Pharmacy N/A 8% patch)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing QVAR Redihaler Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A (beclomethasone Guidelines: Drug Coverage diproprionate HFA) Criteria - New and Therapeutic Equivalent Medications Rabeprazole Tablet J8499 N/A N/A Pharmacy N/A (generic) Radicava Intravenous J1301 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (edaravone) Injection Medical RadicavaTM (Edaravone) Administration of Radicava in a Management Provider Administered Drugs – hospital outpatient facility Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Provider Administered Drugs – Site of Care. Raloxifene (generic) Tablet J8499 PBM Prior Authorization/ Regulatory Pharmacy N/A Guidelines: Raloxifene Ranexa (Brand Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Only) (ranolazine Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Rapaflo (Brand Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A only) (silodosin) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Rapamune Tablet J7520, J8499 PBM Therapeutic Equivalent Pharmacy N/A (sirolimus) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Rasuvo Auto-Injector J3490 N/A N/A Pharmacy N/A (methotrexate injection) Ravicti (Glycerol Oral Liquid J8499 PBM Prior Authorization/Medical Pharmacy N/A. Phenylbutyrate Oral Necessity Guidelines: Ravicti Liquid)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Rayaldee Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (calcifediol) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Rayos (delayed- Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A release prednisone) Authorization Guidelines: New and Therapeutic Equivalent Medications Rebetol (ribavirin) Tablet J8499 N/A N/A Pharmacy N/A Rebif (interferon Injection, Sq J1826, PBM Prior Authorization/Notification Pharmacy N/A beta-1a) Injection Q3025 and Guidelines: Rebif Q3026 Step therapy: Rebif Reblozyl Injection J0896 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (luspatercept-aamt) Medical Reblozyl (Luspatercept-Aamt) Administration of Reblozyl in a Management Provider Administered Drugs - Site hospital outpatient facility of Care (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs - Site of Care. Reclast (zoledronic Iv Infusion J3489 N/A Medical Management Guidelines: Medical N/A acid) Maximum Dosage and Frequency Rectiv (nitroglycerin Ointment J3490 N/A N/A Pharmacy N/A ointment) Reditrex Prefilled J3490 PBM Therapeutic Equivalent Pharmacy N/A (methotrexate) Syringe Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Regranex Gel S0157 PBM* Prior Authorization/Notification Pharmacy* *Pharmacy Benefit: If dispensed (becaplermin gel) Guidelines: Regranex Medical** by a retail pharmacy or mail order (becaplermin) through PBM. Prior authorization through the PBM is required. **Medical Benefit: If provided in a hospital, MD's office, or in

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing conjunction with Home Health Care. Relafen Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (nabumetone) Authorization Guidelines: New and (Brand Only) Therapeutic Equivalent Medications Relafen DS Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (nabumetone) Authorization Guidelines: New and Therapeutic Equivalent Medications Relenza (zanamivir) Oral Inhaler J3490 N/A N/A Pharmacy N/A Relistor Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (methylnaltrexone Necessity Guidelines: Relistor bromide) Relistor Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (methylnaltrexone Necessity Guidelines: Relistor bromide) Relpax (eletriptan) Tablet J8499 PBM* Supply Limit Guidelines*: Triptans Pharmacy** *Prior authorization Notes: (brand only) Supply Limits Prior authorization through the Therapeutic Equivalent PBM is required for quantity Guidelines: Drug Coverage requests exceeding the Triptan Criteria - New and Therapeutic Ceiling Limit. Equivalent Medications NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Reltone (ursodiol) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Remicade Intravenous J1745 Oxford’s Medical Management Guidelines: Medical *Prior authorization Note: (infliximab) Medical Maximum Dosage and Frequency Prior authorization is required for Management* Prior Authorization Guidelines: the drug Remicade in all sites of ™ o Infliximab (Avsola , service. Additional Prior Remicade®, Inflectra®, authorization may be required for Renflexis®) the site of care of the injection. o Provider Administered Drugs – Site of Care Hospital Outpatient Facility: Administration of Remicade (infliximab) in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs – Site of Care Participating hospitals are required to purchase Remicade (infliximab) from the Optum Specialty Pharmacy. Refer to Prior Authorization Guidelines: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting Renflexis Injection Q5104 Oxford’s Medical Management Guidelines: Medical *Prior authorization Note: Prior (infliximab) Medical Maximum Dosage and Frequency authorization is required in all sites Management* Prior Authorization Guidelines: of service. ™ o Infliximab (Avsola , Hospital Outpatient Facility: ® ® Remicade , Inflectra , Administration of Renflexis in a ® Renflexis ) hospital outpatient facility o Provider Administered Drugs (including any ambulatory – Site of Care infusion suite associated with

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs – Site of Care. Participating hospitals are required to purchase Renflexis (infliximab) from the Optum Specialty Pharmacy. Refer to Prior Authorization Guidelines: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Renova (tretinoin) Varies S0117 N/A N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Renvela tablets Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (Brand only) Guidelines: Drug Coverage (sevelamer Criteria - New and Therapeutic carbonate) Equivalent Medications Repatha Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (evolocumab) Necessity Guidelines: Repatha Repository Injection Self- J3490 and PBM Prior Authorization/Medical Pharmacy N/A Corticotropin Administered J0800 Necessity Guidelines: Acthar Injection (Acthar Injection by J3490 and Oxford’s Prior Authorization Guidelines: Medical N/A Gel) a Medical J0800 Medical Repository Corticotropin Injection Professional Management (Acthar Gel) Requip XL Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (ropinirole extended Guidelines: Drug Coverage release)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Rescula Ophthalmic J3490 N/A N/A Pharmacy N/A (unoprostone) Solution Restasis Ophthalmic J3490 PBM Prior Authorization/Medical Pharmacy N/A (cyclosporine Solution Necessity Guidelines: Restasis ophthalmic (cyclosporine ophthalmic emulsion) single-use emulsion) vials Restasis Ophthalmic J3490 PBM Prior Authorization/Medical Pharmacy N/A (cyclosporine Solution Necessity Guidelines: Restasis ophthalmic (cyclosporine ophthalmic emulsion) (multi- emulsion) use) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Retacrit (epoetin Injection Q5105, N/A Prior Authorization Guidelines: Pharmacy*/ *Prior authorization is not required alfa-epbf) Q5106 Erythropoiesis-Stimulating Agents Medical** if dispensed by a retail pharmacy through the PBM. **Prior authorization is not required in any site of service. Retevmo Capsules J8999 PBM Prior Authorization/Notification Pharmacy N/A (selpercatinib) Guidelines: Retevmo Retin-A (tretinoin) Topical S0117, PBM Prior Authorization/Notification Pharmacy N/A (brand only) Cream J3490 Guidelines: Retin-A and Retin-A Micro (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Retin-A Gel Topical Gel S0117, PBM Prior Authorization/Notification Pharmacy N/A (tretinoin) (brand) J3490 Guidelines: Retin-A and Retin-A Micro (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Retin-A Micro Topical S0117 PBM Prior Authorization/Notification Pharmacy N/A (tretinoin Guidelines: Retin-A and Retin-A microspheres) Micro (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Retin-A Micro Pump Topical S0117 PBM Prior Authorization/Notification Pharmacy N/A (tretinoin) (brand Guidelines: Retin-A and Retin-A and generic) Micro (tretinoin) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Revatio (sildenafil Tablet J8499 N/A N/A Pharmacy N/A citrate) Revatio (sildenafil Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A citrate) 10mg/ml Suspension Necessity Guidelines: PAH Agents Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Revatio suspension Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (sildenafil) (Brand Suspension Guidelines: Drug Coverage Only) Criteria - New and Therapeutic Equivalent Medications Revcovi Injection J3490 Oxford Medical Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (elapegademase- Management* Medical Therapies for Enzyme Administration of Revcovi lvlr) Deficiencies (elapegademase-lvlr) in a hospital Provider Administered Drugs – outpatient facility (including any Site of Care ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Authorization Guidelines: Provider Administered Drugs – Site of Care. Revlimid Oral J8999 PBM Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (lenalidomide) Guidelines: Revlimid authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Rexaphenac 1% Cream J3490 N/A N/A Pharmacy Note: Prescription drugs for which cream (diclofenac) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable Rexulti Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (brexpiprazole) Necessity Guidelines: Rexulti Reyataz (atazanavir) Capsules J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Reyvow (lasmiditan) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Reyvow Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Rhinocort Aqua Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (budesonide) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Rho(D) (immune Iv Infusion, J2788, N/A Prior Authorization Guidelines: Medical N/A globulin) BayRHo-D, Im Injection J2790, Immune Globulin (IVIG) and SCIG Gamulin Rh, J2791, HypRho-D Mini- J2792, and Dose, MICRhoGAM, 90384-90386 Mini-Gamulin Rh, RhoGAM, Rhophylac, WinRho SDF Rhofade Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A (oxymetazoline Cream Guidelines: Rhofade hydrochloride) Rhopressa Ophthalmic J3490 N/A N/A Pharmacy N/A (netarsudil) Solution Riabni (rituximab- Injection J3590, eviCore**/ eviCore Guidelines**: Injectable Medical *Prior authorization through arrx) J9999, Oxford* Chemotherapy Drugs: Application Oxford’s Medical Management is Q5123 of NCCN Clinical Practice required for non-oncology Guidelines indications. Prior Authorization Guidelines*: **Prior authorization through Rituximab (Riabni™, Rituxan®, eviCore is required for oncology Ruxience® & Truxima®) indications. Riax (benzoyl Topical J3490 N/A N/A Pharmacy Note: Prescription drugs for which peroxide) Foam there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Ribapak (ribavirin) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ribasphere Capsule J8499 N/A N/A Pharmacy N/A (ribavirin)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Rinvoq Extended- J8499 PBM Prior Authorization/Medical Pharmacy N/A (Upadacitinib) Release Necessity Guidelines: Rinvoq Tablets Riomet ((metformin Oral Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Risperdal Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (risperidone) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Ritalin Tablet J8499 N/A N/A Pharmacy N/A (methylphenidate) Ritalin LA Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (methylphenidate Guidelines: Drug Coverage hydrochloride Criteria - New and Therapeutic [extended release]) Equivalent Medications (brand and generic) Ritalin SR Tablet J8499 N/A N/A Pharmacy N/A (methylphenidate [controlled-release]) Rituxan (rituximab) Infusion J9312 Optum*/ Medical Management Guidelines: Medical *For oncology indications: Oxford** Maximum Dosage and Frequency Prior authorization is required Optum Guidelines**: Oncology through Optum for dates of Medication Clinical Coverage service Aug. 1, 2021 and after; Prior Authorization Guidelines: Prior authorization is required Rituximab (Riabni™, Rituxan®, through eviCore for dates of Ruxience® & Truxima®)* service prior to Aug. 1, 2021 **Prior authorization is required through Oxford for all requests for Non-oncology indications. Rituxan Hycela Injection J9311 Optum**/ Medical Management Guidelines: Medical *Rituxan Hycela is not indicated (rituximab and Oxford* Maximum Dosage and Frequency for the treatment of non-oncology hyaluronidase Optum Guidelines**: Oncology indications. Prior authorization is human)* Medication Clinical Coverage required through Oxford for all

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing requests for Non-oncology indications. **For oncology indications and for Rituxan Hycela (rituximab/hyaluronidase human), refer to: Optum Guidelines: Oncology Medication Clinical Coverage Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Rizatriptan Tablet J8499 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: Supply Limits Prior authorization through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Rocaltrol (calcitriol) Capsule, S0169 N/A N/A Pharmacy N/A Liquid Rocklatan Ophthalmic J3490 N/A N/A Pharmacy N/A (netarsudil and Solution latanoprost) Rogaine (minoxidil) Varies J3490 and N/A N/A Pharmacy* *Benefit Notes: Not covered for S0139 cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Member's pharmacy plan if applicable. Rosadan kit Cream/Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (metronidazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Rosula (sodium Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A sulfacetamide Wash Guidelines: Drug Coverage 10%/sulfur 4%) Criteria - New and Therapeutic Equivalent Medications Rosuvastatin Tablet J8499 N/A N/A Pharmacy N/A (generic Crestor) Roszet (rosuvastatin Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A and ezetimibe) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Roxicodone Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (oxycodone Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic (Brand Only) Equivalent Medications Roxybond Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (oxycodone Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Equivalent Medications Rozerem Tablet J8499 PBM Step Therapy Guidelines: Pharmacy N/A (ramelteon) (Brand Rozerem (Ramelteon) and Generic) Rozlytrek Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (entrectinib) Guidelines: Rozlytrek Rubraca (rucaparib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Rubraca Step Therapy Guidelines: Rubraca Ruconest (C1 Injection J0596 and PBM*/ Prior Authorization Guidelines**: Pharmacy*/ *Self-administered: Ruconest esterase inhibitor J3490 Oxford’s Hereditary Angioedema (HAE), Medical** requires Prior authorization [Recombinant]) Medical Treatment and Prophylaxis through the PBM and is covered Management**

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prior Authorization/Medical under the pharmacy benefit when Necessity Guidelines*: Ruconest obtained at a pharmacy. **Provider administered: Ruconest requires Prior authorization through Oxford’s Medical Management and is covered under the medical benefit. Rukobia Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (fostemsavir) Guidelines: Rukobia Ruxience (rituximab- Intravenous Q5119 Optum*/ Medical Management Guidelines: Medical *For oncology indications: pvvr) Oxford** Maximum Dosage and Frequency Prior authorization is required Optum Guidelines*: Oncology through Optum for dates of Medication Clinical Coverage service Aug. 1, 2021 and after; Prior Authorization Guidelines**: Prior authorization is required Rituximab (Riabni™, Rituxan®, through eviCore for dates of Ruxience® & Truxima®)* service prior to Aug. 1, 2021 **Prior authorization is required through Oxford for all requests for Non-oncology indications. Ruzurgi Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (amifampridine) Guidelines: Ruzurgi Rybelsus Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (Semaglutide) Guidelines: Notification Guidelines: GLP-1 o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Rybix ODT Tablet J8499 N/A N/A Pharmacy N/A (tramadol hydrochloride) Ryclora Oral Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A` (dexchlorphenirami Guidelines: Drug Coverage ne maleate) Criteria - New and Therapeutic Equivalent Medications Rydapt Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (midostaurin) Guidelines: Rydapt Rytary (carbidopa Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A and levodopa) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ryvent Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (carbinoxamine Guidelines: Drug Coverage maleate) Criteria - New and Therapeutic Equivalent Medications Ryzolt (tramadol Tablet J8499 N/A N/A Pharmacy N/A hydrochloride Extended release) Sabril Powder Pack Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (vigabatrin) Necessity Guidelines: Sabril Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Safyral Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (drospirenone/ Guidelines: Drug Coverage ethinyl estradiol/ Criteria - New and Therapeutic levomefolate) Equivalent Medications Saizen (somatropin) Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Saizen (Somatropin) Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Samsca (tolvaptan) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Samsca Sancuso Patch J3490 PBM Therapeutic Equivalent Pharmacy N/A (granisetron Guidelines: Drug Coverage transdermal system) Criteria - New and Therapeutic Equivalent Medications Sanctura (trospium) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand and generic) Guidelines: Drug Coverage and Sanctura XR Criteria - New and Therapeutic (trospium chloride) Equivalent Medications (brand and generic) Sandimmune Capsule J7502, PBM Therapeutic Equivalent Pharmacy N/A (cyclosporine) J7515, J8499 Guidelines: Drug Coverage (brand only) Criteria - New and Therapeutic Equivalent Medications Sandostatin SQ* Or IV J2354 PBM Prior Authorization/Notification Pharmacy *Prior authorization through the (octreotide acetate) Injection Guidelines: Sandostatin PBM is required for subcutaneous formulation. Sandostatin (Brand SQ* Or IV J2354 PBM Prior Authorization/Notification Pharmacy *Prior authorization through the only) (octreotide Injection Guidelines: Sandostatin PBM is required for subcutaneous acetate) Therapeutic Equivalent formulation. Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sandostatin LAR Im Injection J2353 Oxford’s Prior Authorization Guidelines: Medical Prior authorization is required Depot (octreotide Medical Sandostatin LAR DEPOT through Oxford’s Medical acetate) Management (octreotide acetate) Management for all other indications. Saphris (asenapine) Oral J8499 N/A N/A Pharmacy N/A Sarafem Tablets Tablets J8499 PBM Therapeutic Equivalent Pharmacy N/A (fluoxetine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Savaysa (edoxaban) Tablet J8499 N/A N/A Pharmacy N/A

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Savella Tablet J8499 N/A N/A Pharmacy N/A (milnacipran) Scenesse Subcutane- J7352 Oxford’s Prior Authorization Guidelines: Medical N/A (afamelanotide) ous implant Medical Scenesse® (Afamelanotide) Management Seasonique Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (levonorgestrel, Guidelines: Drug Coverage ethinyl estradiol) Criteria - New and Therapeutic (Brand Only) Equivalent Medications Secuado Transdermal J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A (asenapine) Patch Authorization Guidelines: New and Therapeutic Equivalent Medications Seebri Neohaler Inhalation J3490 N/A N/A Pharmacy N/A (glycopyrrolate) Powder Segluromet Tablets J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (ertugliflozin/ Guidelines: Diabetes Medications Notification Guidelines: Diabetes metformin hcl) SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Selrx (selenium Shampoo J3490 N/A N/A N/A Note: Prescription drugs for which sulfide) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Selzentry Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (Maraviroc) Guidelines: Selzentry Semglee (insulin Injection J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A glargine) Authorization Guidelines: New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Sensipar Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (cinacalcet) Necessity Guidelines: Sensipar Sensipar Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (cinacalcet) (Brand Guidelines: Drug Coverage Only) Criteria - New and Therapeutic Equivalent Medications Sernivo spray Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (betamethasone Spray Guidelines: Drug Coverage dipropionate) Criteria - New and Therapeutic Equivalent Medications Seroquel Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (quetiapine Guidelines: Drug Coverage fumarate) (brand Criteria - New and Therapeutic only) Equivalent Medications Seroquel XR (Brand Tablet J8499 PBM Therapeutic Equivalent Pharmacy *Step Therapy coverage criteria is Only) (quetiapine) Guidelines: Drug Coverage for groups on the Essential PDL Criteria - New and Therapeutic only. More information about if this Equivalent Medications program applies can be found on myuhc.com or by calling customer service. Serostim Injection, Sq J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Injection Necessity Guidelines: Serostim (Somatropin) Seysara Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (sarecycline) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Signifor (pasireotide Sq Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A diaspartate) Guidelines: Signifor Siklos (hydroxyurea) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Sildenafil citrate Tablet J8499 N/A N/A Pharmacy N/A (generic Revatio) Silenor (doxepin Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Siliq (brodalumab) Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Siliq Simbrinza 1-0.2% Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (Brimonidine and Suspension Guidelines: Drug Coverage Brinzolamide) Criteria - New and Therapeutic Equivalent Medications Simponi Sq Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (golimumab) Necessity Guidelines: Simponi Simponi Aria Infusion J1602 Oxford’s Medical Management Guidelines: Medical *Hospital Outpatient Facility: (golimumab) Medical Maximum Dosage and Frequency • Administration of Simponi Aria Management* Prior Authorization Guidelines: (golimumab) in a hospital ® o Simponi Aria (Golimumab) outpatient facility (including Injection for Intravenous any ambulatory infusion suite Infusion associated with the hospital) o Provider Administered Drugs requires Prior authorization – Site of Care with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care. • Participating hospitals are required to purchase Simponi Aria (golimumab) from the Optum Specialty Pharmacy. Refer to Prior Authorization Guidelines: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Simvastatin (generic Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Zocor) 5mg, 10mg, Guidelines: Cardiovascular 20mg, 40mg Disease Prevention Zero Cost Share Simvastatin Oral Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A Suspension (Flolipid Suspension Guidelines: Drug Coverage Authorized Generic) Criteria - New and Therapeutic Equivalent Medications Singulair Tablet, J8499 PBM Therapeutic Equivalent Pharmacy N/A (montelukast Granule Guidelines: Drug Coverage sodium) (Brand Criteria - New and Therapeutic only) Equivalent Medications Singulair Chewable Chewable J8499 PBM Therapeutic Equivalent Pharmacy N/A Tablet (montelukast Tablet Guidelines: Drug Coverage sodium) (brand Criteria - New and Therapeutic only) Equivalent Medications Sirturo (bedaquiline) Tablet J8499 N/A N/A Pharmacy N/A Sitavig (acyclovir) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Skelaxin (Brand Oral J8999 PBM Therapeutic Equivalent Pharmacy N/A only) (metaxalone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Skyla Intrauterine Q0090 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (Levonorgestrel- Device with coverage for contraceptives Releasing through their prescription drug Intrauterine plan. If the Member does not have Contraceptive contraceptive coverage through System) 13.5mg their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Skyrizi Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (risankizumab-rzaa) Necessity Guidelines: Skyrizi Slynd Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (drospirenone) Necessity Guidelines: Slynd Sodium Intra- J3490, Oxford’s Prior Authorization Guidelines: Medical *Prior authorization with review by Hyaluronate: Articular J7318**, Medical Sodium Hyaluronate a Medical Director or their Durolane Injection J7320, Management* Designee is required in all sites of Euflexxa J7321, service for J7320, J7321, J7322, Gel-One J7322, J7324, J7325, J7326, J7327, J7329, J7331, J7332, and J3490. Gel-Syn J7323**, **Prior authorization is not Genvisc 850 J7324, J7325, required in office for Oxford's Hyalgan J7326, preferred products of Durolane, Orthovisc J7327, Euflexxa, or Gelsyn-3 (J7318, Suparz J7328**, J7323 and J7328 ). Synojoynt J7329, Synvisc J7331 Synvisc-One J7332 Triluron TriVisc Visco-3 Sodium Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Sulfacetamide/ Lotion Guidelines: Drug Coverage Sulfur 9%-4.5% Kit Criteria - New and Therapeutic (generic Sumadan Equivalent Medications Kit) Solage (mequinol) Varies J3490 N/A N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Solaraze Topical Gel J3490 PBM Prior Authorization/Notification Pharmacy N/A (diclofenac) Guidelines: Solaraze

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Soliqua (insulin Injection J3490 N/A N/A Pharmacy N/A glargine/ lixisenatide) Soliris (eculizumab) Injection J1300 Oxford’s Medical Management Guidelines: Medical *Prior authorization Note: Prior Medical Maximum Dosage and Frequency authorization is required for the Management* Prior Authorization Guidelines: drug Soliris in all sites of service. o Complement Inhibitors Additional Prior authorization may (Soliris® & Ultomiris®) be required for the site of care of o Provider Administered Drugs the injection. – Site of Care When administered in; • Hospital Outpatient Facility: Administration of Soliris in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires additional Prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care. • Home: Administration of Soliris in the home requires additional Prior authorization for the home care services. Refer to Prior Authorization Guidelines: Home Health Care. • Provider’s Office or Freestanding Ambulatory Infusion Suite (not associated with a hospital): Administration of Soliris in a provider’s office or

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing freestanding ambulatory infusion suite not associated with a hospital does not require additional Prior authorization. Solodyn Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (minocycline HCL) Necessity Guidelines: Solodyn Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Solosec Oral J8499 PBM Step Therapy Guidelines: Solosec Pharmacy N/A (secnidazole) Granules Soltamox (tamoxifen Oral Solution J8999 PBM Therapeutic Equivalent Pharmacy N/A citrate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Soma 250mg Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (carisoprodol)/ Guidelines: Drug Coverage carisoprodol 250mg Criteria - New and Therapeutic (generic) Equivalent Medications Somac, Pantoloc, Tablet J8499 N/A N/A Pharmacy N/A Protium, Pantecta, and Pantoheal (Pantoprazole) Somatuline Depot Im Injection J1930 N/A N/A Medical N/A (lanreotide) Somavert Injection, Sq J3590 PBM Prior Authorization/Medical Pharmacy N/A (pegvisomant) Injection Necessity Guidelines: Somavert Sonata (zaleplon) Tablet J8499 N/A N/A Pharmacy N/A Soolantra Cream J3490 N/A N/A Pharmacy N/A (ivermectin) Sorilux Topical J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A (calcipotriene) Authorization Guidelines: New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Sotylize (sotalol Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A hydrochloride) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Sovaldi (sofosbuvir) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Sovaldi

Spinraza Intrathecal J2326 Oxford’s Prior Authorization Guidelines: Medical N/A (Nusinersen) Injection Medical Spinraza (Nusinersen) Management Spiriva Respimat Inhaler J3490 N/A N/A Pharmacy N/A (tiotropium) Sporanox Capsule J1835 N/A N/A Pharmacy N/A (itraconazole) Spravato Nasal Spray S0013 Oxford’s Prior Authorization Guidelines:* Medical*/ *Spravato must be administered in (esketamine) Medical Spravato™ (Esketamine) Pharmacy** the presence of a certified Management* / Prior Authorization/Medical healthcare provider and is covered PBM** Necessity Guidelines:** Spravato under the medical benefit. **If a retail pharmacy meets the REMS requirement and dispenses the drug directly to the administering provider, Spravato would be covered under the pharmacy benefit. Spritam Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (levetiracetam) Authorization Guidelines: New and Therapeutic Equivalent Medications Prior Authorization/Medical Necessity Guidelines: Spritam Sprix Nasal Spray Nasal Spray J3490 PBM Step Therapy Guidelines: Sprix Pharmacy N/A (ketorolac tromethamine)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Sprycel (dasatinib) Oral J8999 PBM* Prior Authorization/Medical Pharmacy** *Prior authorization Note: Prior Necessity Guidelines: Sprycel authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. SSS 10-4 (sodium Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A polystyrene Guidelines: Drug Coverage sulfonate) Criteria - New and Therapeutic Equivalent Medications Staxyn (vardenafil) Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Steglatro Tablets J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (ertugliflozin) Guidelines: Diabetes Medications Notification Guidelines: Diabetes SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Steglujan Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (ertugliflozin/ Guidelines: Diabetes Medications Notification Guidelines: Diabetes sitagliptin) SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Stelara Sub- J3357 PBM*/ Medical Management Pharmacy*/ Prior authorization Notes: (ustekinumab) Cutaneous Oxford’s Guidelines**: Maximum Dosage Medical** *Prior authorization through PBM if Injection Medical and Frequency obtained at a pharmacy. Management Prior authorization Guidelines**: (Pharmacy Benefit) ** o Stelara (Ustekinumab) **Prior authorization is required o Provider Administered Drugs - for the drug Stelara in all sites of Site of Care service through Oxford’s Medical Prior Authorization/Medical Management. Additional Prior Necessity Guidelines*: Stelara authorization may be required for the site of care of the injection. Hospital Outpatient Facility: • Administration of Stelara in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs - Site of Care • Participating hospitals are required to purchase Stelara (ustekinumab) from the Optum Specialty Pharmacy. Refer to Prior Authorization Guidelines: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Stelara Intravenous J3358 Oxford’s Medical Management Guidelines: Medical Prior authorization Notes: (ustekinumab) Infusion Medical Maximum Dosage and Frequency • Hospital Outpatient Facility: Management Prior Authorization Guidelines: Participating hospitals are Stelara (Ustekinumab) required to purchase Stelara (ustekinumab) from the Optum Specialty Pharmacy. Refer to Prior Authorization Guidelines: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. • Prior authorization is required for the drug Stelara in all sites of service through Oxford’s Medical Management. Additional Prior authorization may be required for the site of care of the injection. Stendra (avanafil) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Stendra Stiolto Respimat Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A (olodaterol/ Guidelines: Drug Coverage tiotropium) Criteria - New and Therapeutic Equivalent Medications Stivarga Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (regorafenib) Guidelines: Stivarga Strattera (Brand Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A only) (atomoxetine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Strensiq (asfotase Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A alfa) Necessity Guidelines: Strensiq Striant Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (testosterone) Necessity Guidelines: Striant Stribild® Tablet J8499 N/A N/A Pharmacy N/A (elvitegravir/

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing cobicistat/ emtricitabine/ tenofovir disoproxil fumarate) Striverdi Respimat Inhalation J3490 N/A N/A Pharmacy N/A (olodaterol) Spray Sublingual Sublingual J8499 PBM Prior Authorization/Medical Pharmacy N/A Immunotherapy Tablet Necessity Guidelines: Sublingual (SLIT): Immuunotherapy (SLIT) • Grastek (Timothy Grass Pollen Allergen Extract), • Odactra (Dermatophagoi des farinae/ Dermatophagoi des pteronyssinus allergen extract), • Oralair (Sweet Vernal, Orchard, Perennial Rye, Timothy and Kentucky Blue Grass, Mixed Pollens Allergen Extract), • Ragwitek (Short Ragweed Pollen Allergen Extract) Sublocade Injection Q9991, Oxford’s Prior Authorization Guidelines: Medical N/A (buprenorphine Q9992 Medical Buprenorphine (Probuphine® and extended-release) Management Sublocade®)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Suboxone Sublingual J8499 PBM Prior Authorization/Medical Pharmacy N/A (buprenorphine/ Film Necessity Guidelines: naloxone)(Brand Buprenorphine/Naloxone Only) Products Subsys (fentanyl Oral Spray J8499 PBM* Prior Authorization/Medical Pharmacy* New Jersey Small members should sublingual spray) Necessity Guidelines: Subsys refer to their Certificate of Therapeutic Equivalent Coverage for Prior authorization Guidelines: Drug Coverage guidelines and quantity limit Criteria - New and Therapeutic guidelines. Equivalent Medications Succimer (DMSA), Oral Agent J8499 N/A* N/A Pharmacy *Oral chelation agents do not (dimercaptosuccinic require Prior authorization. acid) Sucraid Oral solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (sacrosidase) Necessity Guidelines: Sucraid Sumadan (sodium Topical Kit J3490 PBM Therapeutic Equivalent Pharmacy N/A sulfacetamide and Guidelines: Drug Coverage sulfur) Criteria - New and Therapeutic Equivalent Medications Sumadan Cleanser Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (sodium Wash Guidelines: Drug Coverage sulfacetamide and Criteria - New and Therapeutic sulfur) in a Equivalent Medications Moisturizing Novasome® Vehicle (brand only) Sumadan XLT Kit Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (sulfacetamide Guidelines: Drug Coverage sodium, sulfur, Criteria - New and Therapeutic avobenzone, Equivalent Medications octinoxate, and octisalate) Sumatriptan Tablet, Nasal J3490, PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: Spray, J8499, and Supply Limits • Prior authorization through the Injection J3030 PBM is only required for

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing quantity requests exceeding the Triptan Ceiling Limit. • NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Sumavel Dosepro Injection J3490 and PBM** Therapeutic Equivalent Pharmacy* (Sumatriptan) J8499 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Sumaxin TS and Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Sumaxin CP Guidelines: Drug Coverage (sodium Criteria - New and Therapeutic sulfacetamide and Equivalent Medications sulfur) Sunosi (solriamfetol) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Sunosi Supprelin LA Sc Implant J9226 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for (histrelin acetate Medical Gonadotropin Releasing Hormone the diagnosis of Gender Dysphoria implant) Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD- 10 diagnosis codes. Suprax Chewable Tablet J8499 N/A N/A Pharmacy N/A Tablet (cefixime) Sustol® (granisetron Injection J1627 Optum* Prior Authorization Guidelines: Medical* *Prior Authorization Notes: extended release) Antiemetics for Oncology* Prior authorization is required through Optum when Sustol is administered prior to chemotherapy infusion. Prior authorization is not required when

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing self-administered outside of the infusion. Sutab (sodium Tablets J8499 N/A N/A Pharmacy N/A sulfate/magnesium sulfate/potassium chloride) Sutent (sunitinib Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior malate) Guidelines: Sutent authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. *Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Sylatron Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A (peginterferon alfa- Guidelines: Sylatron 2b) Symbicort Aerosol J3490 N/A N/A Pharmacy N/A (budesonide/ formoterol fumarate dehydrate) Symdeko Tablets J8499 PBM Prior Authorization/Medical Pharmacy N/A (tezacaftor / Necessity Guidelines: Symdeko ivacaftor) Symfi (efavirenz/ Tablets J8499 N/A N/A Pharmacy N/A lamivudine/ tenofovir disoproxil fumarate) Symfi Lo Tablets J8499 N/A N/A Pharmacy N/A

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing (efavirenz/ lamivudine/ tenofovir disoproxil fumarate) Sympazan Oral Film J8499 PBM Prior Authorization/Notification Pharmacy N/A (clobazam) Guidelines: Sympazan Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Symproic Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (naldemedine) Guidelines: Symproic

Symtuza (darunavir/ Tablets J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A cobicistat/ Authorization Guidelines: New and emtricitabine/ Therapeutic Equivalent tenofovir Medications alafenamide Synagis Injection J3490 Oxford’s Prior Authorization Guidelines: Medical N/A (palivizumab) Medical Synagis (palivizumab) Management Synalar 0.01% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A solution Solution Guidelines: Drug Coverage (fluocinolone Criteria - New and Therapeutic acetonide) (brand) Equivalent Medications Synalar 0.025% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A cream/ointment Cream/ Guidelines: Drug Coverage (fluocinolone Ointment Criteria - New and Therapeutic acetonide) (brand) Equivalent Medications Synalar Kit Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (fluocinolone Guidelines: Drug Coverage acetonide) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Synalar TS Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (fluocinolone Guidelines: Drug Coverage acetonide) Criteria - New and Therapeutic Equivalent Medications Synarel (nafarelin Nasal Spray J3490 N/A N/A Pharmacy N/A acetate) Syndros Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (dronabinol) Necessity Guidelines: Non-Solid Oral and Suppository Dosage Synjardy Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (empagliflozin/ Guidelines: Drug Coverage metformin Criteria - New and Therapeutic hydrochloride) Equivalent Medications Synribo Injection J9262 PBM Prior Authorization/Notification Pharmacy N/A (omacetaxine) Guidelines: Synribo Synthroid (Brand Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A Only) Authorization Guidelines: New and Therapeutic Equivalent Medications Syprine (trientine Oral Agent J8499 PBM Prior Authorization/Notification Pharmacy N/A hydrochloride) Guidelines: Syprine Syprine (trientine Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Tabrecta Tablets J8999 PBM Prior Authorization/Notification Pharmacy N/A (capmatinib) Guidelines: Tabrecta Taclonex Ointment Ointment J3490 PBM Therapeutic Equivalent Pharmacy N/A (Brand Only) Guidelines: Drug Coverage (calcipotriene/ Criteria - New and Therapeutic betamethasone Equivalent Medications dipropionate) Tadalafil 2.5 mg and Tablet J8499 PBM Step Therapy Guidelines: BPH Pharmacy N/A 5 mg (generic Cialis Cialis)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Tafinlar (dabrafenib) Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Tafinlar Tagrisso Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (osimertinib) Guidelines: Tagrisso Takhzyro Injection J0593 PBM Prior Authorization/Medical Pharmacy N/A (lanadelumab-flyo) Necessity Guidelines: Takhzyro Talicia (omeprazole Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A magnesium, Guidelines: Drug Coverage amoxicillin and Criteria - New and Therapeutic rifabutin) Equivalent Medications Taltz (ixekizumab) Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Taltz Talzenna Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (talazoparib) Guidelines: Talzenna Step Therapy Guidelines: Talzenna Tamiflu (oseltamivir Capsule, J8499 N/A N/A Pharmacy N/A phosphate) Powder Or Oral Suspension Tamiflu capsules Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (oseltamivir Guidelines: Drug Coverage phosphate) (brand Criteria - New and Therapeutic only) Equivalent Medications Tamiflu Suspension Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (oseltamivir Suspension Guidelines: Drug Coverage phosphate) (brand Criteria - New and Therapeutic only) Equivalent Medications Tamoxifen 20mg Oral J8999 PBM Prior Authorization/ Regulatory Pharmacy N/A (generic) Guidelines: Tamoxifen Taperdex Pak 6-day Tablets J8499 N/A N/A Pharmacy N/A & 12-day (dexamethasone) Tarceva (erlotinib) Oral J8999 PBM Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (Brand Only) Guidelines: Tarceva authorization through the PBM is

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent only required for those Oral Guidelines: Drug Coverage Oncology Drugs specifically listed Criteria - New and Therapeutic in a Coverage Criteria/Guideline Equivalent Medications when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. *Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Targadox Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (doxycycline) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Targretin Gel Topical Gel J3490 N/A N/A Pharmacy N/A (bexarotene) Tasigna (nilotinib) Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Tasigna authorization through the PBM is Step Therapy Guidelines: Tasigna only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Tasmar (tolcapone) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (brand) Necessity Guidelines: Tasmar Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Tavalisse Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (fostamatinib Guidelines: Tavalilsse disodium Step Therapy Guidelines: hexahydrate) Tavalisse Taytulla Tablet J8499 PBM Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (norethindrone Therapeutic Equivalent with coverage for contraceptives acetate and ethinyl Guidelines: Drug Coverage through their prescription drug estradiol, and Criteria - New and Therapeutic plan. If the Member does not have ferrous fumarate) Equivalent Medications contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Tazarotene 0.1% Topical J3490 PBM* Prior Authorization/Medical Pharmacy** *Prior authorization Note: Prior cream (generic Cream Necessity Guidelines: Tazarotene authorization is not required for Tazorac) Cream Members under 30 years of age. Prior authorization for NJ Small LOBs is based on the Member's benefit. **Benefit Note: Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Tazorac (tazarotene) Varies J3490 PBM* Prior Authorization/Medical Pharmacy** *Prior authorization Note: Prior Necessity Guidelines: Tazorac authorization is not required for Members under 30 years of age. Prior authorization for NJ Small LOBs is based on the Member's benefit. **Benefit Note: Not all groups have selected the standard

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing pharmacy benefit. Refer to Member's pharmacy plan if applicable. Tazverik Tablet J8999 PBM Prior Authorization / Notification Pharmacy N/A (tazemetostat) Guideline: Tazverik Tecfidera (dimethyl Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A fumarate)(Brand) Authorization Guidelines: New and Therapeutic Equivalent Medications Prior Authorization/Notification Guidelines: Tecfidera (Dimethyl Fumarate) Technivie Tablet J8499 N/A N/A Pharmacy N/A (ombitasvir/ paritaprevir/ ritonavir) Teflaro (ceftaroline Injection J0712 N/A N/A Medical N/A fosamil) Tegsedi (inotersen) Injection J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Tegsedi Temixys Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (lamivudine/ Guidelines: Drug Coverage tenofovir disoproxil Criteria - New and Therapeutic fumarate) Equivalent Medications Temodar Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (temozolomide) Guidelines: Temodar authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing authorization guidelines and quantity limit guidelines. Temodar capsules Capsule J8999 PBM Therapeutic Equivalent Pharmacy** *Prior authorization Note: Prior (temozolomide) Guidelines: Drug Coverage authorization through the PBM is (Brand Only) Criteria - New and Therapeutic only required for those Oral Equivalent Medications Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. *Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Tenofovir disoproxil Tablet J8499 PBM Prior Authorization/Regulatory Pharmacy N/A fumarate 300mg Guidelines: HIV Pre-Exposure (generic) Prophylaxis Tenoretic (atenolol/ Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A chlorthalidone) Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Tenormin (atenolol) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tepezza Intravenous J3241 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (teprotumumab- infusion Medical o Provider Administered Drugs - Administration of Tepezza in a trbw) Management Site of Care hospital outpatient facility ® o Tepezza (Teprotumumab- (including any ambulatory infusion trbw) suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs - Site of Care

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Tepmetko Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (tepotinib) Guidelines: Tepmetko Terbinex Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (terbinafine Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Equivalent Medications Teriparatide Injection J3110 PBM Prior Authorization/Notification Pharmacy N/A injectable Guidelines: Teriparatide Test Strips and Test Strips A4253 – Test PBM Prior Authorization/Non-Formulary Pharmacy *Contour Next, OneTouch, and Meters (Diabetic): and Meters strips Guidelines: Test Strips Accu-Chek test strips and meters Abbott Diabetic do not require Prior authorization. Meters (e.g., E0607 – FreeStyle Meter Freedom Lite, FreeStyle InsuLinx, FreeStyle Lite, FreeStyle Neo, Precision Xtra) Abbott Test Strips (e.g., FreeStyle Insulinx, FreeStyle Lite, FreeStyle, FreeStyle Precision Neo, Precision Xtra) Ascensia Diabetic Meters, excluding Contour Next Meters* (e.g., Breeze2, Contour, Contour Next

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Link, Contour Next USB) Ascensia Test Strips, excluding Contour Next* Test Strips (e.g., Breeze2, Contour) Roche Diabetic Meters (e.g., Accu-Chek Aviva Expert, Accu-Chek Aviva Plus, Accu-Chek Compact Plus, Accu-Chek Nano) Roche Test Strips (e.g., Accu-Chek Aviva Plus, Accu-Chek Compact, Accu- Chek Compact Plus, Accu- Chek Smartview) Testim (testosterone Gel J3490 PBM Prior Authorization/Medical Pharmacy N/A gel) Necessity Guidelines: Testim Testopel Pellets S0189 N/A Medical Management Guidelines: Medical N/A (testosterone Maximum Dosage and Frequency pellets) Testosterone Injection J3490 N/A N/A Medical N/A cypionate and estradiol cypionate

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Testosterone Injection J3490 N/A N/A Medical N/A enanthate and estradiol valerate Testosterone Powder J3490 PBM N/A Pharmacy N/A powder Testosterone topical Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A gel (generic Testim) Necessity Guidelines: Topical Androgens Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Testosterone topical Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A gel (generic Necessity Guidelines: Topical Vogelxo) Androgens Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Testosterone topical Topical Gel J3490 PBM Prior Authorization/Medical Pharmacy N/A gel (manufacturer of Necessity Guidelines: Topical Perrigo Israel) Androgens Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Testred (methyl- Capsule J8499 N/A N/A Pharmacy N/A testosterone) Tetrabenazine Tablets J8499 PBM Prior Authorization/Notification Pharmacy N/A (generic) Guidelines: Tetrabenazine Tetravez Gel Topical gel J3490 PBM Therapeutic Equivalent Pharmacy N/A (Triethanolamine, Guidelines: Drug Coverage Benzethonium Criteria - New and Therapeutic chloride) Equivalent Medications Thalomid Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (thalidomide) Guidelines: Thalomid authorization through the PBM is

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Thyquidity Oral Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A (levothyroxine Guidelines: Drug Coverage sodium) Criteria - New and Therapeutic Equivalent Medications Thyrogen Injection J3490 N/A N/A Medical N/A (thyrotropin alfa) Tibsovo (ivosidenib) Tablets J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Tibsovo Tiglutik (riluzole) Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A suspension Necessity Guidelines: Non-Solid Oral and Suppository Dosage Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tirosint Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (levothyroxine Guidelines: Drug Coverage sodium) Criteria - New and Therapeutic Equivalent Medications Tirosint-Sol Oral Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A Solution Necessity Guidelines: Non-Solid (levothyroxine Oral and Suppository Dosage sodium)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Tivorbex Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (indomethacin) Authorization Guidelines: New and Therapeutic Equivalent Medications TNKase Intravenous J3490 and N/A N/A Medical N/A (tenecteplase) J3101 Tobi™ Nebulizer Inhalation J3490 PBM Prior Authorization/Notification Pharmacy N/A Solution Solution Guidelines: TOBI (Tobramycin Therapeutic Equivalent Inhalation Solution) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tobi® Podhaler™ Inhalation J3490 PBM Prior Authorization/Notification Pharmacy N/A (Tobramycin Powder Guidelines: TOBI Inhalation Powder) Tobradex ST Ointment J3490 PBM Therapeutic Equivalent Pharmacy N/A (tobramycin- Guidelines: Drug Coverage dexamethasone) Criteria - New and Therapeutic Equivalent Medications Tobramycin Inhalation J3490 PBM Prior Authorization/Notification Pharmacy N/A nebulized solution Solution Guidelines: Tobramycin nebulized (generic Tobi) solution Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tolak 4% cream Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (fluorouracil) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tolsura (SUBA- Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A itraconazole) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tolterodine (generic Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Detrol) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Topamax Tablet Or J8499 PBM Prior Authorization/Medical Pharmacy N/A (topiramate) Capsule Necessity Guidelines: Topamax Topicort Spray Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (Desoximetasone) Spray Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tosymra Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (sumatriptan) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Toujeo Solostar Injection J3490 N/A N/A Pharmacy N/A (insulin glargine) Tracleer (bosentan) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: PAH Agents Tramadol 100mg Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tramadol extended- Tablet/ J8499 Tramadol Therapeutic Equivalent Pharmacy N/A release (generic Capsule extended- Guidelines: Drug Coverage ryzolt) release (generic Criteria - New and Therapeutic ryzolt) Equivalent Medications Travatan Z Ophthalmic J8499 PBM Therapeutic Equivalent Pharmacy N/A ((travoprost) (Brand Solution Guidelines: Drug Coverage Only) Criteria - New and Therapeutic Equivalent Medications Travoprost (generic Ophthalmic J3490 N/A N/A Pharmacy N/A Travatan) Solution Trazimera Injection J9999 N/A Medical Management Guidelines: Medical N/A (trastuzumab-qyyp) Maximum Dosage and Frequency Trelegy Ellipta Inhaler J3490 N/A N/A Pharmacy N/A (fluticasone furoate/ umeclidinium/ vilanterol)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Trelegy 200/62.5/ Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A 25 mcg (Fluticasone Guidelines: Drug Coverage furoate/ Criteria - New and Therapeutic umeclidinium/ Equivalent Medications vilanterol) Trelstar Injection J3315 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for Medical Gonadotropin Releasing Hormone the diagnosis of Gender Dysphoria Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD- 10 diagnosis codes. Tremfya Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (guselkumab) Necessity Guidelines: Tremfya Tresiba Flex Touch Injection J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A (insulin degludec) Authorization Guidelines: New and Therapeutic Equivalent Medications Tretinoin (generic Topical S0117, PBM Prior Authorization/Notification Pharmacy N/A Retin-A) cream) Cream J3490 Guidelines: Retin-A and Retin-A Micro (tretinoin) Tretinoin Gel Topical Gel S0117, PBM Therapeutic Equivalent Pharmacy N/A (generic Retin-A) J3490 Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Treximet Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (sumatriptan Authorization Guidelines: New and naproxen) Therapeutic Equivalent Medications Trezix Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (acetaminophen/ Guidelines: Drug Coverage caffeine/ Criteria - New and Therapeutic dihydrocodeine) Equivalent Medications Triamcinolone Injection J3300 N/A N/A Medical N/A acetonide

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Trianex Ointment J3490 PBM Therapeutic Equivalent Pharmacy N/A (triamcinolone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tribenzor Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (amlodipine, Guidelines: Drug Coverage olmesartan, Criteria - New and Therapeutic medoxomil, Equivalent Medications hydrochlorothiazide) Tricor/Fenofibrate Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 48mg and 145mg Guidelines: Drug Coverage (generic Tricor) Criteria - New and Therapeutic (fenofibrate) and Equivalent Medications Trilipix (fenofibrate acid) Trientine (generic Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Syprine) Guidelines: Syprine Triglide (fenofibrate) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Trijardy XR Extended- J8499 N/A N/A Pharmacy N/A (empagliflozin/ Release linagliptin/ Tablet metformin hydrochloride) Trikafta Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (elexacaftor/ Necessity Guidelines: Trikafta tezacaftor/ ivacaftor) Trileptal Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (oxcarbazepine) Necessity Guidelines: Trileptal Trilipix (fenofibrate Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A acid) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Tri-Luma Varies J3490 N/A N/A Pharmacy* *Benefit Notes: Not covered for (hydroquinone) cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Trintellix Tablet J8499 PBM Step Therapy Guidelines: Pharmacy N/A (vortioxetine) Antidepressants Triphasil Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (levonorgestrel and with coverage for contraceptives ethinyl estradiol) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Triptodur Injection J3316 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for (triptorelin) Medical Gonadotropin Releasing Hormone the diagnosis of gender dysphoria Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for applicable gender dysphoria ICD- 10 diagnosis codes. Trisenox (arsenic Injection J9017 Optum*/ Optum Guidelines*: Oncology Medical *For oncology indications: trioxide) Oxford** Medication Clinical Coverage Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 **Prior authorization is required through Oxford for all requests for Non-oncology indications.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Triumeq Tablet J8499 N/A N/A Pharmacy N/A (dolutegravir/ abacavir/ lamivudine) Trogarzo Injection J1746 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (Ibalizumab) Medical Trogarzo (Ibalizumab) Administration of Trogarzo in a Management Provider Administered Drugs – hospital outpatient facility Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care Trokendi XR Capsule J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (topiramate) Authorization Guidelines: New and Therapeutic Equivalent Medications Trulance Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (plecanatide) Necessity Guidelines: Trulance Trulicity Injection J3490 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (dulaglutide) Guidelines: Notification Guidelines: GLP-1 o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products. Truseltiq Capsule J8999 PBM Therapeutic Equivalent Pharmacy N/A (Infigratinib) Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Truvada Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (emtricitabine and Authorization Guidelines: New and tenofovir disoproxil Therapeutic Equivalent fumarate) (brand) Medications 200/300mg Truxima (rituximab- Injection Q5115 Optum*/ Medical Management Medical *For oncology indications: abbs) Oxford** Guidelines**: Maximum Dosage Prior authorization is required and Frequency through Optum for dates of Optum Guidelines*: Oncology service Aug. 1, 2021 and after; Medication Clinical Coverage Prior authorization is required Prior Authorization Guidelines**: through eviCore for dates of Rituximab (Riabni™, Rituxan®, service prior to Aug. 1, 2021 Ruxience® & Truxima®) **Prior authorization is required through Oxford for all requests for Non-oncology indications. Tudorza Pressair Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A (aclidinium) Powder Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Tukysa (tucatinib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Tukysa Turalio Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A (pexidartinib) Guidelines: Turalio Tussicaps Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocodone Necessity Guidelines: Opioid polistirex and Containing Cough Medicines chlorpheniramine polistirex) Tussionex All Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A Forms Necessity Guidelines: Opioid Containing Cough Medicines Tuxarin ER (codeine Extended J8499 PBM Prior Authorization/Medical Pharmacy N/A phosphate and release Necessity Guidelines: Opioid tablets Containing Cough Medicines

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing chlorpheniramine maleate) Tuzistra XR Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (codeine/ Suspension Necessity Guidelines: Opioid chlorpheniramine) Containing Cough Medicines Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Twirla (ethinyl Transdermal J3490 PBM Therapeutic Equivalent Pharmacy N/A estradiol and Patch Guidelines: Drug Coverage levonorgestrel) Criteria - New and Therapeutic Equivalent Medications Twynsta Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (Telmisartan, Guidelines: Drug Coverage amlodipine) Criteria - New and Therapeutic Equivalent Medications Tykerb (lapatinib) Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Tykerb authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Tymlos Injection J3490 PBM Prior Authorization/Notification Pharmacy N/A (abaloparatide) Guidelines: Tymlos Tysabri Intravenous J2323 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (natalizumab) Medical Tysabri® (Natalizumab) Participating hospitals are required Management to purchase Tysabri (natalizumab)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing from the Optum Specialty Pharmacy. Refer to Prior Authorization Guidelines: Specialty Pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting. Tyvaso (treprostinil) Inhalation J7686 PBM Prior Authorization/Medical Pharmacy N/A Solution Necessity Guidelines: PAH Agents Ubrelvy Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (Ubrogepant) Necessity Guidelines: Ubrelvy Prior Authorization/Supply Limit Guidelines: Agents for Migraine Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Uceris (budesonide) Tablet J8499 N/A N/A Pharmacy N/A Uceris foam Topical J3490 N/A N/A Pharmacy N/A Udenyca Injection Q5111 PBM*/ Medical Management See *Pharmacy Benefit: If dispensed (pegfilgrastim-cbqv, Optum**/ Guidelines**: Maximum Dosage Notes*,** by a retail pharmacy or mail order biosimilar) Oxford** and Frequency through PBM. Prior authorization is Optum Guidelines**: White Blood required. Cell Colony Stimulating Factors **Medical Benefit: If provided in a Therapeutic Equivalent hospital, MD's office, or in the Guidelines*: Drug Coverage home setting: Criteria - New and Therapeutic For oncology indications: Equivalent Medications o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing • Prior authorization is required through Oxford for non- oncology indications. Ukoniq (umbralisib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Ukoniq Uloric (febuxostat) Tablet J8499 PBM Step Therapy Guidelines: Uloric Pharmacy N/A Ultomiris Injection J1303 Oxford’s Medical Management Guidelines: Medical Hospital Outpatient Facility: (ravulizumab-cwvz) Medical Maximum Dosage and Frequency Administration of Ultomiris in a Management Prior Authorization Guidelines: hospital outpatient facility o Complement Inhibitors (including any ambulatory infusion (Soliris® & Ultomiris®) suite associated with the hospital) o Provider Administered Drugs requires Prior authorization with – Site of Care review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care Ultrasal-ER 28.5% Topical J8499 N/A N/A Pharmacy Note: Prescription drugs for which topical solution Solution there is a therapeutic over-the- (salicylic acid) counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Ultravate Topical J3490 N/A N/A Pharmacy N/A (Halobetasol Cream Propionate) Ultravate Topical J3490 PBM Step Therapy Guidelines: Topical Pharmacy N/A (halobetasol Lotion Steroids propionate) lotion Therapeutic Equivalent 0.05% Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Ultravate X Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Combination Guidelines: Drug Coverage Package Criteria - New and Therapeutic (halobetasol) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Umecta emulsion, Foam/ J3490 PBM Therapeutic Equivalent Pharmacy N/A foam, suspension Suspension Guidelines: Drug Coverage (urea) Criteria - New and Therapeutic Equivalent Medications Umecta Kit (nail film Nail Film J3490 PBM Therapeutic Equivalent Pharmacy N/A pen/film Pen/Film Guidelines: Drug Coverage suspension) (urea Suspension Criteria - New and Therapeutic nail film and Equivalent Medications hyaluronic acid) Umecta PD (urea) Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Uplizna Intravenous J1823 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (inebilizumab-cdon) Medical Provider Administered Drugs – Administration of Uplizna in a Management Site of Care hospital outpatient facility Uplizna™ (Inebilizumab-Cdon) (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to Prior Authorization Guidelines: Provider Administered Drugs – Site of Care Upneeq Opththalmic J3490 PBM Prior Authorization/Medical Pharmacy N/A (oxymetazoline) Solution Necessity Guidelines: Upneeq 0.1% ophthalmic solution Uptravi (selexipag) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: PAH Agents Uramaxin GT 45% Foam J3490 PBM Therapeutic Equivalent Pharmacy N/A (urea in ammonium Guidelines: Drug Coverage lactate) Criteria - New and Therapeutic Equivalent Medications Uramaxin GT Kit Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A urea plus Guidelines: Drug Coverage moisturizer) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Urevaz 44% cream Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (urea) Cream Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Uroxatral (alfuzosin Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A HCL) (Brand Only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Utibron Neohaler Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A (indacaterol/ Powder Guidelines: Drug Coverage glycopyrrolate) Criteria - New and Therapeutic Equivalent Medications Utopic (urea) 41% Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vagifem (estradiol) Vaginal J3490 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Insert Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Valchlor Gel Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A (mechlorethamine) Guidelines: Valchlor Gel Valcyte Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (valganciclovir) Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Valium (diazepam) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and Therapeutic Equivalent Medications Valsartan (generic Capsule J8499 N/A N/A Pharmacy N/A Diovan) Valtoco (diazepam) Nasal Spray J3490 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Valtoco Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Valtrex (valacyclovir) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and Therapeutic Equivalent Medications Valturna 150- Tablet J8499 N/A N/A Pharmacy N/A 160mg, 300mg - 320mg (aliskiren and valsartan) Vanatol LQ Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A (butalbital/ Necessity Guidelines: Non-Solid acetaminophen/ Oral and Suppository Dosage caffeine Vancomycin 250 Oral Solution J8499 N/A N/A Pharmacy N/A mg/5 mL oral solution Vaniqa (eflornithine) Varies J3490 N/A N/A Pharmacy* *Benefit Notes: Not covered for cosmetic conditions. Not all groups have selected the standard pharmacy benefit. Refer to Member's pharmacy plan if applicable. Vanos Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (fluocinonide) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vantas (histrelin Sc Implant J9225 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for implant) Medical Gonadotropin Releasing Hormone the diagnosis of Gender Dysphoria Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD- 10 diagnosis codes. Varubi (rolapitant) Tablet J8670 PBM Pharmacy Benefit/Prior Pharmacy N/A Authorization Guidelines: New and

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Medications Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vascepa (icosapent Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A ethyl) Necessity Guidelines: Vascepa Vascepa 0.5 gram Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A only (icosapent Necessity Guidelines: Vascepa ethyl) Vaseretic (enalapril/ Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A hydrochlorothiazide) Guidelines: Drug Coverage (brand) Criteria - New and Therapeutic Equivalent Medications Vasotec (enalapril) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (Brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vecamyl Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (mecamylamine) Guidelines: Vecamyl (mecamylamine) Vectical Topical J3490 N/A N/A Pharmacy N/A (calcitriol)(generic) Ointment Vectical Ointment Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (Brand only) Ointment Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Velphoro Tablet J8499 N/A N/A Pharmacy N/A (sucroferric oxyhydroxide) Veltassa (patiromer) Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A Suspension Necessity Guidelines: Veltassa Veltin (clindamycin Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A phosphate and Guidelines: Drug Coverage tretinoin)

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Vemlidy (tenofovir Tablet J8499 PBM Step Therapy Guidelines: Vemlidy Pharmacy N/A alafenamide) Venclexta Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (venetoclax) Guidelines: Venclexta Venlafaxine ER Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (venlafaxine Guidelines: Drug Coverage hydrochloride Criteria - New and Therapeutic extended release) Equivalent Medications Ventavis (iloprost) Inhalation Q4074 PBM* Prior Authorization/Medical Pharmacy *The I-neb AAD System (K0730) Solution Necessity Guidelines: PAH Agents and DME for administration of Ventavis® (Medical) (iloprost) requires Prior authorization through Oxford's Medical Management Department and coverage is provide under the Medical benefit. Ventolin HFA Inhaler J3490 PBM Therapeutic Equivalent Pharmacy N/A (albuterol sulfate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Veramyst Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A (fluticasone furoate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Verdeso (desonide) Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Veregen Topical J3490 PBM Step Therapy Guidelines: Veregen Pharmacy N/A (sinecatechins) Ointment Vermox Oral J8499 N/A N/A Pharmacy N/A (mebendazole) Suspension Verquvo (vericiguat) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Verquvo

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Versacloz Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (clozapine) Suspension Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Verzenio Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (abemaciclib) Guidelines: Verzenio Vesicare Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (solifenacin) Authorization Guidelines: New and Therapeutic Equivalent Medications Vesicare LS Oral J8499 PBM Therapeutic Equivalent Pharmacy N/A (solifenacin Suspension Guidelines: Drug Coverage succinate) Criteria - New and Therapeutic Equivalent Medications Viagra (sildenafil Tablet J8499 N/A N/A Pharmacy N/A citrate) Viagra (sildenafil Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A citrate) (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vibativ (telavancin) Injection J3095 N/A N/A Medical N/A Viberzi (eluxadoline) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Viberzi Vicodin 5/300mg Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (hydrocodone and Guidelines: Drug Coverage acetaminophen) Criteria - New and Therapeutic Equivalent Medications Vicodin ES Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 7.5/300mg Guidelines: Drug Coverage (hydrocodone and Criteria - New and Therapeutic acetaminophen) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Vicodin HP Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 10/300mg Guidelines: Drug Coverage (hydrocodone and Criteria - New and Therapeutic acetaminophen) Equivalent Medications Victoza (liraglutide) Injection J3490 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ Guidelines: Notification Guidelines: GLP-1 o GLP-1 Receptor Agonists (CT Receptor Agonists (CT and NY) and NY) policy applies to Connecticut and o GLP-1 Receptor Agonists (NJ) New York plans and products. Step Therapy Guidelines: GLP-1 The Prior Authorization/ Receptor Agonists (NJ) Notification Guidelines: GLP-1 Receptor Agonists (NJ) policy applies to New Jersey plans and products. The Step Therapy Guidelines: GLP-1 Receptor Agonists policy applies to New Jersey plans and products. Viekira Pak Tablets J8499 PBM Prior Authorization/Medical Pharmacy N/A (ombitasvir, Necessity Guidelines: Viekira Pak paritaprevir, and ritonavir tablets; dasabuvir tablets) Vigamox (Brand Ophthalmic J8499 PBM Therapeutic Equivalent Pharmacy N/A only) (moxifloxacin) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Viltepso Intravenous J1427 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: (villtolarsen) infusion J3590 Medical Provider Administered Drugs – Administration of Viltepso in a Management Site of Care* hospital outpatient facility Viltepso (Viltolarsen) (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Authorization Guidelines: Provider Administered Drugs – Site of Care Vimizim (elosulfase Injection J1322 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: alfa) Medical Medical Therapies for Enzyme Administration of Vimizim in a Management Deficiencies hospital outpatient facility Provider Administered Drugs – (including any ambulatory infusion Site of Care suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs - Site of Care Vimovo (naproxen Tablet J8499 N/A N/A N/A Note: Prescription drugs for which sodium plus proton there is a therapeutic over-the- pump inhibitor) counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Vimpat Injection C9254 and N/A N/A Medical N/A (Lacosamide) J3490 Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Single Source Brand Anticonvulsants Viokace Tablet J8499 PBM Step Therapy Guidelines: Viokace Pharmacy N/A (pancrelipase) Viramune Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (nevirapine) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Viramune XR Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A 400mg (Brand Only) Guidelines: Drug Coverage (nevirapine) Criteria - New and Therapeutic Equivalent Medications Virasal (salicylic Topical J3490 N/A N/A Pharmacy Note: Prescription drugs for which acid) (brand only) there is a therapeutic over-the- counter (OTC) equivalent are

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing excluded from coverage. Refer to the member specific benefit plan document as applicable. Viread (Brand only) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (tenofovir disoproxil Guidelines: Drug Coverage fumarate) Criteria - New and Therapeutic Equivalent Medications Visudyne Infusion J3396 N/A N/A Medical N/A (verteporfin) Vitamin B-12 Injection J3420 N/A N/A Medical N/A Vitekta (elvitegravir) Tablet J8499 N/A N/A Pharmacy N/A Vitorin (Brand only) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (ezetimibe and Guidelines: Drug Coverage simvastatin) Criteria - New and Therapeutic Equivalent Medications Vitrakvi® Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (larotrectinib) Guidelines: Vitrakvi Vitrasert-Ganciclovir Eye Implant J3490 N/A N/A Medical N/A Vitreal Implant Vituz (hydrocodone Oral Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A bitartrate, and Guidelines: Drug Coverage chlorpheniramine Criteria - New and Therapeutic maleate) Equivalent Medications Vivitrol (Naltrexone) Injection J2315 N/A N/A Medical N/A Vivlodex Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (meloxicam) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vizimpro Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A (dacomitinib) Guidelines: Vizimpro Vocabria Tablet J8999 PBM Therapeutic Equivalent Pharmacy N/A (Cabotegravir) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Vogelxo Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A (testosterone) Necessity Guidelines: Vogelxo Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vosevi (Sofosbuvir/ Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Velpatasvir/ Necessity Guidelines: Vosevi Voxilaprevir) Votrient (pazopanib) Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior Guidelines: Votrient authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. VPRIV Injection J3385 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is not required (velaglucerase) Medical Intravenous Enzyme Replacement for velaglucerase (VPRIV®) except Management Therapy (ERT) for Gaucher in a hospital outpatient facility Disease setting Provider Administered Drugs – Hospital Outpatient Facility: Site of Care* Administration of VPRIV in a hospital outpatient facility (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Authorization Guidelines: Provider Administered Drugs - Site of Care Vraylar (cariprazine) Capsule J8499 PBM Step Therapy Guidelines: Vraylar Pharmacy N/A Vumerity (diroximel Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A fumarate) Necessity Guidelines: Vumerity Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vusion Ointment J3490 PBM Therapeutic Equivalent Pharmacy N/A (miconazole/zinc Guidelines: Drug Coverage oxide) Criteria - New and Therapeutic Equivalent Medications Vyepti Injection J3032 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (eptinezumab- Medical Provider Administered Drugs - Site Administration of Vyepti in a JJMR) Management of Care hospital outpatient facility VyeptiTM (eptinezumab-JJMR) (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to: Prior Authorization Guidelines: Provider Administered Drugs - Site of Care Vyleesi Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (bremelanotide) Necessity Guidelines: Vyleesi Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Vyndamax Capsules J8499 PBM Prior Authorization/Medical Pharmacy N/A (tafamidis) Necessity Guidelines: Vyndamax Vyndaqel (tafamidis Capsules J8499 PBM Prior Authorization/Medical Pharmacy N/A meglumine) Necessity Guidelines: Vyndaqel Vyondys 53™ Intravenous J1429 Oxford’s Prior Authorization Guidelines: Medical Hospital Outpatient Facility: (golodirsen) Infusion Medical Provider Administered Drugs - Site Administration of Vyondys 53™ in a Management of Care hospital outpatient facility

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Vyondys 53™ (Bolodirsen) (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee; refer to Prior Authorization Guidelines: Provider Administered Drugs - Site of Care. Vytone Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (hydrocortisone/ Guidelines: Drug Coverage lodoquinol) Criteria - New and Therapeutic Equivalent Medications Vyvanse Tablet J8499 N/A N/A Pharmacy N/A (lisdexamfetamine) Vyzulta Ophthalmic J3490 PBM Step Therapy Guidelines: Vyzulta Pharmacy N/A (latanoprostene Solution bunod) Wakix (Pitolisant) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Wakix Weight Loss: Tablet Or J8499 PBM Prior Authorization/ Regulatory Pharmacy* Includes both brand and generic Includes both brand Capsule Guidelines**: Weight Loss versions and all formulations of the and generic listed products unless otherwise versions and all noted. formulations of the listed: *Coverage is limited to Members benzphetamine, with coverage for weight loss diethylpropion, medications through their Contrave prescription drug plan. If the (naltrexone and Member does not have weight loss bupropion), medication coverage through their Imcivree prescription drug plan, then these (setmelanotide) are not covered. Members should refer to their Certificate of phendimetrazine, Coverage, or Prescription Drug phentermine (all Rider language for coverage brands including guidelines. Adipex-P and Lomaira),

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Qsymia **Prior Authorization Guidelines (phentermine and only apply to New York plans and topiramate products extended-release), Saxenda (liraglutide), Xenical (orlistat) Wellbutrin Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (bupropion) (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Wellbutrin SR Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and (bupropion) Therapeutic Equivalent Medications Wellbutrin XL Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (bupropion Authorization Guidelines: New and extended release) Therapeutic Equivalent Medications Winlevi Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A (clascoterone cream cream Necessity Guidelines: Winlevi 1%) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Winstrol (stanozolol) Tablet J8499 N/A N/A Pharmacy N/A Wynzora Topical J3490 PBM Therapeutic Equivalent Pharmacy N/A (calcipotriene and cream Guidelines: Drug Coverage betamethasone Criteria - New and Therapeutic dipropionate) Equivalent Medications Xadago Tablet J8499 N/A N/A Pharmacy N/A (safinamide) Xalatan (Brand only) Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A (latanoprost) Drops Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

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

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Xeljanz (tofacitinib) Extended- J8499 PBM Prior Authorization/Medical Pharmacy N/A XR Release Necessity Guidelines: Xeljanz XR Tablet Xeloda Tablet J8999 PBM Therapeutic Equivalent Pharmacy** *Prior authorization Note: Prior (Capecitabine) Guidelines: Drug Coverage authorization through the PBM is (Brand Only) Criteria - New and Therapeutic only required for those Oral Equivalent Medications Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. *Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Xelpros Ophthalmic J3490 N/A N/A Pharmacy N/A (latanoprost) emulsion Xenazine Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A (tetrabenazine) Guidelines: Tetrabenazine (brand) Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Xenleta (lefamulin) Tablet J8499 N/A N/A Pharmacy N/A Xeomin Sq Injection J0588 Oxford’s Prior Authorization Guidelines: Medical N/A (incobotulinumtoxin Medical Botulinum Toxins A and B A) Management Xepi (ozenoxacin) Topical J3490 N/A N/A Pharmacy N/A cream Xerese (acyclovir or Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A hydrocortisone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Xermelo (telotristat Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A ethyl) Guidelines: Xermelo Xhance (fluticasone Nasal Spray J3490 PBM Therapeutic Equivalent Pharmacy N/A propionate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Xiaflex (collagenase Injection J0775 N/A N/A Medical N/A clostridium histolyticum) Xifaxan (rifaximin) Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Xifaxan Xigduo XR Tablet J8499 PBM Prior Authorization/Notification Pharmacy The Prior Authorization/ (Dapagliflozin and Guidelines: Diabetes Medications Notification Guidelines: Diabetes Metformin HCl) SGLT2 Inhibitors (CT/NY) Medications SGLT2 Inhibitors Step Therapy Guidelines: Diabetes (CT/NY) policy applies to New Medications SGLT2 Inhibitors (NJ) York and Connecticut plans and products. The Step Therapy Guidelines: Diabetes Medications SGLT2 Inhibitors (NJ) policy applies to New Jersey plans and products. Xiidra (lifitegrast 5% Ophthalmic J3490 PBM Prior Authorization/Medical Pharmacy N/A ophthalmic solution) Solution Necessity Guidelines: Xiidra Ximino Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Ximino Xodol 10/300 Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (hydrocodone/ Guidelines: Drug Coverage acetaminophen)(bra Criteria - New and Therapeutic nd and generic) Equivalent Medications Xodol 5/300 Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (hydrocodone / Guidelines: Drug Coverage acetaminophen) Criteria - New and Therapeutic (brand and generic) Equivalent Medications Xodol 7.5/300 Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (hydrocodone / Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing acetaminophen) Criteria - New and Therapeutic (brand and generic) Equivalent Medications Xofluza (baloxavir Injection J3490 N/A N/A Pharmacy N/A marboxil) Xolair (omalizumab) Subcutan- J2357 Oxford’s Medical Management Guidelines: Medical Provider administered: Xolair (Subcutaneous eous Medical Maximum Dosage and Frequency requires Prior authorization Injection) Injection Management Prior Authorization Guidelines: through Oxford’s Medical Xolair (omalizumab) Management and is covered under the medical benefit. Xolair (omalizumab) Prefilled J2357 PBM Medical Management Pharmacy Self-administered: Xolair requires (prefilled syringe) syringe Guidelines**: Maximum Dosage Prior authorization through the and Frequency PBM and is covered under the Prior Authorization/Medical pharmacy benefit when obtained at Necessity Guidelines: Xolair a pharmacy. Therapeutic Equivalent Guidelines*: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Xopenex Nebules Inhalation J3490 PBM Therapeutic Equivalent Pharmacy N/A (levalbuterol Solution Guidelines: Drug Coverage hydrochloride) Criteria - New and Therapeutic Generic Xopenex Equivalent Medications nebules Xospata (gilteritinib) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Xospata Xpovio (selinexor) Tablet J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Xpovio Xtampza ER Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (oxycodone) Necessity Guidelines: Xtampza ER Xtandi Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A (enzalutamide) Guidelines: Xtandi Step Therapy Guidelines: Xtandi

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Xultophy (insulin Injection J3490 PBM Therapeutic Equivalent Pharmacy N/A degludec and Guidelines: Drug Coverage liraglutide) Criteria - New and Therapeutic Equivalent Medications Xuriden (uridine Oral J8499 PBM Prior Authorization/Notification Pharmacy N/A triacetate) Granules Guidelines: Xuriden Xyosted Injection J3490 PBM Prior Authorization/Medical Pharmacy N/A (testosterone Necessity Guidelines: enanthate) Testosterone Xyrem (Sodium Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A Oxybate) Necessity Guidelines: Xyrem (sodium oxybate) Xywav (calcium, Oral Solution J8499 PBM Prior Authorization/Medical Pharmacy N/A magnesium, Necessity Guidelines: Xywav potassium, and sodium oxybates) Yasmin 28 Pill S4993 N/A Benefit Guidelines: Contraceptives Pharmacy* *Coverage is limited to Members (drospirenone- with coverage for contraceptives ethinyl estradiol) through their prescription drug plan. If the Member does not have contraceptive coverage through their prescription drug plan, then these are not covered. Members should refer to their Certificate of Coverage or Prescription Drug Rider language for coverage guidelines. Yonsa (abiraterone Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A acetate) Guidelines: Yonsa Step Therapy Guidelines: Yonsa Yosprala (aspirin/ Tablet J8499 N/A N/A N/A Note: Prescription drugs for which omeprazole) there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to member specific benefit plan document as applicable.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Yupelri Inhalation J7677 PBM Prior Authorization/Medical Pharmacy N/A (revefenacin) solution Necessity Guidelines: Yupelri Zarxio (filgrastim- Injection Q5101 Optum**/ Optum Guidelines**: White Blood See *Pharmacy Benefit: If dispensed sndz) Oxford Cell Colony Stimulating Factors Notes*,** by a retail pharmacy or mail order through PBM. Prior authorization is not required. **Medical Benefit: If provided in a hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021 Prior authorization is required through Oxford for non- oncology indications. Zavesca® (miglustat) Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zcort (Deflazacort) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zecuity 6.5mg/4 hr Transdermal J3490 PBM Therapeutic Equivalent Pharmacy N/A patch (sumatriptan Patch Guidelines: Drug Coverage iontophoretic) Criteria - New and Therapeutic Equivalent Medications Zegalogue Injection J3490 PBM Therapeutic Equivalent Pharmacy N/A (dasiglucagon) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Zegerid Capsule J8499 N/A N/A Not covered Note: Prescription drugs for which (omeprazole/ there is a therapeutic over-the- sodium counter (OTC) equivalent are bicarbonate) excluded from coverage. Refer to member specific benefit plan document as applicable. Zegerid suspension Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A (omeprazole/ Suspension Necessity Guidelines: Non-Solid sodium Oral and Suppository Dosage bicarbonate) Zejula (niraparib) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Zejula Zelboraf Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior (vemurafenib) Guidelines: Zelboraf authorization through the PBM is only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Zelnorm (tegaserod Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A maleate) Necessity Guidelines: Zelnorm

Zemaira [Alpha1- Intravenous J0256 Oxford’s Prior Authorization Guidelines: Medical *Hospital Outpatient Facility: Proteinase Inhibitor Injection Medical Alpha1-Proteinase Inhibitors Administration of Zemaira in a (Human)] Management Provider Administered Drugs – hospital outpatient facility Site of Care* (including any ambulatory infusion suite associated with the hospital) requires Prior authorization with review by a Medical Director or their designee. Refer to Prior

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Authorization Guidelines: Provider Administered Drugs – Site of Care Zembrace Injection J3490 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: SymTouch Supply Limits Prior authorization through the (sumatriptan Therapeutic Equivalent PBM is only required for quantity succinate) Guidelines: Drug Coverage requests exceeding the Triptan Criteria - New and Therapeutic Ceiling Limit. Equivalent Medications **NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Zemplar Injection J2501 N/A N/A Pharmacy N/A (paricalcitol) Zenatane Capsule J8499 N/A N/A Pharmacy N/A Zenzedi Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (dextroampheta- Guidelines: Drug Coverage mine sulfate) Criteria - New And Therapeutic Equivalent Medications Zepatier (elbasvir/ Tablet J8499 PBM Prior Authorization/ Medical Pharmacy N/A grazoprevir) Necessity Guidelines: Zepatier Zeposia (ozanimod) Capsule J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Zeposia Zerviate (cetirizine Ophthalmic J3490 PBM Therapeutic Equivalent Pharmacy N/A ophthalmic solution) Solution Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zestoretic Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (lisinopril/ Guidelines: Drug Coverage hydrochlorothia- Criteria - New and Therapeutic zide) (brand) Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Zestril (lisinopril) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zetia (ezetimibe) Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (brand only) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zetonna Inhalation J8499 N/A N/A Pharmacy N/A (ciclesonide) Solution Zevalin Injection A9542 and N/A N/A Medical N/A (ibritumomab A9543 tiuxetan) Powder J3490 N/A N/A Pharmacy N/A Packet Ziana (clindamycin Gel J3490 PBM Therapeutic Equivalent Pharmacy N/A phosphate and Guidelines: Drug Coverage Tretinoin Criteria - New and Therapeutic Equivalent Medications Ziextenzo Injection Q5120 Optum**/ Medical Management Pharmacy*/ Prior authorization Notes: (pegfilgrastim-bmez) Oxford** Guidelines**: Maximum Dosage Medical** *Obtained at a pharmacy for self- and Frequency administration: Prior authorization Optum Guidelines**: White Blood is not required and covered under Cell Colony Stimulating Factors the pharmacy benefit. **Medical Benefit: If provided in a hospital, MD's office, or in the home setting: For oncology indications: o Prior authorization is required through Optum for dates of service Aug. 1, 2021 and after; o Prior authorization is required through eviCore for dates of service prior to Aug. 1, 2021

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Prior authorization is required through Oxford for non- oncology indications. Zileuton extended- Tablet J8499 PBM Step Therapy Guidelines: Zileuton Pharmacy N/A release (generic Zyflo CR) Zilxi 1.5% Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A (minocycline) Foam Guidelines: Zilxi Step Therapy Guidelines: Zilxi Zinbryta Injection J7513 N/A N/A Pharmacy N/A (daclizumab) Zioptan (tafluprost) Ophthalmic J8499 PBM Step Therapy Guidelines: Zioptan Pharmacy N/A Solution (tafluprost) Zipsor 25mg Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (diclofenac Guidelines: Drug Coverage pottassium) Criteria - New and Therapeutic Equivalent Medications Zirabev Injection Q5118 N/A Medical Management Guidelines: Medical N/A (bevacizumab-bvzr) Maximum Dosage and Frequency Zithromax Capsule, J8499 N/A N/A Pharmacy N/A (azithromycin) Oral Solution or Tablet Zodex 6 & 12-Day Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A pack Guidelines: Drug Coverage (dexamethasone) Criteria - New and Therapeutic Equivalent Medications Zofran (ondansetron Oral Solution Q0162 and N/A Prior Authorization Guidelines: Pharmacy N/A hydrochloride) S0119 Antiemetics for Oncology Injection J2405 N/A Prior Authorization Guidelines: Medical N/A Antiemetics for Oncology Zofran and Zofran Tablet Q0162 and N/A Prior Authorization Guidelines: Pharmacy N/A ODT (ondansetron) S0119 Antiemetics for Oncology Zohydro ER Tablet J8499 PBM Prior Authorization/Medical Pharmacy N/A (hydrocodone Necessity Guidelines: Zohydro ER bitartrate extended

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing release) (Brand and Therapeutic Equivalent Generic) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zokinvy (lonafarnib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Zokinvy Zoladex Sc Implant J9202 Oxford’s Prior Authorization Guidelines: Medical *Prior authorization is required for Medical Gonadotropin Releasing Hormone the diagnosis of Gender Dysphoria Management* Analogs only; refer to Prior Authorization Guidelines: Gonadotropin Releasing Hormone Analogs for applicable Gender Dysphoria ICD- 10 diagnosis codes. Zoledronic acid Injection J3489 N/A Medical Management Guidelines: Medical N/A Maximum Dosage and Frequency Zolgensma Infusion J3399 Oxford’s Prior Authorization Guidelines: Medical N/A (Onasemnogene Medical Zolgensma (Onasemnogene Abeparvovec-xioi) Management Abeparvovec-XIOI) Zolinza (vorinostat) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Zolinza Zoloft (sertraline) Tablet J8499 PBM Pharmacy Benefit/Prior Pharmacy N/A (brand only) Authorization Guidelines: New and Therapeutic Equivalent Medications Zolpidem extended Tablet J8499 N/A N/A Pharmacy N/A release (zolpidem) Zolpimist (zolpidem Oral Spray J8499 PBM Step Therapy Guidelines: Pharmacy N/A tartrate) Zolpimist (Zolpidem Tartrate) Zolvit (hydrocodone Liquid J8499 N/A N/A Pharmacy N/A bitartrate and acetaminophen) Zomacton Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: Zomacton Therapeutic Equivalent Guidelines: Drug Coverage

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Criteria - New and Therapeutic Equivalent Medications Zometa (zoledronic Injection J3489 N/A Medical Management Guidelines: Medical N/A acid) Maximum Dosage and Frequency Zomig (zolmitriptan) Nasal spray J3490 PBM Step Therapy Guidelines: Zomig Pharmacy N/A (nasal spray) (Brand Supply Limit Guidelines: Triptans Only) Supply Limits Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zomig and Zomig- Tablet J8499 PBM* Supply Limit Guidelines: Triptans Pharmacy** *Prior authorization Notes: ZMT (zolmitriptan) Supply Limits Prior authorization through the PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Prior authorization. **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Zomig tablets Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (zolmitriptan) (Brand Guidelines: Drug Coverage Only) Criteria - New and Therapeutic Equivalent Medications Zomig (zolmitriptan) Nasal Spray J3490 PBM* Sterapy Guidelines: Zomig Pharmacy** *Prior authorization Notes: Supply Limit Guidelines: Triptans Prior authorization through the Supply Limits PBM is only required for quantity requests exceeding the Triptan Ceiling Limit. NJ Plans do not require Prior authorization.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing **Benefit Note: For New York plans and products, members should refer to their Certificate of Coverage as certain Triptan drugs are included in the select designated pharmacy program. Zonacort Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (dexamethasone) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zonalon (Doxepin) Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A Cream Necessity Guidelines: Zonalon Zonalon (doxepin Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A hydrochloride) Guidelines: Drug Coverage (Brand Only) Criteria - New and Therapeutic Equivalent Medications Zonatuss Capsule J8499 PBM Therapeutic Equivalent Pharmacy N/A (benzonatate) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zonegran Capsule J8499 PBM Prior Authorization/Medical Pharmacy N/A (zonisamide) Necessity Guidelines: Zonegran Zontivity (vorapaxar) Tablet J8499 N/A N/A Pharmacy N/A Zorbtive Injection J2941 PBM Prior Authorization/Medical Pharmacy N/A (somatropin) Necessity Guidelines: Zorbtive (Somatropin) Zortress Tablet J8999 PBM Therapeutic Equivalent Pharmacy *Prior authorization Note: Prior (everolimus) (Brand Guidelines: Drug Coverage authorization through the PBM is Only) Criteria - New and Therapeutic only required for those Oral Equivalent Medications Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization.

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing *Benefit Note: NJ Small Members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Zorvolex Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (diclofenac) Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zovirax cream Cream J3490 PBM Pharmacy Benefit/Prior Pharmacy N/A (acyclovir) Authorization Guidelines: New and Therapeutic Equivalent Medications Zovirax Ointment Topical J3490 PBM Prior Authorization/Medical Pharmacy N/A Necessity Guidelines: Zovirax ZTLido (lidocaine) Topical J3490 PBM Prior Authorization/Notification Pharmacy N/A Patch Guidelines: ZTLido Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zubsolv Tablet J8499 N/A N/A Pharmacy N/A (buprenorphine/ naloxone) Zulresso Intravenous J1632 N/A Prior Authorization Guidelines: Medical N/A (Brexanolone) Injection Zulresso (Brexanolone) Zuplenz Tablet Or J8499 PBM Therapeutic Equivalent Pharmacy N/A (Ondansetron) Film Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zurampic Tablet J8499 N/A N/A Pharmacy N/A (lesinurad) Zutripo All Oral J8499 PBM Prior Authorization/Medical Pharmacy N/A Forms Necessity Guidelines: Opioid Containing Cough Medicines

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Zutripro (Brand Oral Solution J8499 PBM Therapeutic Equivalent Pharmacy N/A Only) (hydrocodone Guidelines: Drug Coverage bitartrate, Criteria - New and Therapeutic chlorpheniramine Equivalent Medications maleate and pseudoephedrine hcl) Zyban (bupropion) Tablet, Nasal J8499 PBM N/A Pharmacy* *Not all Commercial plans have Spray, the additional pharmacy rider that Inhaler provides coverage for smoking deterrents. Please refer to the Member's individual pharmacy benefit description to determine coverage. Zyclara (Imiquimod) Cream J3490 PBM Therapeutic Equivalent Pharmacy N/A Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Zydelig (idelalisib) Tablet J8499 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Zydelig Zyflo (zileuton) Tablet J8499 PBM Step Therapy Guidelines: Zyflo Pharmacy N/A (brand only) Zyflo CR (zileuton) Tablet J8499 N/A N/A Pharmacy N/A (brand only) Zykadia (ceritinib) Capsule J8999 PBM Prior Authorization/Notification Pharmacy N/A Guidelines: Zykadia Zymaxid Ophthalmic J3490 N/A N/A Pharmacy N/A (Gatifloxacin Solution ophthalmic solution) Zypitamag Tablet J8499 PBM Step Therapy Guidelines: Pharmacy N/A (Pitavastatin) Zypitamag Zyprexa Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (olanzapine) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications

Prior Dosage CPT/HCPCS Medication/Drug Authorization Coverage Criteria/Guidelines Benefit Type Notes Form Code(s) Routing Zyprexa Zydis Tablet J8499 PBM Therapeutic Equivalent Pharmacy N/A (olanzapine) (brand Guidelines: Drug Coverage only) Criteria - New and Therapeutic Equivalent Medications Zyrtec (cetirizine) Oral Solution J8499 N/A N/A N/A Note: Prescription drugs for which solution there is a therapeutic over-the- counter (OTC) equivalent are excluded from coverage. Refer to the member specific benefit plan document as applicable. Zytiga (abiraterone Oral J8999 PBM* Prior Authorization/Notification Pharmacy** *Prior authorization Note: Prior acetate) 250 mg Guidelines: Zytiga authorization through the PBM is (Generic Only) only required for those Oral Oncology Drugs specifically listed in a Coverage Criteria/Guideline when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small members should refer to their Certificate of Coverage for Prior authorization guidelines and quantity limit guidelines. Zytiga (abiraterone Oral J8999 PBM* Prior Authorization/ Notification Pharmacy** *Prior authorization Note: Prior acetate) 250 mg Guidelines: Zytiga authorization through the PBM is (Brand Only) Therapeutic Equivalent only required for those Oral Guidelines: Drug Coverage Oncology Drugs specifically listed Criteria - New and Therapeutic in a Coverage Criteria/Guideline Equivalent Medications when the Member is age 19 years or older. All other oral chemotherapy drugs do not require Prior authorization. **Benefit Note: NJ Small members should refer to their Certificate of Coverage for Prior

Policy History/Revision Information

Date Summary of Changes 09/01/2021 Payment Guidelines Revised Quantity Duration (QD) and Quantity Level Limitations (QLL) guidelines; removed language instructing providers to call Oxford’s Pharmacy Benefit Manager (PBM) to request coverage for a greater quantity of a medication with a QLL Revised coverage guidelines for the following drugs/medications: Drug/Medication Status Summary of Changes Actemra (Tocilizumab): Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Sq. Injection Necessity Guidelines: Actemra for complete details Actimmune (Interferon Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Gamma-1b) Guidelines: Actimmune (Interferon Gamma-1b) for complete details

Date Summary of Changes Adcirca (Brand Only) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: (Tadalafill) PAH Agents; no change to coverage guidelines Adempas (Riociguat) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: PAH Agents; no change to coverage guidelines Aimovig (Erenumab- Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Aooe) Necessity Guidelines: Aimovig for complete details Ajovy (Fremanezumab- Revised • Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Vfrm) Necessity Guidelines: Ajovy for complete details Alunbrig (Brigatinib) Revised • Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Alunbrig for complete details Arcalyst (Rilonacept) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Rilonacept (Arcalyst) for complete details Brexafemme New • Added language to indicate prior authorization is required through the Pharmacy Benefit Manager (Ibrexafungerp) (PBM) Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Bronchitol (Mannitol) Revised Added step therapy guidelines; refer to Step Therapy Guidelines: Bronchitol for complete details Bryhali 0.01% Updated Updated medication/drug name; added “0.01%” (Halobetasol Propionate) Cimzia (Certolizumab Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Pegol) Necessity Guidelines: Cimzia for complete details Continuous Glucose Revised Added prior authorization/notification guidelines all brands except Guardian Connect; refer to Prior Monitor Authorization/Notification Guidelines: Continuous Glucose Monitors, Sensors and Transmitters (All Brands Except Guardian Connect) for complete details Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Guardian Connect Sensor and Transmitter for Continuous Glucose Monitoring for complete details Cordran 0.05% Ointment Updated Updated medication/drug name; added “0.05%” (Flurandrenolide) Cosentyx (Secukinumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Cosentyx for complete details Depakote (Divalproex Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Sodium) Necessity Guidelines: Depakote for complete details Depakote ER (Divalproex Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Sodium Extended Necessity Guidelines: Depakote ER for complete details Release) Dupixent (Dupilumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Dupixent for complete details

Date Summary of Changes Emgality (Galcanezumab- Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Gnlm) Necessity Guidelines: Emgality for complete details Emgality (100mg Only) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Galcanezumab-Gnlm) Necessity Guidelines: Emgality for complete details Enbrel (Etanercept) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Enbrel for complete details Exforge HCT Revised Added non-formulary guidelines; refer to Non-Formulary Guidelines: Exforge for complete details (Amlodipine, Hydrochlorothiazide and Valsartan) Exjade (Brand Only) Updated Updated prior authorization/notification guidelines and corresponding reference link to reflect title (Deferasirox) change; refer to Prior Authorization/Notification Guidelines: Iron Chelators for complete details Fasenra Pen Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Benralizumab) Necessity Guidelines: Fasenra for complete details Felbatol (Felbamate) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Felbatol for complete details Ferriprox (Deferiprone) Revised Revised prior authorization/notification guidelines and corresponding reference link to reflect title change; refer to Prior Authorization/Notification Guidelines: Iron Chelators for complete details Fetzima Updated Updated step therapy guidelines and corresponding reference link to reflect title change; refer to (Levomilnacipran) Step Therapy Guidelines: Antidepressants for complete details Gilotrif (Afatinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Gilotrif (Afatinib) for complete details Humira (Adalimumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Humira for complete details Humira (Adalimumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical 10 mg/0.1 ml, 20 mg/0.2 Necessity Guidelines: Humira for complete details ml, 40 mg/0.4 ml, 80 mg/0.8 ml Strengths Only Ilumya (Tildrakizumab- Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Asmn) Necessity Guidelines: Ilumya for complete details Jadenu (Defirasirox) Updated Updated prior authorization/notification guidelines and corresponding reference link to reflect title change; refer to Prior Authorization/Notification Guidelines: Iron Chelators for complete details Keppra (Levetiracetam): Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Tablet Necessity Guidelines: Keppra for complete details Keppra XR Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Levetiracetam Extended Necessity Guidelines: Keppra XR for complete details Release [XR])

Date Summary of Changes Kevzara (Sarilumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Kevzara for complete details Klisyri (Tirbanibuli) Revised Added step therapy guidelines; refer to Step Therapy Guidelines: Klisyri for complete details Kloxxado (Naloxone New • Added language to indicate prior authorization is required through the Pharmacy Benefit Manager Hydrochloride) (PBM) Added therapeutic equivalent guidelines; refer to Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications for complete details Lamictal (Lamotrigine) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Lamictal for complete details Lamictal ODT Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Lamotrigine Orally Necessity Guidelines: Lamictal ODT for complete details Disintegrating Tablet) (Brand and Generic) Lamictal XR (Lamotrigine Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Extended Release) Necessity Guidelines: Lamictal XR for complete details (Brand and Generic) Lamotrigine XR Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Lamotrigine XR for complete details Letairis (Brand Only) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: (Ambrisentan) PAH Agents; no change to coverage guidelines Lyrica (Pregabalin) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Brand Only) Necessity Guidelines: Lyrica for complete details Lyrica CR (Pregabalin) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Lyrica CR for complete details Mektovi (Binimetinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Mektovi for complete details Mysoline (Primidone) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Mysoline for complete details Neurontin (Gabapentin) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Neurontin for complete details Nucala (Auto-Injector & Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Prefilled Syringe) Necessity Guidelines: Nucala for complete details (Mepolizumab) Nucala (Mepolizumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Nucala for complete details Nurtec ODT Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Rimegepant) Necessity Guidelines: Nurtec ODT for complete details

Date Summary of Changes Revised prior authorization/supply limit guidelines; refer to Prior Authorization/Supply Limit Guidelines: Agents for Migraine for complete details Olumiant (Baricitinib) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Olumiant for complete details Onfi (Clobazam) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Onfi for complete details Removed prior authorization/notification guidelines and corresponding reference link to the policy titled Prior Authorization/Notification Guidelines Onfi Opsumit (Macitentan) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: PAH Agents; no change to coverage guidelines Orencia (Abatacept): Sq. Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Injection Necessity Guidelines: Orencia for complete details Orenitram (Treprostinil) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: PAH Agents; no change to coverage guidelines Orgovyx (Relugolix) Revised Revised coverage guidelines to indicate prior authorization is not required Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior Authorization/Medical Necessity Guidelines: Orgovyx Oxtellar XR Revised Added pharmacy benefit/prior authorization guidelines; refer to Pharmacy Benefit/Prior Authorization (Oxcarbazepine Extended Guidelines: New and Therapeutic Equivalent Medications for complete details Release) Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior Authorization/Medical Necessity Guidelines: Oxtellar XR Palynziq (Pegvaliase- Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Pqpz) Necessity Guidelines: Palynziq for complete details Pemazyre (Pemigatinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Pemazyre for complete details Praluent (Alirocumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Praluent (Alirocumab) for complete details Qudexy XR (Topiramate) Revised Added pharmacy benefit/prior authorization guidelines; refer to Pharmacy Benefit/Prior Authorization (Brand and Authorized Guidelines: New and Therapeutic Equivalent Medications for complete details Generic) Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior Authorization/Medical Necessity Guidelines: Qudexy XR Repatha (Evolocumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Repatha for complete details Revatio (Sildenafil Citrate) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: 10mg/ml PAH Agents; no change to coverage guidelines Reyvow (Lasmiditan) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Reyvow for complete details

Date Summary of Changes Rinvoq (Upadacitinib) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Rinvoq for complete details Rydapt (Midostaurin) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Rydapt for complete details Sabril Powder Pack Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Vigabatrin) Necessity Guidelines: Sabril for complete details Removed prior authorization/notification guidelines and corresponding reference link to the policy titled Prior Authorization/Notification Guidelines: Sabril Samsca (Tolvaptan) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Samsca for complete details Siliq (Brodalumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Siliq for complete details Simponi (Golimumab): Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Sq. Injection Necessity Guidelines: Simponi for complete details Skyrizi (Risankizumab- Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Rzaa) Necessity Guidelines: Skyrizi for complete details Sorilux (Calcipotriene) Revised Added pharmacy benefit/prior authorization guidelines; refer to Pharmacy Benefit/Prior Authorization Guidelines: New and Therapeutic Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Spritam (Levetiracetam) Revised Added pharmacy benefit/prior authorization guidelines; refer to Pharmacy Benefit/Prior Authorization Guidelines: New and Therapeutic Equivalent Medications for complete details Removed therapeutic equivalent guidelines and corresponding reference link to the policy titled Therapeutic Equivalent Guidelines: Drug Coverage Criteria - New and Therapeutic Equivalent Medications Stelara (Ustekinumab): Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Sub-Cutaneous Injection Necessity Guidelines: Stelara for complete details Stendra (Avanafil) Revised Added language to indicate prior authorization is required through the Pharmacy Benefit Manager (PBM) Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Stendra for complete details Stivarga (Regorafenib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Stivarga for complete details Strensiq (Asfotase Alfa) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Strensiq for complete details Taltz (Ixekizumab) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Taltz for complete details

Date Summary of Changes Tasmar (Tolcapone) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Brand) Necessity Guidelines: Tasmar for complete details Tibsovo (Ivosidenib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Tibsovo for complete details Topamax (Topiramate) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Topamax for complete details Tracleer (Bosentan) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: PAH Agents; no change to coverage guidelines Tremfya (Guselkumab) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Tremfya for complete details Trileptal (Oxcarbazepine) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Trileptal for complete details Trintellix (Vortioxetine) Updated Updated step therapy guidelines and corresponding reference link to reflect title change; refer to Step Therapy Guidelines: Antidepressants for complete details Trokendi XR (Topiramate) Revised Added pharmacy benefit/prior authorization guidelines; refer to Pharmacy Benefit/Prior Authorization Guidelines: New and Therapeutic Equivalent Medications for complete details Removed prior authorization/medical necessity guidelines and corresponding reference link to the policy titled Prior Authorization/Medical Necessity Guidelines: Trokendi XR Tyvaso (Treprostinil) Revised Revised prior authorization/medical necessity guidelines and corresponding reference link to reflect title change; refer to Prior Authorization/Medical Necessity Guidelines: PAH Agents for complete details Ubrelvy (Ubrogepant) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Ubrelvy for complete details Updated prior authorization/supply limit guidelines; refer to Prior Authorization/Supply Limit Guidelines: Agents for Migraine for complete details Uptravi (Selexipag) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: PAH Agents; no change to coverage guidelines Ventavis (Iloprost) Updated Updated reference link to reflect title change for Prior Authorization/Medical Necessity Guidelines: PAH Agents; no change to coverage guidelines Verquvo (Vericiguat) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Verquvo for complete details Vraylar (Cariprazine) Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Vraylar for complete details Wakix (Pitolisant) Revised Revised prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Wakix for complete details Winlevi (Clascoterone Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Cream 1%) Necessity Guidelines: Winlevi for complete details Xeljanz (Tofacitinib) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xeljanz for complete details

Date Summary of Changes Xeljanz (Tofacitinib) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xeljanz for complete details Xeljanz (Tofacitinib) XR Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Xeljanz XR for complete details Xolair (Omalizumab) Revised Added prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical (Prefilled Syringe) Necessity Guidelines: Xolair for complete details Zejula (Niraparib) Updated Updated prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Zejula for complete details Zileuton Extended- Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Zileuton for complete details Release (Generic Zyflo CR) Zonegran (Zonisamide) Updated Updated prior authorization/medical necessity guidelines; refer to Prior Authorization/Medical Necessity Guidelines: Zonegran for complete details Zyflo (Zileuton) (Brand Revised Revised step therapy guidelines; refer to Step Therapy Guidelines: Zyflo for complete details Only) Zykadia (Ceritinib) Revised Revised prior authorization/notification guidelines; refer to Prior Authorization/Notification Guidelines: Zykadia for complete details • Archived previous policy version PHARMACY 098.214 T0

Instructions for Use

This Clinical Policy provides assistance in interpreting UnitedHealthcare Oxford standard benefit plans. When deciding coverage, the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using this policy, please check the member specific benefit plan document and any applicable federal or state mandates. UnitedHealthcare Oxford reserves the right to modify its Policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice.

The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members.

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