Cigna National Formulary Coverage Policy

Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review

Table of Contents Product Identifier(s)

National Formulary Medical Necessity ...... 1 Various Product-Specific Exception Criteria ...... 2 Conditions Not Covered...... 56

INSTRUCTIONS FOR USE The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients. Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

National Formulary Medical Necessity

The Cigna National Formulary list may not cover certain drugs or biologics unless those products are approved based on a medical necessity review.

Cigna covers these drugs or biologics as medically necessary when the following criteria are met: • [see Product-Specific Exception Criteria]

Approval duration is 12 months unless otherwise noted.

Documentation: When documentation is required, the prescriber must provide written documentation supporting the trials of these other agents, noted in the criteria as [documentation required]. Documentation may include, but is not limited to, chart notes, prescription claims records, and/or prescription receipts.

Page 1 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review

Product-Specific Exception Criteria

Non-Covered Chemical Name Exception Criteria Product and Aciphex Sprinkle rabeprazole 1. Approve if the individual has tried five proton pump inhibitors (PPIs). and authorized sodium delayed- generic release capsules Note: Examples of PPIs include rabeprazole delayed-release (DR) tablets (Aciphex, generics), Dexilant DR capsules, esomeprazole DR capsules (Nexium, generics), Nexium DR packet (granules for oral ), pantoprazole DR tablets (Protonix, generics), Protonix suspension (granules), lansoprazole orally dissolving tablets (Prevacid/Solutabs, generics), omeprazole DR capsules, Prilosec DR suspension, omeprazole/sodium bicarbonate capsules (Zegerid, generics), or omeprazole/sodium bicarbonate packet (Zegerid, generics).

2. Individuals < 18 years of age OR individuals who have difficulty swallowing tablets/capsules: Approve if the individual has tried two proton pump inhibitors (PPIs).

Note: The requested agent would NOT count as a trial of an alternative. Note: If an approval is entered, it will be entered for the authorized generic. Acuvail ketorolac 1. Approve if the individual has tried two products from the following list (if two are tromethamine formulary, or one of the following if one is formulary): diclofenac ophthalmic 0.45% (generics), bromfenac 0.09% ophthalmic solution (generics), Prolensa, preservative-free BromSite, Nevanac, Ilevro, or ketorolac ophthalmic solution (Acular, Acular LS, solution generics). If none are formulary, approve.

2. Individuals with a sulfite allergy: approve if the individual has tried two of the following, if two are formulary (or one if only one is formulary): BromSite, diclofenac ophthalmic solution (generics), Nevanac, Ilevro, or ketorolac ophthalmic solution (Acular, Acular LS, generics). If none are formulary, approve.

3. Individuals with a known sensitivity to a preservative (e.g., benzalkonium chloride [BAK]): approve if the individual has tried diclofenac ophthalmic solution (generics), if formulary. If diclofenac ophthalmic solution is non-formulary, approve.

Adlyxin lixisenatide 1. Approve if the individual has tried two formulary alternatives from the following list (or one if only one is formulary): Trulicity, Byetta, Bydureon BCise, Ozempic, or Victoza [documentation required]. If none are formulary, approve.

NOTE: Bydureon BCise and Byetta would count as one alternative.

2. Individuals with a personal or family history of medullary thyroid carcinoma or in individuals with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2): approve if the individual has tried Byetta [documentation required], if formulary. If Byetta is non-formulary, approve.

Admelog insulin lispro vial, Approve if the individual meets the following (1 or 2): SoloStar (prefilled 1. Individual meets the following (A, B, C, and D): pen) A. Individual has tried Apidra, if formulary; AND B. Individual has tried Fiasp, if formulary; AND C. Individual has one of the following, if formulary: Insulin Lispro (authorized generic of Humalog) or Humalog; AND D. Individual has tried one of the following, if formulary: NovoLog or Insulin Aspart (authorized generic of NovoLog); OR 2. Individual is using an insulin pump that is not compatible with the formulary alternative(s), approve.

Note: If no products in A, B, C, or D are formulary, approve.

Page 2 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form

Note: The same product with different dosage forms count as one alternative (e.g., Humalog vial and Humalog Kwikpen would count as one alternative).

Adzenys XR amphetamine 1. Approve if the individual has tried and, according to the prescriber, has experienced suspension and extended-release inadequate OR significant intolerance with five central nervous system authorized generic oral suspension (CNS) stimulants.

Note: Examples of central nervous system stimulants include: amphetamine sulfate, mixed amphetamine salts (Adderall, generics), amphetamine aspartate extended-release capsules (Adderall XR, generics); methylphenidate extended- release tablets (Concerta, generics); dextroamphetamine sulfate sustained-release capsules (Dexedrine Spansules, generics); dexmethylphenidate extended-release capsules (Focalin, Focalin XR, generics); methylphenidate extended-release tablets or capsules, or sustained-release tablets (Metadate CD, Metadate ER, Methylin ER, Ritalin LA, Ritalin-SR).

Afrezza insulin human Approve if the individual meets the following (A, B, C and D): [rDNA origin] A. Individual has tried Apidra, if formulary; AND inhalation B. Individual has tried Fiasp, if formulary; AND C. Individual has tried one of the following, if formulary: NovoLog or Insulin Aspart (authorized generic); AND D. Individual has tried one of the following, if formulary: Insulin Lispro (authorized generic), Humalog, or Admelog.

Note: If no products in A, B, C, or D are formulary, approve.

Note: The same product with different dosage forms count as one alternative (e.g., Humalog vial and Humalog Kwikpen would count as one alternative).

AirDuo Digihaler fluticasone/ 1. Approve if the individual has tried four of the following (if four are formulary, or three salmeterol if three are formulary, or two if two are formulary, or one if one is formulary): inhalation powder Symbicort, Dulera, Breo Ellipta, fluticasone propionate/salmeterol multidose dry powder inhaler (AirDuo RespiClick, authorized generics), Advair HFA, or fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics). If none are formulary, approve.

2. Individuals who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried two of the following (if two are formulary or one if only one is formulary): fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), fluticasone propionate/salmeterol multidose DPI (AirDuo Respiclick, authorized generic), or Breo Ellipta. If none are formulary, approve.

3. Individuals < 18 years of age: approve if the individual has tried three of the following, if three are formulary (if three are formulary, or two if two are formulary, or one if only one is formulary): Symbicort, Dulera, fluticasone propionate/salmeterol multidose dry powder inhaler (AirDuo RespiClick, authorized generics), Advair HFA, or fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics). If none are formulary, approve.

4. Individuals < 18 years of age who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried one of fluticasone propionate/salmeterol inhalation, Wixela (Advair Diskus, generics), or fluticasone propionate/salmeterol multidose DPI (AirDuo RespiClick, authorized generics), if one is formulary. If none are formulary, approve.

Note: Fluticasone proprionate-salmetrol inhalation powder, Wixela, and Advair

Page 3 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Diskus count as one alternative. Fluticasone propionate-salmeterol multidose dry powder inhaler and AirDuo RespiClick count as one alternative.

AirDuo RespiClick fluticasone 1. Approve if the individual has tried four of the following (if four are formulary, or three propionate/salmet if three are formulary, or two if two are formulary, or one if only one is formulary): erol inhalation Advair HFA, fluticasone propionate/salmeterol inhalation powder, Wixela (Advair powder Diskus, generics), Breo Ellipta, Dulera, fluticasone propionate/salmeterol multidose dry powder inhaler (authorized generic of AirDuo RespiClick), AirDuo Digihaler, or Symbicort. If none are formulary, approve.

2. Individuals who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried two of the following (if two are formulary or one if only one is formulary): fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), fluticasone propionate/salmeterol multidose DPI (authorized generic of AirDuo RespiClick), AirDuo Digihaler, or Breo Ellipta. If none are formulary, approve.

3. Individuals < 18 years of age: approve if the individual has tried three of the following (if three are formulary, or two if two are formulary, or one if only one is formulary): Symbicort, Advair HFA, fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), fluticasone propionate/salmeterol multidose DPI (authorized generic of AirDuo RespiClick), AirDuo Digihaler, or Dulera. If none are formulary, approve.

4. Individuals < 18 years of age who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried one of fluticasone propionate/salmeterol inhalation, Wixela (Advair Diskus, generics) or fluticasone propionate/salmeterol multidose DPI (authorized generic of AirDuo RespiClick), or AirDuo Digihaler, if one is formulary. If none are formulary, approve.

Note: Fluticasone proprionate-salmetrol inhalation powder, Wixela, and Advair Diskus count as one alternative. Fluticasone propionate/salmeterol multidose DPI (authorized generic of AirDuo RespiClick) and AirDuo Digihaler would count as one alternative.

Akynzeo netupitant/ 1. Approve if the individual has tried three formulary 5-HT3 receptor antagonists from palonosetron the following list (if three are formulary or two if two are formulary or one if one is capsules formulary [if none are formulary, approve]): ondansetron (Zofran, generics), granisetron (generics), Sancuso, Anzemet tablets, palonosetron (Aloxi, generics) AND one of aprepitant capsules (Emend, generics) or Varubi tablets, if one is formulary. If neither are formulary, approve.

2. Approve if the individual has already started Akynzeo to complete all cycles in the current course of chemotherapy. albuterol HFA albuterol sulfate 1. Individual is directed to use Ventolin HFA (brand). If Ventolin HFA (brand) is non- inhaler inhalation aerosol formulary, approve if the individual has tried one product from the following list, if (authorized formulary: albuterol HFA (ProAir HFA, generics), albuterol HFA (Proventil HFA, generic to Ventolin generics), ProAir Respiclick, ProAir Digihaler, Xopenex HFA, or levalbuterol HFA HFA) inhaler. If none are formulary, approve.

2. Individuals < 12 years of age or individuals who have a low inspiratory flow rate and are unable to use a dry powder inhaler (DPI): Individual is directed to use Ventolin

Page 4 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form HFA (brand). If Ventolin HFA (brand) is non-formulary, approve if the individual has tried one product from the following list, if formulary: albuterol HFA (ProAir HFA, generics), albuterol HFA (Proventil HFA, generics), Xopenex HFA, or levalbuterol HFA inhaler. If none are formulary, approve.

Alcortin A hydrocortisone 1. Approve if the individual has tried and, according to the prescriber, has experienced 2%/ iodoquinol inadequate efficacy OR significant intolerance with five single-entity 1%/ aloe 1% gel topical agents AND one prescription topical anti-infective agent.

Note: Examples of topical include: hydrocortisone //ointment [multiple brand and generic products], betamethasone cream/ointment/lotion [Diprolene, generics], clobetasol cream/gel/lotion [Temovate, Clobex, generics], fluocinolone ointment/cream [Synalar, generics], fluocinonide cream/ointment/gel [generics], mometasone cream/lotion/ointment [Elocon, generics], triamcinolone cream/ointment/lotion [generics].

Note: Examples of prescription topical anti-infectives include: mupirocin 2% cream [Bactroban, generics], mupirocin 2% ointment [Bactroban, generics], Centany ointment, Centany AT ointment, Altabax ointment).

Alkindi Sprinkle hydrocortisone 1. Approve if the individual has tried and cannot take hydrocortisone tablets. oral granules 2. Approve if the individual cannot swallow or has difficulty swallowing hydrocortisone tablets. 3. Approve if the individual’s dose cannot be obtained using whole hydrocortisone tablets.

Alocril nedocromil 1. Approve if the individual has tried three products from the following list (if three are sodium 2% formulary; or two if two are formulary; or one if one is formulary): Alomide, ophthalmic cromolyn sodium 4% solution (generics), azelastine 0.05% solution (generics), solution Bepreve, epinastine 0.05% solution (Elestat, generics), Lastacaft, olopatadine 0.2% solution (Pataday, generics), olopatadine 0.1% solution (Patanol, generics), Pazeo, or Zerviate. If none are formulary, approve. alogliptin and alogliptin and 1. Approve if the individual has tried three metformin-DPP-4 inhibitor combination metformin tablets metformin tablets products from the following list (if three are formulary, or two if two are formulary, or (authorized one if one is formulary): Janumet, Janumet XR, Jentadueto, Jentadueto XR, generic of Kombiglyze XR. If none are formulary, approve if the individual has tried metformin Kazano) (Glucophage, Glucophage ER, generics) AND two of the following, if two are formulary (or one if only one is formulary): Onglyza, alogliptin (Nesina, generics), Tradjenta, or Januvia. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Note: Janumet and Janumet XR would count as one alternative. Jentadueto and Jentadueto XR would count as one alternative. alogliptin and alogliptin and 1. Approve if the individual has tried pioglitazone (Actos, generics) AND two of the pioglitazone tablets pioglitazone following, if two are formulary (or one if only one is formulary): Onglyza, alogliptin tablets (authorized (Nesina, generics), Tradjenta, or Januvia. If none are formulary, approve if the generic of Oseni) individual has tried pioglitazone (Actos, generics).

Note: A trial of Oseni or the alogliptin and pioglitazone combination tablets (authorized generics) would not count toward this requirement.

Page 5 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Alomide lodoxamide 1. Approve if the individual has tried three products from the following list (if three are tromethamine formulary; or two if two are formulary; or one if one is formulary): Alocril, cromolyn 0.1% ophthalmic sodium 4% solution (generics), azelastine 0.05% solution (generics), Bepreve, solution epinastine 0.05% solution (Elestat, generics), Lastacaft, olopatadine 0.2% solution (Pataday, generics), olopatadine 0.1% solution (Patanol, generics), Pazeo, or Zerviate. If none are formulary, approve.

2. For a diagnosis of vernal keratoconjunctivitis, vernal conjunctivitis, and vernal keratitis, approve if the individual has tried cromolyn sodium 4% solution (generics). If cromolyn sodium 4% solution (generic) is non-formulary, approve.

Altoprev lovastatin 1. Approve if the individual has tried, and according to the prescriber, has experienced extended-release inadequate efficacy OR significant intolerance with five statins from the following list tablets (if five are formulary or four if four are formulary or three if three are formulary or two if only two are formulary, or one if only one is formulary): lovastatin, atorvastatin {Lipitor, generics}, rosuvastatin {Crestor, generics}, fluvastatin, {Lescol/XL, generics}, pitavastatin {Livalo, Nikita, Zypitamag}, pravastatin {Pravachol}, Livalo, or simvastatin {Zocor, generics}. If none are formulary, approve.

Amitiza and lubiprostone 1. Approve if the individual has tried three products from the following list: Linzess, authorized generic capsules Trulance, or Motegrity, if three are formulary (or two if two are formulary or one if one is formulary). If none are formulary, approve.

2. Individuals with irritable bowel syndrome with constipation: approve if the individual has tried two product from the following list: Linzess, Trulance, or Zelnorm, if two are formulary (or one if one is formulary). If none are formulary, approve.

3. Chronic opioid- induced constipation: approve if the individual has tried three of Movantik, Symproic, or Relistor tablets, if three are formulary or two if two are formulary or one if one is formulary. If none are formulary, approve if individual has tried two laxative agents (e.g., bisacodyl containing products, senna containing products, milk of magnesia, lactulose). Amrix and generic cyclobenzaprine 1. Approve if the individual has tried and cannot take cyclobenzaprine 5 mg or 10 mg extended-release tablets (generics), if formulary. If cyclobenzaprine 5 mg or 10 mg tablets (generics) 15 mg and 30 mg are non-formulary, approve.

Annovera segesterone Approve if the individual meets one of the following criteria (1 or 2): acetate and 1. Individual has tried three other contraceptive agents (e.g., oral contraceptives ethinyl tablets, Twirla [contraceptive patch], Xulane [contraceptive patch], Eluryng vaginal system [contraceptive ], -ethinyl estradiol ring [contracetive vaginal ring], NuvaRing [contraceptive vaginal ring]); OR

Note: A trial of the three different oral contraceptive agents would meet the requirement.

2. If according to the prescriber, these alternatives would not be as medically appropriate for the individual as the requested non-formulary drug.

Apadaz and benzhydrocodone 1. Approve if the individual has tried two other hydrocodone/acetaminophen authorized generic and containing products (e.g., Vicodin, Vicodin ES, Norco, Lortab, Lorcet, multiple acetaminophen generics). tablets Approval duration: 1 month

Page 6 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Apidra insulin glulisine Approve if the individual meets the following (1 or 2): vial/Solostar 1. Individual meets the following (A, B, and C): (prefilled pen) A. Individual has tried Fiasp, if formulary; AND B. Individual has tried one of the following, if formulary: Insulin Lispro (authorized generic of Humalog), Humalog, or Admelog; AND C. Individual has tried one of the following, if formulary: NovoLog or Insulin Aspart (authorized generic of NovoLog);OR 2. Individual is using an insulin pump that is not compatible with the formulary alternative(s), approve.

Note: If no products in A, B, or C are formulary, approve.

Note: The same product with different dosage forms count as one alternative (e.g., Humalog vial and Humalog Kwikpen would count as one alternative). Apokyn apomorphine 1. Parkinson’s Disease: Approve if the individual has tried and, according to the injection prescriber, has experienced inadequate efficacy OR significant intolerance with Kynmobi, if formulary. If Kynmobi is non-formulary, approve.

2. Approve if the individual has already been started on Apokyn.

Aptiom eslicarbazepine 1. Approve if the individual has tried three other antiepileptic agents (e.g., Vimpat acetate tablets tablets or oral solution, topiramate [Topamax, generics], lamotrigine [Lamictal, generics], gabapentin [Neurontin, generics], zonisamide [Zonegran, generics], Lyrica, oxcarbazepine [Trileptal, generics], levetiracetam [Keppra, Keppra XR, generics], divalproex sodium [Depakote, Depakote ER, generics], carbamazepine [Tegretol, Tegretol XR, generics], Spritam, Fycompa, Briviact, Qudexy XR, Trokendi XR, Oxtellar XR).

2. Approve if the individual has been started on Aptiom or has taken Aptiom in the past.

Aranesp darbepoetin alfa 1. Approve if the individual has tried one product from the following list: Epogen, Procrit or Retacrit [documentation required], if one is formulary. If none are formulary, approve.

ArmonAir Digihaler fluticasone 1. Approve if the individual has tried five formulary alternatives from the following list (if propionate five are formulary, or four if four are formulary, or three if three are formulary, or two powder, metered if two are formulary, or one if only one is formulary): Alvesco, Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, or Qvar RediHaler. If none are formulary, approve.

2. If the individual is unable to coordinate breath and actuation with an inhaler, approve if the individual has tried three formulary alternatives from the following list (if three are formulary, or two if two are formulary, or one if only one is formulary): Arnuity Ellipta, Asmanex Twisthaler, Flovent Diskus, Pulmicort Flexhaler, or Qvar RediHaler. If none are formulary, approve.

Note: Asmanex HFA and Asmanex Twisthaler would count as one alternative. Flovent Diskus and Flovent HFA would count as one alternative.

Auvi-Q epinephrine 0.15 1. Approve if the individual has tried and could not appropriately administer one mg and 0.3 mg product from the following list, if formulary: epinephrine auto-injector auto-injector (EpiPen/EpiPen Jr., generics). If none are formulary, approve.

2. Approve if the individual or his/her caregiver is blind or significantly visually- impaired.

Page 7 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Auvi-Q epinephrine 0.1 1. Approve if the individual has tried and could not appropriately administer one mg auto-injector product from the following list, if formulary: epinephrine auto-injector (EpiPen/EpiPen Jr., generics). If none are formulary, approve.

2. Approve if the individual or his/her caregiver is blind or significantly visually- impaired.

3. Individual weighs less than 33 pounds (15 kg): approve.

Aveed 1. Approve if the individual has tried one of the following injectable for products, if one is formulary: injection [generics], intramuscular use injection [Depo-Testosterone, generics], or Xyosted. If none are formulary, approve.

Balcoltra ethinyl estradiol Approve if the individual meets one of the following criteria (1 or 2): 0.02 mg; 1. Individual has tried four other oral contraceptive agents; OR 0.1 2. If according to the prescriber, these alternatives would not be as medically mg; ferrous appropriate for the individual as the requested non-formulary drug. bisglycinate

Beconase AQ beclomethasone 1. Approve if the individual has tried five nasal from the following list, if formulary (or four if four are formulary or three if three are formulary or two if two are formulary or one if one is formulary): fluticasone nasal spray, mometasone nasal spray (Nasonex, generics), flunisolide nasal spray (generics), Omnaris, Qnasl, or Zetonna.

Note: Over-the-counter (OTC) nasal steroids would count as a trial of an alternative.

Besivance besifloxacin 1. Approve if the individual has tried two products from the following list, (if two are ophthalmic formulary, or one if one is formulary): gatifloxacin 0.5% ophthalmic solution suspension 0.6% (Zymaxid, generics), Moxeza, moxifloxacin 0.5% ophthalmic solution (Vigamox, generics), levofloxacin 0.5% ophthalmic solution, ofloxacin 0.3% ophthalmic solution (Ocuflox, generics), or ciprofloxacin 0.3% ophthalmic solution (Ciloxan, generics). If none are formulary, approve.

2. Approve if there is laboratory data that the individual has an eye infection due to pathogens resistant to ciprofloxacin and one other ophthalmic quinolone.

3. For the treatment of currently active eye infections: approve in individuals already receiving Besivance therapy to complete the course of therapy.

Betimol timolol 1. Approve if the individual has tried four of the following, if formulary (or three if three hemihydrates are formulary or two if two are formulary or one if one is formulary): levobunolol 0.25% and 0.5% ophthalmic solution (Betagan, generics), timolol once-daily (Istalol, generics), ophthalmic betaxolol ophthalmic solution (generics), Betoptic S, carteolol opthalmic solution solution (generics),, timolol (Timoptic, generics), Timoptic in Ocudose, and timolol gel- forming solution (Timoptic XE, generics). If none are formulary, approve.

Bijuva estradiol 1 mg and 1. Approve if the individual has tried two oral /progestin combination products 100 from the following list: Activella, Femhrt, Prefest, Premphase, Prempro or generics mg capsules of the products, if two are formulary (or one if one is formulary). If none are formulary, approve.

Page 8 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form BlenRep belantamab 1. Multiple Myeloma: approve if the individual has tried at least four prior systemic mafodotin for lines of therapy, including one therapy from each of the following drug classes (i, ii intravenous and iii) infusion i. A proteasome inhibitor (e.g., Velcade, Kyprolis, Ninlaro); AND ii. An immunomodulary drug (e.g., Revlimid, Pomalyst, Thalomid); AND; iii. An anti-CD38 monoclonal antibody (e.g., Darzalex, Darzalex Faspro, Sarclisa)

2. Multiple Myeloma: Approve if the individual has already been started on BlenRep.

BromSite bromfenac 1. Approve if the individual has tried two products from the following list (if two are 0.075% formulary, or one of the following if one is formulary): Nevanac, Ilevro, diclofenac ophthalmic ophthalmic solution (generics), Acuvail, ketorolac ophthalmic solution (Acular, solution Acular LS, generics), bromfenac 0.09% ophthalmic solution (generics), or Prolensa. If none of the agents are formulary, then approve.

2. Individuals with a sulfite allergy: approve if the individual has tried two of the following, if two are formulary (or one if only one is formulary): diclofenac ophthalmic solution (generics), Nevanac, Ilevro, Acuvail, or ketorolac ophthalmic solution (Acular, Acular LS, generics). If none are formulary, approve. budesonide- budesonide- 1. The individual is directed to use Symbicort (brand), if formulary. If Symbicort formoterol formoterol (brand) is non-formulary, approve if the individual has tried three of the following (if (authorized generic (inhalation three are formulary, or two if two are formulary, or one if only one is formulary): of Symbicort) aerosol) Advair HFA, fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), fluticasone propionate/salmeterol multidose dry powder inhaler (AirDuo RespiClick, authorized generics), AirDuo Digihaler, Breo Ellipta, or Dulera. If none are formulary, approve. 2. Individuals < 18 years of age: approve if the individual has tried two of the following (if two are formulary or one if only one is formulary): Advair HFA, fluticasone propionate/salmeterol multidose dry powder inhaler (AirDuo RespiClick, authorized generics), AirDuo Digihaler, Dulera, or fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics). If none are formulary, approve.

3. Individuals < 12 years of age: approve if the individual has tried two of the following (if two are formulary or one if only one is formulary): fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics) or Dulera. If none are non-formulary, approve.

4. Individuals < 12 years of age with a low inspiratory flow rate who are unable to use a dry powder inhaler (DPI): approve if the individual has tried Dulera, if formulary. If Dulera is non-formulary, approve.

5. Individuals with a low inspiratory flow rate who are unable to use a dry powder inhaler (DPI): approve if the individual has tried both Advair HFA and Dulera (if both are formulary or one if only one is formulary). If neither are formulary, approve.

6. Individuals with COPD: Approve if the individual has tried both fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics) and Breo Ellipta (if both are formulary or one if only one is formulary). If none are formulary, approve.

7. Individuals with COPD AND a low inspiratory flow rate who are unable to use a dry- powder inhaler (DPI): approve.

Note: Fluticasone proprionate-salmetrol inhalation powder, Wixela, and Advair Diskus count as one alternative. Fluticasone propionate-salmeterol multidose dry powder inhaler, AirDuo RespiClick, and AirDuo Digihaler count as one alternative.

Page 9 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Bunavail buprenorphine 1. Approve if the individual has tried one product from the following list (if one is and naloxone formulary): buprenorphine and naloxone sublingual tablets, buprenorphine and buccal film naloxone sublingual film (Suboxone sublingual film, generics), or Zubsolv. If none are formulary, approve. Bupap tablet butalbital 50 mg, 1. Approve if the individual has tried one other formulary butalbital-containing product, acetaminophen if one is formulary (e.g., butalbital/acetaminophen capsule or tablet, 300 mg tablet butalbital/acetaminophen/caffeine capsule or tablet, butalbital/ acetaminophen/caffeine/codeine capsule, butalbital/aspirin/caffeine capsule or tablet, butalbital/aspirin/caffeine/codeine capsule). If none are formulary, approve.

Bystolic nebivolol tablets 1. Approve if the individual has tried and, according to the prescriber, has experienced inadequate efficacy OR significant intolerance with three generic beta-blockers or beta-blocker combination products.

Cabenuva cabotegravir 1. Human Immunodeficiency Virus (HIV). Approve if the individual meets ONE of the extended-release following conditions (A or B): injectable A. Initial Therapy. Approve if the individual meets all of the following (i, ii, suspension; iii, iv, v, vi, and vii): rilpivirine i. Individual is ≥ 18 years of age; AND extended-release ii. Individual has HIV type-1 (HIV-1) infection; AND injectable iii. Individual has HIV-1 RNA < 50 copies/mL (viral suppression) suspension, co- [documentation required]; AND packaged iv. Individual has completed, or will complete, and tolerated 1 month of therapy with Vocabria (cabotegravir tablets) + Edurant (rilpivirine tablets), according to the prescriber; AND v. Prior to initiating Vocabria, the individual was treated with a stable regimen (≥ 4 months) of antiretrovirals for HIV-1 [documentation required]; AND vi. According to the prescriber, the individual meets ONE of the following (a or b): a) Individual has difficulty maintaining compliance with a daily antiretroviral regimen for HIV-1; OR b) Individual has severe gastrointestinal issues that may limit absorption or tolerance of oral medications; AND vii. The medication is prescribed by or in consultation with a physician who specializes in the treatment of HIV infection. B. Individual is Currently Receiving Cabenuva. Approve if the individual meets all of the following (i and ii): i. Individual has HIV type-1 (HIV-1) infection; AND ii. Individual has HIV-1 RNA < 50 copies/mL (viral suppression) [documentation required].

Coverage of Cabenuva is not recommended in the following situations: 1. Pre-exposure Prophylaxis (PrEP). 2. Human Immunodeficiency Virus, Antiretroviral Treatment-Naïve Individuals. 3. Co-administration with Antiretrovirals for Human Immunodeficiency Virus.

Calquence acalabrutinib Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma: capsules 1. Approve if the individual has tried Imbruvica or Venclexta. If neither are formulary, approve. 2. If, per the prescriber, the individual has atrial fibrillation/atrial flutter or is at risk for atrial fibrillation/atrial flutter: approve if the individual has tried Venclexta. If Venclexta is non-formulary, approve. 3. Individual started on therapy with Calquence: approve.

Mantle Lymphoma:

Page 10 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form 1. Approve if the individual has tried Imbruvia or Brukinsa. If neither are formulary, approve. 2. If, per the prescriber, the individual has atrial fibrillation/atrial flutter or is at risk for atrial fibrillation/atrial flutter: approve. 3. Individuals started on therapy with Calquence: approve.

Waldenstrom’s Macroglobulinemia/Lymphoplasmacytic Lymphoma: 1. Approve if the individual has tried at least one prior therapy. Note: Examples of therapies include Imbruvica (ibrutinib tablets and capsules) with or without rituximab; Treanda (bendamustine injection for intravenous infusion); rituximab; rituximab/cyclophosphamide/dexamethasone; Velcade (bortezomib injection for subcutaneous or intravenous use)/dexamethasone/rituximab; Velcade with or without rituximab; Velcade/dexamethasone; and fludarabine with or without rituximab. 2. Individual started on therapy with Calquence: approve.

Marginal Zone Lymphoma: 1. Approve if the individual has tried at least one other therapy for the condition. 2. Individual started on therapy with Calquence: approve.

Caplyta lumateperone 1. Approve if the individual has tried three oral antipsychotic agents (e.g., risperidone capsules tablets/orally disintegrating tablets [ODT]/solution [Risperdal, generics], olanzapine tablets/ODT [Zyprexa/Zydis, generics], quetiapine tablets [Seroquel, generics], quetiapine extended-release tablets [Seroquel XR, generics], aripiprazole tablets [Abilify, generics], ziprasidone capsules [Geodon, generics], Fanapt tablets, Latuda tablets, Rexulti tablets, Vraylar capsules, asenapine sublingual tablets [Saprhis, generics], paliperidone ER tablets [Invega, generics]). 2. Approve if the individual is currently taking Caplyta.

3. Approve if the individual has taken Caplyta at any time in the past.

Carac and fluorouracil 0.5% 1. Approve if the individual has tried one of the following products, if formulary: Tolak, authorized generic cream Fluoroplex, fluorouracil 2% solution, fluorouracil 5% solution, or fluorouracil 5% 0.5% cream (Efudex, generics). If none are formulary, approve.

Ciloxan ointment ciprofloxacin 1. Approve if the individual has tried four products from the following list, if formulary ophthalmic (or three if three are formulary, or two if two are formulary, or one if one is ointment 0.3% formulary): ciprofloxacin 0.3% ophthalmic solution (Ciloxan, generics), gatifloxacin 0.5% ophthalmic solution (Zymaxid, generics), moxifloxacin 0.5% ophthalmic solution (Vigamox, generics), levofloxacin 0.5% ophthalmic solution, or ofloxacin 0.3% ophthalmic solution (Ocuflox, generics). If none are formulary, approve.

2. If the individual is allergic to benzalkonium chloride, approve if the individual has tried moxifloxacin (Vigamox, generics), if formulary. If moxifloxacin (Vigamox, generics) are non-formulary, approve.

3. For the treatment of currently active eye infections: approve in individuals already receiving Ciloxan ointment to complete the course of therapy.

Page 11 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form ciprofloxacin/ ciprofloxacin and 1. Approve if the individual has tried Otovel, if formulary. If Otovel is non-formulary, fluocinolone otic fluocinolone approve if the individual has tried Ciprodex otic suspension or Cipro HC otic solution (authorized acetonide otic suspenstion (if one is formulary). If none are formulary, approve. generic to Otovel) solution, 0.3%/0.025% 2. Individuals treating acute otitis media through tympanostomy tubes (AOMT), individuals with a perforated ear drum (tympanic membrane), or individuals < 1 year of age: approve if the individual has tried Otovel or Ciprodex otic suspension, if one is formulary. If neither are formulary, approve.

3. Individual has a known hypersensitity to a preservative (e.g., benzalkonium chloride [BAK], benzyl alcohol), approve if the individual has tried Otovel, if formulary. If Otovel is non-formulary, approve.

Clenia Plus sodium 1. Direct the individual to a topical product containing sodium sulfacetamide/sulfur sulfacetamide 9%- (e.g., Sulfacetamide Sod 10%, Sulfur 5%, Topical suspension). sulfur 4.25% suspension

Clenpiq sodium 1. Approve if the individual meets one of the following criteria (a, b, c, d, or e): picosulfate; a. Individual has tried PEG3350 powder packet (Moviprep, generics). If oxide; PEG3350 powder packet (Moviprep, generics) are non-formulary, approve; OR anhydrous citric b. If PEG3350 powder packet (generic of Moviprep) is unavailable; OR acid solution c. The individual is less than 18 years of age; OR d. Individuals with phenylketonuria; OR e. Individuals with glucose-6-phosphate dehydrogenase deficiency.

Approval duration: 1 month

Climara Pro estradiol/ 1. Approve if the individual has tried CombiPatch, if formulary. If CombiPatch is non- levonorgestrel formulary, approve if the individual has tried one oral estrogen/progestin patch combination product (e.g., estradiol/norethindrone [Activella, generics], Prempro, Premphase, ethinyl estradiol/norethindrone acetate [Femhrt, generics], Prefest, Angeliq).

Clindagel 1% gel clindamycin 1% 1. Approve if the individual has tried topical clindamycin phosphate gel AND topical and authorized gel erythromycin gel. generic

Cloderm cream (and clocortolone 1. Approve if the individual has tried and, according to the prescriber, has experienced authorized generic) pivalate 0.1% inadequate efficacy OR significant intolerance with five unique, generic prescription- cream strength topical corticosteroid products.

Note: Examples of topical products include: betamethasone, fluocinolone acetonide, hydrocortisone valerate, mometasone, triamcinolone acetonide.

Note: The five products must be chemically unique (i.e., a trial of betamethasone 0.1% and 0.05% would NOT fulfill the requirement). colchicine capsules colchicine 1. Approve if the individual has tried one product from the following list: colchicine capsules tablets (Colcrys, generics), Mitigare capsules, or Gloperba oral solution, if one is formulary. If none are formulary, approve.

Page 12 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Complera emtricitabline/rilpiv 1. Approve if the individual has tried Odefsey, if formulary. If Odefsey is non- irine/tenofovir formulary, approve if the individual has tried one of the following products: Biktarvy, disoproxil Genvoya, Stribild, Triumeq, Symtuza, Atripla, Symfi (generics) or Symfi Lo fumarate (TDF) (generics), if formulary. If none are formulary, approve. tablets 2. Approve if the individual is currently taking single-entity or combination products containing emtricitabine, rilpivirine, and tenofovir disoproxil fumarate and is requesting Complera for a single-table regimen.

3. Individuals already started on therapy with Complera: approve.

Conjupri levamlodipine 1. Approve if the individual has tried and, according to the prescriber, has experienced tablets inadequate efficacy OR a significant intolerance with four formulary products from the following list: amlodipine, felodipine, nifedipine LA, nisoldipine (if four are formulary, or three if three are formulary, or two if two are formulary, or one if one is formulary). 2. If the individual is < 18 years of age, approve if the individual has tried amlodipine, if formulary. If amlodipine is non-formulary, approve.

Corlanor ivabradine tablets 1. Approve if the individual has tried, or is currently taking a beta-blocker (e.g., and solution bisoprolol, carvedilol, metoprolol) OR the individual has a contraindication to beta- blockers. 2. Heart failure due to dilated cardiomyopathy, approve if the individual is < 18 years of age. 3. Inappropriate sinus tachycardia: approve. 4. Approve if the individual has already been started on Corlanor.

Cortifoam hydrocortisone 1. Approve if the individual has tried Uceris foam, if formulary. If Uceris foam is non- acetate aerosol formulary, approve if the individual has tried one corticosteroid from the foam following list (if one is formulary): Cortenema or hydrocortisone enema.. If none are formulary, approve.

2. Individuals who are unable to retain a corticosteroid enema: approve if the individual has tried Uceris, if formulary. If Uceris non-formulary, approve.

Crinone 4% Gel progesterone gel 1. Approve if the individual has tried one product from the following list (if one is 4% formulary): medroxyprogesterone [Provera, generics], , norethindrone tablets [Nor-Q.D., Jolivette, Aygestin, generics], or progesterone capsules (Prometrium, generics). If none are formulary, approve.

Crinone 8% Gel progesterone gel 1. For use as progesterone supplementation/replacement to achieve or maintain 8% : approve if the individual has tried Endometrin, if formulary. If Endometrin is non-formulary, approve.

2. Individuals started on a course of therapy with Crinone 8% gel for progesterone supplementation/replacement to achieve or maintain pregnancy: approve to complete the current course of therapy.

3. Approve if the individual has tried one product from the following list (if one is formulary): medroxyprogesterone [Provera, generics], megestrol acetate, norethindrone tablets [Nor-Q.D., Jolivette, Aygestin, generics], or progesterone capsules (Prometrium, generics). If none are formulary, approve.

Cutaquig Immune globulin 1. Approve if the individual has tried three products from the following list, if formulary subcutaneous (or two if two are formulary or one if one is formulary): Cuvitru, Hizentra, Xembify, [human] 16.5% Gamunex-C, Gammagard , or Gammaked. If none are formulary, approve. solution

Page 13 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Cystadrops cysteamine 1. Cystinosis with Corneal Cysteine Crystal Deposits: Approve, if the individual has ophthalmic tried Cystaran, if formulary. If Cystaran is non-formulary, approve. solution Daliresp roflumilast tablets 1. Approve if the individual has tried one formulary agent from at least two of the following classes: long-acting beta2-agonists [LABAs]: Perforomist, Brovana, Serevent Diskus, or Striverdi Respimat), long-acting muscarinic antagonists [LAMAs]: Spiriva HandiHaler/Respimat, Tudorza Pressair, Incruse Ellipta, methylxanthines (aminophylline or theophylline), or inhaled corticosteroids [ICSs]: Pulmicort Flexhaler, Flovent HFA, Flovent Diskus, Asmanex Twisthaler, Asmanex HFA, Qvar RediHaler, Arnuity Ellipta, ArmonAir RespiClick, and Alvesco.

NOTE: If the individual has tried one formulary combination LABA/ICS product: Advair Diskus, fluticasone-salmeterol Diskus, Wixela Inhub, Advair HFA, AirDuo RespiClick, Dulera, Symbicort, Breo Ellipta or one formulary combination LAMA/LABA product: Anoro Ellipta, Stiolto Respimat, Bevespi Aerosphere, Duaklir Pressair that would meet this requirement.

Delstrigo doravirine/lamivud 1. Approve if the individual has tried one of the following products: Biktarvy, Genvoya, ine/tenofovir Odefsey, Stribild, Complera, Triumeq, Symtuza, Symfi (generics) or Symfi Lo disoproxil (generics), if formulary. If none are formulary, approve. fumarate tablets 2. Approve if the individual is currently taking single-entity or combination products containing doravirine, lamivudine, and tenofovir disoproxil fumarate and is requesting Delstrigo for a single tablet regimen.

3. Individuals already started on therapy with Delstrigo, approve.

Diabetic Supplies Blood glucose 1. Approve if the individual has tried one formulary meter/test strip/control solution meters/test (e.g. Freestyle, One Touch, Verio, Verio Flex, Precision, Accu-Check, Breeze, strips/control Contour, Truetest, Truetrack). If none are formulary, approve. /continuo Note: This is not an all-inclusive list of blood glucose meters/test strips/control us glucose solutions. monitoring Note: A TRIAL OF THE REQUESTED PRODUCT WOULD NOT COUNT products TOWARD THIS REQUIREMENT.

2. If requesting a continuous glucose monitoring (CGM) monitor/receiver or supplies (sensor, transmitter), approve if the individual has tried one formulary CGM product (e.g., Freestyle Libre, Dexcom, Eversense). If no CGMs are formulary, approve if the individual has tried one traditional formulary meter/test strip/control solution. If none are formulary, approve. Note: This is not an all-inclusive list of continuous glucose monitoring products. Note: A TRIAL OF THE REQUESTED PRODUCT WOULD NOT COUNT TOWARD THIS REQUIREMENT.

3. Individuals who are blind or significantly visually impaired who are requesting a meter with audio capabilities: approve if the individual has tried one other formulary meter with audio capabilities (e.g., Advocate [Redi-Code], Arkray [Glucocard Expression, Glucocard Shine Express], Foracare [Fora D40D, Fora D40G, For a Premium V10 BLE, Fora Test N’ Go, For a Tn’G Voice, Fora V30], Oak Tree Health [EasyMax V, Fortiscare V3], Omnis Health [Embrace Talk], Prodigy [Prodigy Autocode, Prodigy Voice], Relion Premier Voice). If none are formulary, approve. Note: This is not an all-inclusive list of blood glucose meters with audio capabilities. Note: A TRIAL OF THE REQUESTED PRODUCT WOULD NOT COUNT TOWARD THIS REQUIREMENT.

Page 14 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form 4. Individuals using an insulin pump/meter system that is not compatible with one of the available formulary alternatives: approve.

5. If the request is for Freestyle Precision Neo strips for use in a Freestyle Libre reader, approve. diclofenac diclofenac 1. Direct the individual to use Flector patch (brand), if formulary. If Flector patch epolamine 1.3% epolamine 1.3% (brand) is non-formulary, approve if the individual has tried, and according to the topical patch topical patch prescriber, has experienced inadequate efficacy OR significant intolerance with four (authorized generic products from the following list (if four are formulary or three if three are formulary or of Flector Patch) two if two are formulary or one if one is formulary): Licart 1.3% topical system, Pennsaid 2.0% topical solution (pump), diclofenac sodium 1.5% topical solution (generics), or prescription diclofenac sodium topical 1% gel (Voltaren 1% gel, generics), if one is formulary. If none are formulary, approve if the individual has tried over-the-counter Voltaren 1% gel.

Dipentum olsalazine capsule 1. Approve if the individual has tried two products from the following list (if two are formulary, or one if one is formulary): mesalamine delayed-release tablets (Asacol HD, generics), sulfasalazine (generics), mesalamine delayed-release tablets (Lialda, generics), Delzicol, balsalazide (Colazal, generics), mesalamine extended- release capsules (Apriso, generics) or Pentasa. If none are formulary, approve.

Divigel estradiol gel 0.1% 1. Approve if the individual has tried one formulary non-patch topical estradiol product: Elestrin, Evamist, Estrogel, if one is formulary. If none of these are formulary, then approve if the individual has tried one estradiol patch (e.g., Alora, estradiol patch [Climara, Vivelle Dot generics], Minivelle [generics).

Doral and quazepam tablets 1. Approve if the individual has tried estazolam or lorazepam, if formulary. If neither authorized generic are formulary, approve.

Doryx DR 80 mg and doxycycline 1. Direct individual to other doxycycline products. authorized generic hyclate delayed- release tablets An approval can be provided if, per the prescriber, the 80 mg tablet is required to meet the prescribed dosing requirement. doxycycline 40 mg doxycycline 40 mg 1. Approve if the individual has tried one other formulary oral doxycycline product. capsules capsules (authorized generic NOTE: A trial of the requested product does not count toward the requirement. of Oracea) Drizalma Sprinkle duloxetine 1. Approve if the individual has tried one product from the following list (if one is delayed-release formulary): duloxetine capsules (Cymbalta, generics), Fetzima, desvenlafaxine capsules succinate extended-release (ER) [Pristiq, generics], venlafaxine ER capsules (Effexor XR, generics), or venlafaxine extended-release tablets. If none are formulary, approve.

NOTE: If individual has tried venlafaxine immediate-release, a trial of venlafaxine extended-release is not required.

2. Approve if the individual is unable to swallow, has difficulty swallowing, or requires administration via a nasogastric tube.

Page 15 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Drysol aluminum chloride 1. Approve if the individual has tried one over-the-counter aluminum-containing 20% topical product (such as Certain Dri, Bromi-lotion). solution

Duaklir Pressair aclidinium 1. Approve if the individual has tried three of Anoro Ellipta, Bevespi Aerosphere, or bromide and Stiolto Respimat, if three are formulary, or two if two are formulary or one if one is formoterol formulary. fumarate inhalation powder 2. If the individual is unable to coordinate breath and actuation with a metered-dose inhaler (MDI), approve if the individual has tried Anoro Ellipta, if formulary. If Anoro Ellipta is non-formulary, approve.

3. If none of the LAMA/LABA combination inhalers are formulary, approve if the individual has tried one formulary single-entity long-acting beta-agonist (LABA) inhaler: Serevent Diskus or Striverdi Respimat AND one formulary single-entity long-acting muscarinic antagonist (LAMA) inhaler: Incruse Ellipta, Spiriva HandiHaler, Spiriva Respimat, or Tudorza Pressair. If there are no formulary single-entity LABAs, approve. If there are no formulary single-entity LAMAs, approve.

Dutoprol metoprolol 1. Approve if the individual has tried and, according to the prescriber, has experienced succinate inadequate efficacy OR a significant intolerance with metoprolol-HCTZ (immediate- extended- release) tablets. release/HCTZ tablets 2. Approve if the individual has tried and, according to the prescriber, has experienced inadequate efficacy OR a significant intolerance with metoprolol succinate extended-release tablets (Toprol XL, generics) AND hydrochlorothiazide (HCTZ) taken concomitantly.

Ecoza foam econazole nitrate 1. Approve if the individual has tried and, according to the prescriber, has experienced topical foam inadequate efficacy OR a significant intolerance with five topical .

Note: Examples of topical antifungals include: naftifine 1% or 2% cream or 1% gel (Naftin, generics), Naftin 2% gel, Lotrimin Ultra (over-the-counter [OTC]), clotrimazole 1% cream (OTC formulation), econazole 1% cream, 2% cream or foam (Extina, generics), Oxistat 1% lotion, oxiconazole 1% cream (Oxistat, generics), Ertaczo 2% cream, Exelderm 1% cream or solution, ciclopirox 0.77% cream or gel (generics), Mentax 1% cream, Xolegel 2% gel. Edarbi azilsartan 1. Approve if the individual has tried five of the following, if five are formulary (or four if four are formulary or three if three are formulary or two if two are formulary; or one if only one is formulary): candesartan (Atacand, generics), irbesartan (Avapro, generics), olmesartan (Benicar, generics), losartan (Cozaar, generics), valsartan (Diovan, generics), telmisartan (Micardis, generics), or eprosartan. If none are formulary, approve.

2. Individuals recently hospitalized (and discharged within 30 days) for a cardiovascular event (e.g., myocardial infarction [MI], hypertensive emergency) who has already been started and stabilized on Edarbi: approve.

Page 16 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Edarbyclor azilsartan and 1. Approve if the individual has tried five of the following formulary angiotensin chlorthalidone receptor blocker/diuretic combination products, if five are formulary, or four if four tablets are formulary, or three if three are formlary, or two are formulary, or one if only one is formulary): candesartan-hydrochlorothiazide (Atacand HCT, generics), irbesartan-hydrochlorothiazide (Avalide, generics), losartan-hydrochlorothiazide (Hyzaar, generics), telmisartan-hydrochlorothiazide (Micardis HCT, generics), valsartan-hydrochlorothiazide (Diovan HCT, generics), olmesartan- hydrochlorothiazide (Benicar HCT, generics).

2. Approve if the individual has tried chlorthalidone AND Edarbi, if Edarbi is formulary. If Edarbi is non-formulary, approve if the individual has tried five of the following formulary angiotensin receptor blockers (ARBs), if five are formulary or four if four are formulary or three if three are formulary, or two if only two are formulary; or one if only one is formulary): candesartan (Atacand, generics), irbesartan (Avapro, generics), olmesartan (Benicar, generics), losartan (Cozaar, generics), valsartan (Diovan, generics), telmisartan (Micardis, generics), or eprosartan. If none are formulary, approve.

Elestrin estradiol gel 1. Approve if the individual has tried one formulary non-patch topical estradiol product: 0.06% Elestrin, Evamist, Estrogel, if one is formulary. If none of these are formulary, then approve if the individual has tried one estradiol patch (e.g., Alora, estradiol patch [Climara, Vivelle Dot generics], Minivelle [generics).

Emend oral aprepitant oral 1. Approve if the individual has tried one formulary alternative from the following list: suspension suspension aprepitant capsules (Emend, generics) or Varubi tablets. If none are formulary, approve.

2. Individuals ≥ 12 and <18 years of age: approve if the individual has tried aprepitant capsules (Emend, generics), if formulary. If aprepitant capsules (Emend, generics) are non-formulary, approve.

3. Individuals < 12 years of age: approve.

4. Individuals who cannot swallow or have difficulty swallowing capsules, approve.

5. Approve if the individual has already started Emend oral suspension to complete all cycles in the current course of chemotherapy.

Emflaza deflazacort tablets Duchenne Muscular Dystrophy (DMD): Approve if the individual meets the following and oral criteria (A or B): suspension A. Initial Therapy. Approve if the individual meets the following criteria (i, ii, and iii): i. The individual is 2 years of age or older; AND ii. The individual meets ONE of the following conditions (a or b): a. Individual has tried prednisone or prednisolone for ≥ 6 months [documentation required] AND according to the prescriber, the individual has had at least one of the following significant intolerable adverse effects (AEs) [1, 2, 3, or 4]: 1. Cushingoid appearance [documentation required]; OR 2. Central (truncal) obesity [documentation required]; OR 3. Undesirable weight gain, defined as a ≥ 10% of body weight gain increase over a 6-month period [documentation required]; OR 4. Diabetes and/or hypertension that is difficult to manage according to the prescriber [documentation required]; OR b. According to the prescriber, the individual has experienced a severe behavioral adverse event while on prednisone or prednisolone therapy that has or would require a prednisone or prednisolone dose reduction [documentation required]; AND iii. The medication is prescribed by or in consultation with a physician who specializes in the treatment of Duchenne muscular dystrophy and/or neuromuscular disorders.

Page 17 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form

B. Individual is Currently Receiving Emflaza. Approve if the individual meets the following criteria (i, ii, and iii): i. Individual has tried prednisone or prednisolone [documentation required]; AND ii. According to the prescriber, the individual has responded to or continues to have improvement or benefit from Emflaza therapy [documentation required]; AND

Note: Examples of improvement or benefit from Emflaza therapy would include improvements in motor function (time from supine to standing, time to climb four stairs, time to run or walk 30 feet), improvement in muscle strength, improve pulmonary function, etc.

iii. The medication is prescribed by or in consultation with a physician who specializes in the treatment of Duchenne muscular dystrophy and/or neuromuscular disorders.

Envarsus XR tacrolimus 1. Approve if the individual has tried and cannot take tacrolimus immediate-release extended-release capsules (Prograf, generics), if formulary. If tacrolimus immediate-release capsules tablets (Prograf, generics) are non-formulary, approve. 2. Approve if the individual has the CYP3A5*1 allele. Note: The CYP3A5*1 allele is a gene variant determined by testing that may confer faster metabolism of certain medications. 3. If the individual has already started on therapy with Envarsus XR, approve.

Epaned enalapril maleate 1. Approve if the individuals has tried enalapril tablets (Vasotec, generics), if powder for oral formulary. If enalapril tablets (Vasotec, generics) are non-formulary, approve. solution, enalapril maleate oral 2. Approve if the individual cannot swallow or has difficulty swallowing tablets. solution

Epiduo Forte adapalene 0.3%- 1. Approve if the individual has tried adapalene 0.1%-benzoyl peroxide 2.5% gel benzoyl peroxide (Epiduo, generics). 2.5%

epinephrine auto- epinephrine 0.15 1. Approve if the individual has tried one product from the following list, if one is injector (authorized mg, 0.3 mg auto- formulary: epinephrine auto-injector (EpiPen/EpiPen Jr., generics). If none are generic for injector authorized formulary, approve. Adrenaclick) generic (Impax and A-S Medication)

Epogen epoetin alfa 1. Approve if the individual meets the following criteria (A and B): A. Individual meets the following criteria (i and ii): i. Individual has tried both products from the following list, if formulary (or one if only one is formulary): Procrit and Retacrit [documentation required]; AND Note: If neither are formulary, would still need to meet criteria B, if Aranesp is formulary. ii. Individual cannot continue to use each formulary alternative due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction; AND B. Individual has tried Aranesp, if formulary [documentation required]. Note: If none of the following products are formulary: Aranesp, Procrit, and Retacrit, approve.

Page 18 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form 2. Pediatric individuals with anemia due to cancer chemotherapy; Individuals undergoing surgery requesting agent for the reduction of allogeneic red blood cell transfusion; Individuals with anemia and human immunodeficiency virus (HIV) infection who are receiving zidovudine:

Individual meets the following criteria (i and ii): i. Individual has tried both products from the following list, if formulary (or one if only one is formulary): Procrit and Retacrit [documentation required]; AND Note: If neither are formulary, approve. ii. Individual cannot continue to use each formulary alternative due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction. esomeprazole esomeprazole 1. Approve if the individual has tried five proton pump inhibitors (PPIs). strontium 49.3 mg capsules Note: Examples of PPIs include rabeprazole delayed-release (DR) tablets (Aciphex, generics), Aciphex Sprinkle DR capsules or authorized generic, Dexilant DR capsules, esomeprazole DR capsules (Nexium, generics), pantoprazole DR tablets (Protonix, generics), Protonix suspension (granules), lansoprazole DR capsules (Prevacid, generics), lansoprazole oral disintegrating tablets (Prevacid Solutab, generics), omeprazole DR capsules (Prilosec, generics), Prilosec DR suspension, omeprazole/sodium bicarbonate capsules (Zegerid, generics), or omeprazole/sodium bicarbonate packet (Zegerid, generics). Estring estradiol 2 mg 1. Approve if the individual has tried two formulary alternatives from the following list vaginal ring (or one if only one is formulary): Imvexxy vaginal insert, Femring vaginal ring, Premarin Cream, estradiol 0.01% cream (Estrace Cream, generics), or estradiol vaginal tablet (e.g., Yuvafem, Vagifem, generics). If none are formulary, approve.

2. If according to the prescriber, the individual requires a low-dose vaginal product, approve if the individual has tried one of Imvexxy vaginal insert or estradiol vaginal tablets (e.g., Yuvagen, Vagifem, generics), if formulary. If neither are formulary, approve.

Estrogel estradiol gel 1. Approve if the individual has tried one formulary non-patch topical estradiol product: 0.06% Elestrin, Evamist, Estrogel, if one is formulary. If none of these are formulary, then approve if the individual has tried one estradiol patch (e.g., Alora, estradiol patch [Climara, Vivelle Dot generics], Minivelle [generics).

Evamist estradiol 1. Approve if the individual has tried one formulary non-patch topical estradiol product: spray Elestrin, Evamist, Estrogel, if one is formulary. If none of these are formulary, then approve if the individual has tried one estradiol patch (e.g., Alora, estradiol patch [Climara, Vivelle Dot generics], Minivelle [generics).

Evzio and naloxone 1. Approve if the prescriber can confirm that the individual’s caregiver is blind or authorized generic hydrochloride significantly visually impaired. injection (auto- injector) Note: If the prescriber does not know or cannot confirm that the individual’s caregiver is blind or significantly visually impaired, the request should NOT be approved.

Note: Denial reason is: Coverage is provided in situations where the prescriber can confirm that the individual’s caregiver is blind or significantly visually impaired. The individual should be prescribed naloxone syringe for injection or Narcan Nasal Spray, whichever is formulary.

Page 19 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Exelderm and sulconazole 1. Approve if the individual has tried four topical antifungals (e.g., naftifine 1% or 2% authorized generic nitrate 1% (cream cream or 1% gel (Naftin, generics), Naftin 2% gel, Lotrimin Ultra [over-the-counter (sulconazole nitrate and solution) {OTC}], clotrimazole 1% cream [OTC formulation], econazole 1% cream, Ecoza 1% 1%) foam, ketoconazole 2% cream or foam [Extina, generics], Oxistat 1% lotion, oxiconazole 1% cream (Oxistat, generics), Ertaczo 2% cream, ciclopirox 0.77% cream or gel [generics], Luzu 1% cream, Mentax 1% cream, Xolegel 2% gel).

Extavia interferon beta-1b 1. Approve if the individual has tried three formulary products from the following list: injection Betaseron, Rebif, Avonex, or Plegridy [documentation required], if three are formulary (or two if two are formulary or one if one is formulary). If none are formulary, approve.

Note: Avonex administration pack and Avonex Pen would count as one alternative. Rebif and Rebif Rebidose would count as one alternative.

2. If the individual has been established on Extavia for greater than or equal to 120 days, direct to Betaseron. If Betaseron is non-formulary, approve.

Ezallor Sprinkle rosuvastatin 1. Approve if the individual has tried, and according to the prescriber, has experienced capsules inadequate efficacy OR significant intolerance with three statins from the following list (if three are formulary or two if only two are formulary, or one if only is formulary): lovastatin, rosuvastatin (Crestor, generics), atorvastatin (Lipitor, generics), fluvastatin (Lescol/XL, generics), pitavastatin (Livalo, Nikita, Zypitamag), pravastatin (Pravachol), Livalo, or simvastatin (Zocor, generics). If none are formulary, approve.

2. Individuals who cannot swallow or have difficulty swallowing tablets or capsules, approve.

Fabior and tazarotene 0.1% 1. Approve if the individual has tried one of tazarotene cream (Tazorac cream, authorized generic foam generics) or Tazorac gel, if one is formulary. If none are formulary, approve.

Femring estradiol vaginal 1. Approve if the individual has tried two formulary alternatives from the following list ring (0.05 mg and (or one if only one is formulary): Imvexxy vaginal insert, Premarin cream, estradiol 0.10 mg) 0.01% cream (Estrace Cream, generics), Estring vaginal ring, estradiol vaginal tablet (e.g., Yuvafem, Vagifem, generics), Alora patch, estradiol patch (Climara, generics), estradiol patch (Vivelle Dot, generics), Menostar patch, estradiol tablets (Estrace, generics), Menest tablets, or Premarin tablets. If none are formulary, approve.

Fenoprofen fenoprofen 1. Approve if the individual has tried five prescription-strength, oral NSAIDs. capsules [brand] capsules Note: For example: fenoprofen (tablets/generic), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

Fenortho fenoprofen 1. Approve if the individual has tried five prescription-strength, oral NSAIDs. capsules Note: For example: fenoprofen (tablets/generic), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics),

Page 20 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

Fensolvi leuprolide acetate 1. Approve if the individual has tried both Lupron Depot-Ped and Triptodur, if for injectable formulary, or try one if one is formulary. If neither are formulary, approve. suspension 2. Gender-dysphoric/gender-incongruent persons; persons undergoing gender reassignment (female-to-male or male-to-female), approve if the individual has tried Lupron Depot-Ped, if formulary. If Lupron Depot-Ped is non-formulary, approve.

Fiasp insulin aspart Approve if the individual meets the following (1 or 2): injection vial, pen, 1. Individual meets the following (A, B, and C): cartridge A. Individual has tried Apidra, if formulary; AND B. Individual has tried one of the following, if formulary: Insulin Lispro (authorized generic of Humalog), Humalog, or Admelog; AND C. Individual has tried one of the following, if formulary: NovoLog or Insulin Aspart (authorized generic of NovoLog); OR

2. Individual is using an insulin pump that is not compatible with the formulary alternative(s), approve.

Note: If no products in A, B, or C are formulary, approve.

Note: The same product with different dosage forms count as one alternative (e.g., Humalog vial and Humalog Kwikpen would count as one alternative).

Fintepla fenfluramine oral 1. Dravet Syndrome: Approve if the individual meets ONE of the following (a or b): solution a. The individual has tried or is concomitantly receiving one of Epidiolex or Diacomit, if formulary. If neither are formulary, approve; OR b. The individual has tried or is concomitantly receiving at least two other antiepileptic drugs.

Note: Examples of other antiepileptic drugs include valproic acid, clobazam, topiramate, clonazepam, levetiracetam, zonisamide.

2. Dravet Syndrome: Approve if the individual has already been started on therapy with Fintepla.

Firdapse amifampridine 10 1. Approve if the individual has tried Ruzurgi, if formulary. If Ruzurgi is non-formulary, mg tablets approve.

Firvanq vancomycin oral 1. Approve if the individual has tried vancomycin capsules (Vancocin oral capsule, solution generics) or vancomycin oral solution (Vancocin oral solution, generics), if formulary. If neither are formulary, approve.

2. If the individual is unable to swallow or has difficulty swallowing capsules, approve if the individual has tried vancomycin oral solution (Vancocin oral solution, generics), if formulary. If vancomycin oral solution is non-formulary, approve.

Page 21 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Flarex fluorometholone 1. Approve if individual has tried two formulary ophthalmic corticosteroids from the acetate following list: dexamethasone (generics), Maxidex, fluorometholone (FML Liquifilm, ophthalmic generics), FML Forte/S.O.P., Inveltys, Durezol, loteprednol etabonate (Lotemax, suspension 0.1% generics), Lotemax SM, prednisolone (Pred Forte, Omnipred, generics), or Pred Mild, if two are formulary (or one if one is formulary). If none are formulary, approve.

2. If the individual has elevated intraocular pressure (IOP) or glaucoma after a trial of another corticosteroid (i.e., topical, inhaled, oral, ophthalmic): approve if the individual has tried one of the following, if one is formulary: fluorometholone (FML Liquifilm, generics), FML Forte/S.O.P., Inveltys, loteprednol etabonate (Lotemax, generics), Lotemax SM, or Durezol. If none are formulary, approve. fluticasone fluticasone 1. Approve if the individual has tried four of the following (if four are formulary, or three propionate/salmeter propionate/salmet if three are formulary, or two if two are formulary, or one if only one is formulary): ol multidose dry erol inhalation Advair HFA, fluticasone propionate/salmeterol inhalation powder, Wixela (Advair powder inhaler powder Diskus, generics), AirDuo RespiClick, AirDuo Digihaler, Breo Ellipta, Dulera or (authorized Symbicort. If none are formulary, approve. generic to AirDuo RespiClick) 2. Individuals who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried two of the following (if two are formulary or one if only one is formulary): fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), AirDuo RespiClick, AirDuo Digihaler, or Breo Ellipta. If none are formulary, approve.

3. Individuals < 18 years of age: approve if the individual has tried three of the following (if three are formulary, or two if two are formulary, or one if only one is formulary): Symbicort, Advair HFA, fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), AirDuo RespiClick, AirDuo Digihaler, or Dulera. If none are formulary, approve.

4. Individuals < 18 years of age who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried one of fluticasone propionate/salmeterol inhalation powder, Wixela (Advair Diskus, generics), AirDuo RespiClick, or AirDuo Digihaler, if formulary. If neither are formulary, approve.

Note: Fluticasone proprionate-salmetrol inhalation powder, Wixela, and Advair Diskus count as one alternative. AirDuo RespiClick and AirDuo Digihaler count as one alternative.

FML Forte fluorometholone 1. Approve if individual has tried two formulary ophthalmic corticosteroids from the 0.25% ophthalmic following list: dexamethasone (generics), Maxidex, fluorometholone (FML Liquifilm, suspension generics), FML S.O.P., Flarex, Inveltys, Durezol, loteprednol etabonate (Lotemax, generics), Lotemax SM, prednisolone (Pred Forte, Omnipred, generics), or Pred Mild, if two are formulary (or one if one is formulary). If none are formulary, approve.

2. If the individual has elevated intraocular pressure (IOP) or glaucoma after a trial of another corticosteroid (i.e., topical, inhaled, oral, ophthalmic): approve if the individual has tried one of the following, if one is formulary: loteprednol etabonate (Lotemax, generics), Lotemax SM, Inveltys, fluorometholone (FML Liquifilm, generics), FML S.O.P., Flarex, or Durezol. If none are formulary, approve.

FML S.O.P. fluorometholone 1. Approve if individual has tried two formulary ophthalmic corticosteroids from the ophthalmic following list: dexamethasone (generics), Maxidex, fluorometholone (FML Liquifilm, ointment 0.1% generics), Flarex, FML Forte, Inveltys, Durezol, loteprednol etabonate (Lotemax, generics), Lotemax SM, prednisolone (Pred Forte, Omnipred, generics), or Pred

Page 22 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Mild, if two are formulary (or one if one is formulary). If none are formulary, approve.

2. Approve if the individual has elevated intraocular pressure (IOP) or glaucoma after a trial of another corticosteroid (i.e., topical, inhaled, oral, ophthalmic): approve if the individual has tried one of the following, if one is formulary: loteprednol etabonate (Lotemax, generics), Lotemax SM, Inveltys, fluorometholone (FML Liquifilm, generics), Flarex, FML Forte, or Durezol. If none are formulary, approve.

Follistim AQ follitropin beta 1. Approve if the individual has tried one product from the following list: Gonal- F/Gonal-F RFF, if formulary. If Gonal-F/Gonal-F RFF is non-formulary, approve.

2. Individual has been started on a current cycle of therapy with Follistim AQ: approve to complete the current cycle.

Fosrenol oral lanthanum 1. Approve if the individual has tried two formulary alternatives from the following list (if powder carbonate oral two are formulary or one if one is formulary): sevelamer hydrochloride tablets powder (Renagel, generics), Velphoro chewable tablets, Auryxia tablets, Phoslyra, or sevelamer carbonate tablets/powder for oral suspension (Renvela, generics). If none are formulary, approve.

2. Individuals who are unable to chew and swallow tablets: approve if the individual has tried sevelamer carbonate powder for oral suspension (Renvela powder, generics), if formulary. If sevelamer carbonate powder for oral suspension (Renvela powder, generics) is non-formulary, approve.

Fotivda tivozanib capsules Renal Cell Carcinoma. Approve if the individual meets one of the following (1 or 2): 1. Individual has tried one other kinase inhibitor; OR For example: Sutent, Cabometyx, Inlyta, Lenvima, Votrient, Nexavar, or Afinitor. 2. Individual has already been started on therapy with Fotivda.

Gimoti metoclopramide 1. No exceptions are recommended. Due to insufficient clinical efficacy data, approval nasal spray is not recommended for Gimoti. (NOTE: It is not appropriate to use standard global criteria for this medication; Denial reason is: No exceptions are recommended. Due to insufficient clinical efficacy data, approval is not recommended.)

Glumetza metformin 1. Approve if the individual has tried BOTH one metformin immediate-release tablet extended-release product AND two other formulary metformin extended-release products (if two are tablets formulary or one if one is formulary): metformin extended-release tablets, Fortamet (brand or generic), or Riomet ER.

NOTE: A trial of Glumetza would NOT count toward this requirement.

Gocovri ER amantadine 1. Approve if the individual has tried one product from the following list: amantadine extended-release capsules, amantadine tablets, or amantadine oral solution AND experienced capsules inadequate efficacy or intolerability with the product.

Golytely packets polyethylene 1. Direct to peg-electrolyte solution (Golytely, generics) [not in packet form]. glycol; electrolytes powder for Approval duration: 1 month solution

Page 23 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Granix tbo-filgrastim 1. Approve if the individual meets BOTH of the following (a and b): injection a. Individual has tried three of the following products (if three are formulary, or two if two are formulary, or one if one is formulary): Neupogen, Nivestym, or Zarxio [documentation required]; AND Note: If none are formulary, approve. b. Individual cannot continue to use each of the formulary alternative(s) due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction. 2. Individuals requiring a dose < 180 mcg: approve if the individual meets the following (a and b): a. Individual has tried Neupogen or Nivestym [documentation required], if formulary; AND Note: If neither are formulary, approve. b. Individual cannot continue to use each of the formulary alternative(s) due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction. 3. Individuals who initiated therapy with Granix and requires further medication to complete the current cycle of chemotherapy: approve.

Helidac bismuth 1. Approve if the individual meets ONE of the following (A or B): subsalicylate A. The individual has tried and, according to the prescriber, has experienced chewable tablets, inadequate efficacy OR significant intolerance with two different regimens of metronidazole single-entity products (e.g., clarithromycin + amoxicillin + proton pump inhibitor tablets, [e.g., omeprazole, lansoprazole]; bismuth subcitrate + + tetracycline metronidazole + proton pump inhibitor [e.g., omeprazole, lansoprazole]); OR capsules B. The individual has tried and, according to the prescriber, has experienced inadequate efficacy OR significant intolerance to any TWO pre-packaged products (e.g., amoxicillin/clarithromycin/lansoprazole (Prevpac, generics), Omeclamox-Pak, Talicia, Pylera).

Approval duration: 1 month

Hemady dexamethasone 1. Approve if the individual has tried generic dexamethasone tablets, if formulary. If 20 mg tablets dexamethasone tablets are non-formulary, approve.

Humatrope somatropin Growth hormone deficiency (GHD) in children, Turner syndrome, GHD in adults, Prader injection Willi syndrome, Idiopathic short stature in children, Children with chronic kidney disease, Short Stature Homeobox-Containing Gene deficiency, Children Born Small for Gestational Age or with Intrauterine Growth Restriction, Noonan syndrome, Short bowel syndrome: 1. Approve if the individual has tried five of the following (if five are formulary, or four if four are formulary, or three if three are formulary, or two if only two are formulary, or one if only one is formulary): Genotropin, Norditropin Flexpro, Nutropin AQ, Omnitrope, Saizen, or Zomacton. If none are formulary, approve.

Impeklo clobetasol 1. Approve if the individual has tried and, according to the prescriber, has experienced propionate lotion, inadequate efficacy OR significant intolerance with five unique, generic prescription- 0.05% strength topical corticosteroid products.

Note: Examples of topical steroid products include: desoximetasone, triamcinolone, desonide, betamethasone, clobetasol, fluocinonide, halobetasol, mometasone, halcinonide, diflorasone.

Page 24 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form NOTE: The five products must be chemically unique (i.e., a trial of desoximetasone 0.05% and 0.25% would NOT fulfill the requirement).

Imvexxy estradiol vaginal 1. Approve if the individual has tried two formulary alternatives from the following list insert (or one if only one is formulary): Premarin vaginal cream, Femring vaginal ring, estradiol 0.01% cream (Estrace Cream, generics), Estring vaginal ring, or estradiol vaginal tablet (e.g., Yuvafem, Vagifem, generics). If none are formulary, approve.

2. If according to the prescriber, the individual requires a low-dose vaginal product, approve if the individual has tried one of Estring or estradiol vaginal tablets (e.g., Yuvagen, Vagifem, generics), if formulary. If neither are formulary, approve.

Inderal XL propranolol 1. Direct the individual to propranolol extended-release capsules. If propranolol hydrochloride extended-release capsules are non-formulary, approve. capsule, extended release

Ingrezza and valbenazine 1. Approve if the individual has tried Austedo [documentation required], if formulary. titration pack capsules If Austedo is non-formulary, approve if the individual has tried tetrabenazine tablets (Xenazine, generics), if formulary. If tetrabenazine tablets (Xenazine, generics) are non-formulary, approve.

Innopran XL propranolol 1. Direct the individual to propranolol extended-release capsules. If propranolol hydrochloride extended-release capsules are non-formulary, approve. capsule, extended release

Inqovi decitabine and 1. Approve if the individual has tried decitabine injection (Dacogen, generics), if cedazuridine formulary. tablets 2. If decitabine injection (Dacogen, generics) is non-formulary, approve.

3. Approve if the individual is unable to obtain and/or maintain intravenous access.

4. Approve if the individual has already started therapy with Inqovi.

Inrebic febratinib For Myelofibrosis: capsules 1. Approve if the individual has tried Jakafi, if formulary. If Jakafi is non-formulary, approve. 2. Approve if the individual has already been started on Inrebic.

Insulin Lispro JR Insulin lispro JR 1. Direct the individual to Humalog JR (brand). If Humalog JR (brand) is non- formulary, approve.

Insulin Lispro Mix 75% Insulin lispro 1. Direct the individual is Humalog 75/25 (brand), if formulary. If Humalog 75/25 75/25 protamine/25% (brand) is non-formulary, approve if the individual has tried one of Novolog 70/30 or insulin lispro Insulin Aspart Protamine-Insulin Aspart Mix, if formulary. If neither are formulary, Kwikpen approve.

Page 25 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Intrarosa vaginal 1. Approve if the individual has tried one formulary alternative from the following list: inserts Imvexxy vaginal ring, Femring vaginal ring, Premarin Cream, Estring vaginal ring, estradiol 0.01% cream (Estrace cream, generics), or estradiol vaginal tablet (e.g., Yuvafem, Vagifem, generics). If none are formulary, approve.

2. Approve if, according to the prescriber, the individual is at an increased risk of endometrial cancer, stroke, or deep vein (DVT).

Isturisa osilodrostat 1. Cushing’s Disease: Approve if the individual has tried one of Signifor or Signifor tablets LAR, if formulary. If neither are formulary, approve.

2. Endogenous Cushing’s Syndrome: approve if the individual has tried one of Signifor, Signifor LAR, ketoconazole, Metoprione (metyrapone capsules), Lysodren (mitotane tablets), or Korlym, if formulary. If none are formulary, approve.

3. Endogenous Cushing’s Syndrome, Individuals awaiting surgery: approve.

4. Endogenous Cushing’s Syndrome, Individuals awaiting response after radiotherapy: approve.

5. Approve if the individual has been started on Isturisa.

Jentadueto linagliptin and 1. Approve if the individual has tried three metformin-DPP-4 inhibitor combination metformin tablets products from the following list (if three are formulary, or two if two are formulary, or one if one is formulary): Jentadueto XR, alogliptin and metformin tablets, Janumet, Janumet XR, Kazano, Kombiglyze XR. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics) AND two of the following, if two are formulary (or one if only one is formulary): alogliptin tablets (Nesina, generics), Tradjenta, Onglyza, or Januvia. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Note: Janumet and Janumet XR would count as one alternative. Alogliptin/metformin tablets and Kazano would count as one alternative.

2. Individuals with a history of heart failure (HF) or renal impairment: approve if the individual has tried ONE of Jentadueto XR, Janumet or Janumet XR, if one is formulary. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics) AND one of the following, if one is formulary: Januvia or Tradjenta. If neither are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Page 26 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Jentadueto XR linagliptin and 1. Approve if the individual has tried three metformin-DPP-4 inhibitor combination metformin products from the following list: (if three are formulary, or two if two are formulary, or extended-release one if one is formulary): Jentadueto (NOT XR), alogliptin and metformin tablets, tablets Janumet, Janumet XR, Kazano, Kombiglyze XR. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics) AND two of the following, if two are formulary (or one if only one is formulary): alogliptin tablets (Nesina, generics), Tradjenta, Onglyza, or Januvia. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Note: Janumet and Janumet XR would count as one alternative. Alogliptin/metformin tablets and Kazano would count as one alternative.

2. Individuals with a history of heart failure or renal impairment: approve if the individual has tried one of Jentadueto (NOT XR), Janumet or Janumet XR, if formulary. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics) AND one of the following, if one is formulary: Januvia or Tradjenta. If neither are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Kapspargo Sprinkle metoprolol 1. Approve if the individual has tried metoprolol succinate extended-release tablets, if succinate formulary. If non-formulary, approve. extended-release capsules 2. If the individual requires a dosage form which can be opened and sprinkled for alternative administration (e.g., for individuals unable to swallow capsules, for nasogastric tube administration), approve.

Katerzia amlodipine oral 1. Approve if the individual has tried amlodipine tablets or Norvasc tablets. suspension 2. Approve if the individual is unable to swallow or has difficulty swallowing tablets.

Kazano alogliptin and 1. Approve if the individual has tried three metformin-DPP-4 inhibitor combination metformin tablets products from the following list (if three are formulary, or two if two are formulary, or one if one is formulary): Jentadueto, Jentadueto XR, Janumet, Janumet XR, Kombiglyze XR. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics) AND two of the following, if two are formulary (or one if only one is formulary): Onglyza, alogliptin tablets (Nesina, generics), Tradjenta, or Januvia. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Note: Jentadueto and Jentadueto XR would count as one alternative. Janumet and Janumet XR would count as one alternative.

Klisyri tirbanibulin 1. Approve if the individual has tried three of the following products: diclofenac 3% gel ointment 1% (Solaraze, generics), a fluorouracil-containing product (e.g., fluorouracil cream, Carac, fluorouracil topical solution), an imiquimod-containing product (e.g., imiquimod 5% cream, Aldara, Zyclara), or Picato topical gel.

Kombiglyze XR saxagliptin plus 1. Approve if the individual has tried three metformin-DPP-4 inhibitor combination metformin products from the following list (if three are formulary, or two if two are formulary, or extended-release one if one is formulary): alogliptin and metformin tablets, Jentadueto, Jentadueto tablets XR, Kazano, Janumet, Janumet XR. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics) AND two of the following, if two are formulary (or one if only one is formulary): alogliptin tablets (Nesina, generics), Onglyza, Tradjenta, or Januvia. If none are formulary, approve if the individual has tried metformin (Glucophage, Glucophage ER, generics).

Page 27 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: Jentadueto and Jentadueto XR would count as one alternative. Alogliptin/metformin tablets and Kazano would count as one alternative. Janumet and Janumet XR would count as one alternative.

Korlym 300 Endogenous Cushing’s Syndrome: mg tablets 1. Approve in individuals who meet the following criteria (A, B, and C): A. Individual is ≥ 18 years of age; AND B. Korlym is being used to control hyperglycemia secondary to hypercortisolism in individuals who have type 2 diabetes mellitus or glucose intolerance; AND C. The individual meets ONE of the following (1 or 2): 1. Individuals have tried one product from the following list (if one is formulary): ketoconazole tablets, Metopirone capsules, Signifor/Signifor LAR injection, or Lysodren tablets. If none are formulary, approve; OR 2. The individual has already been started on Korlym therapy.

Lastacaft alcaftadine 1. Approve if the individual has tried three products from the following list (if three are ophthalmic formulary; or two if two are formulary; or one if one is formulary): Alocril, Alomide, solution cromolyn sodium 4% solution (generics), azelastine 0.05% solution (generics), Bepreve, epinastine 0.05% solution (Elestat, generics), olopatadine 0.2% solution (Pataday, generics), olopatadine 0.1% solution (Patanol, generics), Pazeo, or Zerviate. If none are formulary, approve. ledipasvir / ledipasvir/sofosbu 1. Individual is directed to use Harvoni 90 mg/400 mg. If Harvoni 90 mg/400 mg is sofosbuvir tablets vir tablets 90 non-formulary, approve. 90 mg/400 mg mg/400 mg (Authorized generic Approval duration: 24 weeks for Harvoni) levalbuterol HFA levalbuterol 1. Approve if the individual has tried one formulary albuterol containing inhaler from inhaler inhalation aerosol the following list: albuterol HFA (Proventil HFA, generics), Ventolin HFA, albuterol (authorized HFA inhaler (authorized generic for Ventolin HFA), albuterol HFA (ProAir HFA, generic) generics), ProAir Respiclick, ProAir Digihaler, if one is formulary. If none are formulary, approve.

2. Individuals < 12 years of age or individuals who have a low inspiratory flow rate and are unable to use a dry powder inhaler (DPI): approve if the individual has tried one product from the following list (if one is formulary): albuterol HFA (ProAir HFA, generics), Ventolin HFA, albuterol HFA inhaler (authorized generic for Ventolin HFA), or albuterol HFA (Proventil HFA, generics). If none are formulary, approve.

Lispro (authorized Insulin lispro Direct the individual to brand Humalog, if formulary. If brand Humalog is non-formulary, generic to Humalog) vial/Kwikpen approve if the individual meets the following (1 or 2): 1. Individual meets the following (A, B, C, and D): A. Individual has tried Apidra, if formulary; AND B. Individual has tried Fiasp, if formulary; AND C. Individual has tried one of the following, if formulary: NovoLog, or Insulin Aspart (authorized generic of NovoLog); AND D. Individual has tried Admelog, if formulary; OR

2. Individual is using an insulin pump that is not compatible with the formulary alternative(s), approve.

Note: If no products in A, B, C, or D are formulary, approve.

Note: The same product with different dosage forms count as one alternative (e.g., Fiasp vial, Fiasp Flextouch, Fiasp penfil would all count as one alternative).

Page 28 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Lo Loestrin FE ethinyl estradiol Approve if the individual meets one of the following criteria (1 or 2): 0.01 mg; 1. Individual has tried two other oral contraceptive agents; OR norethindrone acetate 1 mg; 2. If according to the prescriber, these alternatives would not be as medically ferrous fumarate appropriate for the individual as the requested non-formulary drug. tablet

Lucemyra lofexidine tablets 1. Approve if the individual has tried, and according to the prescriber, has experienced inadequate efficacy OR significant intolerance with clonidine.

Lupkynis voclosporin Lupus nephritis: capsules 1. Approve if the individual meets ONE of the following (a or b): a) The medication is being used concurrently with mycophenolate mofetil and a systemic corticosteroid; OR b) According to the prescriber, individual is not a candidate for mycophenolate mofetil and a systemic corticosteroid due to inadequate efficacy OR significant intolerance with these medications. 2. Approve if the individual has already been started on Lupkynis.

Luzu and authorized luliconazole 1% 1. Approve if the individual has tried four topical antifungals (e.g., naftifine 1% or 2% generic cream cream or 1% gel (Naftin, generics), Naftin 2% gel, Lotrimin Ultra [over-the-counter (luliconazole 1% {OTC}], clotrimazole 1% cream [OTC formulation], econazole 1% cream, Ecoza 1% cream) foam, ketoconazole 2% cream or foam [Extina, generics], Oxistat 1% lotion, oxiconazole 1% cream (Oxistat, generics), Ertaczo 2% cream, Exelderm 1% cream or solution, ciclopirox 0.77% cream or gel [generics], Mentax 1% cream, Xolegel 2% gel).

Maxidex dexamethasone 1. Approve if the individual has tried two formulary ophthalmic corticosteroids from the 0.1% ophthalmic following list (if two are formulary; or one if one is formulary): dexamethasone suspension (generics), Durezol, loteprednol etabonate (Lotemax, generics), Lotemax SM, Inveltys, fluorometholone (FML Liquifilm, generics), FML Forte/S.O.P., Flarex, prednisolone (Pred Forte, Omnipred, generics), or Pred Mild. If none are formulary, approve.

2. If the individual has elevated intraocular pressure (IOP) or glaucoma after a trial of another corticosteroid (i.e., topical, inhaled, oral, ophthalmic): approve if the individual has tried one product from the following list (if one is formulary): fluorometholone (FML Liquifilm, generics), loteprednol etabonate (Lotemax, generics), Lotemax SM, Inveltys, Flarex, FML Forte/S.O.P., or Durezol. If none are formulary, approve.

Menest esterified 1. Approve if the individual has tried and, according to the prescriber, has experienced tablets inadequate efficacy OR significant intolerance with two products (or one if one is formulary) from the following list: estradiol tablets (Estrace, generics) and Premarin tablets. If neither are formulary, approve.

Mircera methoxy Approve if the individual meets the following criteria (1 AND 2): polyethylene 1. Individual has tried one epoetin alpha product from the following list, if formulary: glycol-epoetin Epogen, Procrit, or Retacrit [documentation required]; AND beta solution for injection Note: If none are formulary, would still need to meet criteria 2, if Aranesp is formulary.

2. Individual has tried Aranesp, if formulary [documentation required].

Note: If none of the following products are formulary: Aranesp, Epogen, Procrit, and Retacrit, approve.

Page 29 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: The requirements are that one epoetin alpha product and Aranesp have been tried, if both are formulary. If only epoetin alpha product(s) is/are formulary and the individual has tried an epoetin alpha product, then the request should be approved.

MorphaBond morphine sulfate 1. Approve if the individual has tried three other oral long-acting opioid products. extended-release For example: Arymo ER, OxyContin, oxycodone ER tablets [generics], Xtampza tablets ER, morphine sulfate controlled-release/ extended-release capsules or tablets [MS Contin, generics; Kadian, generics for some strengths], Nucynta ER, oxymorphone extended-release tablets, Zohydro ER, Hysingla ER, or hydromorphone extended- release tablets [Exalgo, generics].

Mulpleta lusutrombopag 1. Approve if the individual has tried Doptelet, if formulary. If Doptelet is non- tablets formulary, approve.

2. Approve if the individual has already started a course of therapy with Mulpleta in order to finish the course.

Approval duration: 1 month

Mycapssa octreotide 1. Approve if the individual has tried one of Sandostatin LAR, Somatuline Depot, or delayed-release Signifor LAR, if formulary. If none are formulary, approve. capsules 2. Individuals with diabetes: approve if the individuals has tried one of Sandostatin LAR Depot or Somatuline Depot, if formulary. If neither are formulary, approve.

Mytesi crofelemer 1. For the symptomatic relief of non-infectious diarrhea in adult individuals with Human delayed-release immunodeficiency virus (HIV) or Acquired immunodeficiency syndrome (AIDS): tablets Approve if the individual has tried and, according to the prescriber, has experienced inadequate efficacy OR a significant intolerance with both diphenoxylate-atropine tablets AND loperamide.

Nalfon fenoprofen 1. Approve if the individual has tried five prescription-strength, oral NSAIDs. capsules Note: Examples include: fenoprofen (tablets/generic), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

Natazia ; Approve if the individual meets one of the following criteria (1 or 2): 1. Individual has tried four other oral contraceptive agents; OR tablet 2. If according to the prescriber, these alternatives would not be as medically appropriate for the individual as the requested non-formulary drug.

Nesina and alogliptin tablets 1. Approve if the individual has tried two products from the following list (if two are authorized generic formulary, or one if only one is formulary): Onglyza, Tradjenta, or Januvia. If none are formulary, approve.

Page 30 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Neulasta pegfilgrastim 1. Approve if the individual meets BOTH of the following (a and b): injection a. The individual has tried four of the following, if four are formulary (or three if three are formulary or two if two are formulary or one if one is formulary): Fulphila, Udenyca, Ziextenzo, or Nyvepria; AND

Note: If none are formulary, approve.

b. Individual cannot continue to use each of the formulary alternative(s) due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction.

2. Individuals who have initiated therapy with Neulasta and requires further medication to complete the current cycle of chemotherapy: approve.

Neupogen filgrastim injection 1. Approve if the individual meets BOTH of the following (a and b): a. Individual has tried three of the following products (if three are formulary, or two if two are formulary, or one if one is formulary): Zarxio, Nivestym, or Granix [documentation required]; AND Note: If none are formulary, approve. b. b. Individual cannot continue to use each of the formulary alternative(s) due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction. 2. For allogeneic donor peripheral blood progenitor cells mobilization OR Individuals who require administration by intravenous (IV) infusion: approve if the individual meets the following (a and b): a. Individual has tried Zarxio or Nivestym [documentation required], if formulary; AND Note: If neither are formulary, approve. b. Individual cannot continue to use each of the formulary alternative(s) due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction.

3. Individuals requiring a dose < 180 mcg: approve if the individual meets the following (a and b): a. Individual has tried Nivestym [documentation required]; AND Note: If Nivestym is non-formulary, approve. b. b. Individual cannot continue to use Nivestym due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction.

4. Individuals who initiated therapy with Neupogen and requires further medication to complete the current cycle of chemotherapy: approve.

Nevanac nepafenac 1. Approve if the individual has tried two products from the following list (if two are ophthalmic formulary, or one of the following if one is formulary): diclofenac ophthalmic suspension 0.1% solution (generics), ketorolac ophthalmic solution (Acular, Acular LS, generics), Acuvail, Ilevro, Prolensa, BromSite or bromfenac 0.09% ophthalmic solution (generics). If none are formulary, approve.

2. Individuals with a sulfite allergy: approve if the individual has tried two of the following, if two are formulary (or one if only one is formulary): BromSite, diclofenac ophthalmic solution (generics), Ilevro, ketorolac ophthalmic solution (Acular, Acular

Page 31 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form LS, generics), or Acuvail. If none are formulary, approve.

3. Individuals < 18 years of age: approve if the individual has tried ketorolac ophthalmic solution (Acular, Acular LS, generics) or Ilevro, if one is formulary. If neither are formulary, approve.

Nexium packet esomeprazole 1. Approve if the individual has tried five proton pump inhibitors (PPIs). (granules for oral delayed-release suspension) 5 mg granules for oral Note: Examples of PPIs include rabeprazole delayed-release (DR) tablets and 2.5 mg packets suspension (Aciphex, generics), Aciphex Sprinkle DR capsules or authorized generic, Dexilant (packet) DR capsules, esomeprazole DR capsules (Nexium, generics), pantoprazole DR tablets (Protonix, generics), Protonix suspension (granules), lansoprazole DR capsules (Prevacid, generics), lansoprazole oral disintegrating tablets (Prevacid Solutab, generics), omeprazole DR capsules, Prilosec DR suspension, omeprazole/sodium bicarbonate capsules (Zegerid, generics), or omeprazole/sodium bicarbonate packet (Zegerid, generics).

2. Individuals < 18 years of age OR individuals who have difficulty swallowing tablets/capsules: Approve if the individual has tried two proton pump inhibitors (PPIs).

3. Individuals < 1 year of age: approve if the individual has tried Prilosec DR suspension, if formulary. If Prilosec DR suspension is non-formulary, approve.

Note: The requested agent would NOT count as a trial of an alternative.

Noctiva desmopressin Nocturia due to Nocturnal Polyuria. Approve for 1 year if the individual meets all of the acetate nasal following criteria (A, B, C, D, E, F, G and H): spray for A) Individual is ≥ 50 years of age; AND intranasal use B) The diagnosis of nocturnal polyuria has been confirmed with a 24-hour urine collection before treatment initiation and the individual meets one of the following (i or ii): i. The nocturnal urine volume exceeds 20% of the total 24-hour urine volume in individuals < 65 years of age; OR ii. The nocturnal urine volume exceeds 33% of the total 24-hour urine volume in individuals ≥ 65 years of age; AND C) Prior to desmopressin therapy, individual awakens at least two times per night to void; AND D) Individual has serum sodium concentrations within the normal range (135 to 145 mmol/L); AND E) Prescriber has verified that the individual does not have the following conditions/circumstances in which use of Noctiva is not recommended (i, ii, iii, iv, v, or vi): i. Currently receiving loop diuretics (e.g., furosemide, torsemide, bumetanide); OR ii. Currently receiving systemic or inhaled glucocorticoids; OR iii. Renal impairment with an estimated glomerular filtration rate < 50 mL/min/1.73 m2; OR iv. New York Heart Association class II to IV congestive heart failure; OR v. Polydipsia; OR vi. Known or suspected syndrome of inappropriate antidiuretic hormone secretion; AND F) Individual has tried non-pharmacologic techniques or lifestyle interventions to manage the nocturia; AND

Note: Examples of non-pharmacologic techniques include nighttime fluid restriction, avoidance of caffeine and alcohol, earlier timing of medications, leg elevation, or use of compression stockings.

Page 32 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form G) Individual tried one of Nocdurna (desmopressin acetate sublingual tablets) or oral desmopressin acetate tablets (DDAVP tablets, generics); AND H) Noctiva is prescribed by or in consultation with a urologist, geriatrician, or endocrinologist.

Northera droxydopa Neurogenic Orthostatic Hypotension: capsules 1. Approve if the individual has tried two of the following, if two are formulary (or one if one is formulary): midodrine tablets (generics); fludrocortisone tablets; desmopressin tablets/nasal spray; dihydroergotamine injection/nasal spray; indomethacin capsules/injection; or pyridostigmine tablets. If none are formulary, approve.

Novolin 70/30 insulin, 70/30 pen 1. Approve if the individual has tried Humulin 70/30 Kwikpens or Humulin 70/30 vials, Flexpen and Relion if formulary. If both Humulin 70/30 Kwikpens and Humulin 70/30 vials are non- Novolin 70/30 formulary, approve. Flexpen 2. If only Humulin 70/30 vials are formulary, approve in individuals who are visually impaired, disabled (unable to draw up dose because of arthritis or otherwise physically disabled), or have coordination issues.

Novolin 70/30 vials insulin, 70/30 vials 1. Approve if the individual has tried Humulin 70/30 vials or Humulin 70/30 Kwikpens, and Relion Novolin if formulary. If both Humulin 70/30 vials and Humulin 70/30 Kwikpens are non- 70/30 vials formulary, approve.

Novolin N Flexpen insulin, NPH pen 1. Approve if the individual has tried Humulin N Kwikpens or Humulin N vials, if and Relion Novolin formulary. If both Humulin N Kwikpens and Humulin N vials are non-formulary, N Flexpen approve.

2. If only Humulin N vials are formulary, approve in individuals who are visually impaired, disabled (unable to draw up dose because of arthritis or otherwise physically disabled), or have coordination issues.

Novolin N vials and insulin, NPH vials 1. Approve if the individual has tried Humulin N vials or Humulin N Kwikpens, if Relion Novolin N formulary. If both Humulin N vials and Humulin N Kwikpens are non-formulary, vials approve.

Novolin R Flexpen insulin, regular 1. Approve if the individual has tried Humulin R U-100 vials, if formulary. If Humulin R and Relion Novolin pen U-100 vials are non-formulary, approve. R U-100 Flexpen 2. Approve in individuals who are visually impaired, disabled (unable to draw up dose because of arthritis or otherwise physically disable), or have coordination issues.

Novolin R U-100 insulin, regular 1. Approve if the individual has tried Humulin R U-100 vials, if formulary. If Humulin R vials and Relion vials U-100 vials are non-formulary, approve. Novolin R vials

NovoLog 70/30 and insulin aspart 1. Approve if the individual has tried Humalog 75/25, if formulary. If Humalog 75/25 is authorized generic protamine/insulin non-formulary, approve. (insulin aspart aspart, Flexpen protamine-insulin (prefilled aspart) syringe)/vial

Page 33 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form NovoLog and insulin aspart Approve if the individual meets (1 or 2): authorized generic syringe, 1. Approve if the individual meets the following (A, B, and C): (insulin aspart) cartridge/Flexpen A. Individual has tried Apidra, if formulary; AND (prefilled B. Individual has tried Fiasp, if formulary; AND syringe)/vial C. Individual has tried one of following, if formulary: Insulin Lispro (authorized generic of Humalog), Humalog, or Admelog; OR

2. Individual is using an insulin pump that is not compatible with the formulary alternative(s), approve.

Note: If no products in A, B, or C are formulary, approve.

Note: The same product with different dosage forms count as one alternative (e.g., Humalog vial and Humalog Kwikpen would count as one alternative).

Nucynta tapentadol 1. Approve if the individual has tried three other oral centrally acting/opioid analgesics. immediate-release Examples of centrally acting/opioid analgesics include, but are not limited to: tablets hydromorphone (Dilaudid, generics), oxycodone hydrochloride tablets (Roxicodone, generics), oxymorphone (generics), morphine (generics), hydrocodone/acetaminophen (Vicodin, Vicodin ES, Norco, Lortab, Lorcet, multiple generics), oxycodone/acetaminophen (Percocet, Endocet, Roxicet, multiple generics), tramadol (Ultram, generics), tramadol/acetaminophen (Ultracet, generics),

NOTE: a trial of the requested product does not count toward this requirement.

Nucynta ER tapentadol 1. Approve if the individual has tried three other oral long-acting opioid products. extended-release For example: morphine sulfate controlled-release/extended-release capsules or tablets tablets [MS Contin, generics; Kadian, generics for some strengths], OxyContin, oxycodone ER tablets [generics], Xtampza ER, hydromorphone extended-release tablets [Exalgo, generics], oxymorphone extended-release tablets, Zohydro ER, Hysingla ER, Arymo ER, or MorphaBond.

2. Individual is intolerant or allergic to morphine: approve if the individual has tried one product from the following list (if one is formulary): Zohydro ER, Hysingla ER, OxyContin, Xtampza ER, or oxycodone ER tablets (generics). If none are formulary, approve.

3. Individual has renal insufficiency: approve if the individual has tried one product from the following list (if one is formulary): Zohydro ER, Hysingla ER, OxyContin, Xtampza ER, or oxycodone ER tablets (generics). If none are formulary, approve.

Nutropin AQ Nuspin somatropin Growth hormone deficiency (GHD) in children, Turner syndrome, GHD in adults, Prader injection Willi syndrome, Idiopathic short stature in children, Children with chronic kidney disease, Short Stature Homeobox-Containing Gene deficiency, Children Born Small for Gestational Age or with Intrauterine Growth Restriction, Noonan syndrome, Short bowel syndrome: 1. Approve if the individual has tried five of the following (if five are formulary, or four if four are formulary, or three if three are formulary, or two if only two are formulary, or one if only one is formulary): Genotropin, Humatrope, Norditropin Flexpro, Omnitrope, Saizen, or Zomacton. If none are formulary, approve. Omnaris ciclesonide nasal 1. Approve if the individual has tried five nasal steroids from the following list, if spray formulary (or four if four are formulary or three if three are formulary or two if two are formulary or one if one is formulary): fluticasone propionate spray, Beconase AQ, mometasone nasal spray (Nasonex, generics), flunisolide nasal spray (generics), Qnasl, or Zetonna.

Page 34 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: Over-the-counter (OTC) nasal steroids would count as a trial of an alternative.

Omnitrope somatropin Growth hormone deficiency (GHD) in children, Turner syndrome, GHD in adults, Prader injection Willi syndrome, Idiopathic short stature in children, Children with chronic kidney disease, Short Stature Homeobox-Containing Gene deficiency, Children Born Small for Gestational Age or with Intrauterine Growth Restriction, Noonan syndrome, Short bowel syndrome: 1. Approve if the individual has tried five of the following (if five are formulary, or four if four are formulary, or three if three are formulary, or two if only two are formulary, or one if only one is formulary): Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ, Saizen, or Zomacton. If none are formulary, approve.

Ongentys opicapone 1. Approve if the individual has tried and, according to the prescriber, has experienced capsules inadequate efficacy OR significant intolerance with entacapone tablets (Comtan, generics). If entacapone tablets (Comtan, generics) are non-formulary, approve.

2. If the individual has been on Ongentys for more than one month, approve.

Onglyza saxagliptin tablets 1. Approve if the individual has tried two products from the following list (if two are formulary, or one if only one is formulary): alogliptin tablets (Nesina, generics), Tradjenta, or Januvia. If none are formulary, approve.

Onureg azacitadine tablets Acute Myeloid Leukemia: Approve if the individual meets the following (1, 2, OR 3): 1. Individual is ≥ 18 years of age who achieved remission with intensive induction therapy, but cannot continue with conventional consolidation therapy, and has tried injectable azacitidine or injectable decitabine. If injectable azacitadine or injectable decitabine are non-formulary, approve; OR

2. Individual is ≥ 18 years of age with intermediate- or poor cytogenetics who is not fit or eligible for a hematopoietic stem cell transplantation; OR

3. The individual has been started on therapy with Onureg. Orencia IV abatacept 1. Individual has tried at least one biologic: Approve. injection for intravenous use Examples: a tocilizumab product (e.g., Actemra intravenous or subcutaneous), a sarilumab product (Kevzara), an etanercept product (e.g., Enbrel, biosimilars), an adalimumab product (e.g., Humira, biosimilars), a certolizumab pegol product (e.g., Cimzia), a golimumab product (e.g., Simponi Aria or subcutaneous), an infliximab product (e.g., Remicade, biosimilars), a rituximab product (e.g., Rituxan intravenous, biosimilars), a secukinumab product (e.g., Cosentyx), an ixekizumab product (e.g., Taltz), a guselkumab product (e.g., Tremfya), or a ustekizumab product (e.g., Stelara SC). If none are formulary, approve.

2. According to the prescriber, the individual previously experienced a serious infection: Approve.

3. Individual is currently taking Orencia intravenous or subcutaneous: Approve if the individual has been established on Orencia intravenous or subcutaneous for ≥ 90 days.

4. Individual has been started on Orencia intravenous or subcutaneous for < 90 days: Refer to the appropriate criteria above.

Page 35 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Orgovyx relugolix tablets Prostate Cancer: 1. Approve if the individual has triedone of the following: Lupron Depot, Trelstar, Firmagon, or Eligard. If none are formulary, approve.

2. If, according to the prescriber, the individual is at risk of cardiovascular disease, approve.

3. If the individual is using for intermittent deprivation therapy, approve.

4. Individuals currently receiving therapy with Orgovyx: approve.

OsmoPrep sodium 1. Approve if the individual meets one of the following criteria (a, b, c, or d): phosphate, a. Individual has tried PEG3350 powder packet (Moviprep, generics). If monobasic, PEG3350 powder packet (Moviprep, generics) are non-formulary, approve; OR monohydrate, b. If PEG3350 powder packet (generic of Moviprep) is unavailable; OR sodium c. Individuals with phenylketonuria; OR phosphate, d. Individuals with glucose-6-phosphate dehydrogenase deficiency. dibasic anhydrous tablet Approval duration: 1 month

Otrexup methotrexate 1. Approve if the individual has tried Rasuvo or RediTrex, if formulary. If neither are injection for formulary, approve if, according to the prescriber, the individual and caregiver are subcutaneous unable to administer methotrexate injection (NOT including Otrexup, Rasuvo, or use; 10mg, 12.5 RediTrex). mg, 15 mg, 17.5 mg, 20 mg, 22.5 mg, 25 mg

Oxbryta voxelotor tablets Sickle Cell Disease in Individuals ≥ 12 Years of Age: 1. Approve if the individual has tried or is currently receiving one of the following agents (if one is formulary): 1) a hydroxyurea product (hydroxyurea, Droxia, Siklos) OR 2) Endari. If none are formulary, approve.

2. If, according to the prescriber, the individual is not a candidate for a hydroxyurea product (e.g., a individual who is planning to become pregnant; a pregnant individual; or a individual with an immunosuppressive condition [such as cancer]), approve.

3. Approve if the individual is currently receiving Oxbryta. oxycodone ER oxycodone 1. Approve if the individual has tried three other oral long-acting opioid products. extended-release For example: morphine sulfate controlled-release/extended-release capsules or tablets tablets [MS Contin, generics; Kadian, generics for some strengths], hydromorphone extended-release tablets [Exalgo, generics], oxymorphone extended-release, Nucynta ER, Zohydro ER, OxyContin, Xtampza ER, Hysingla ER, Arymo ER, or MorphaBond.

2. Individual is intolerant or allergic to morphine: approve if the individual has tried one product from the following list (if one is formulary): Nucynta ER, Zohydro ER, Hysingla ER, Xtampza ER, or OxyContin. If none are formulary, approve.

3. Individual has renal insufficiency: approve if the individual has tried one product from the following list (if one is formulary): Nucynta ER, Zohydro ER, Hysingla ER, Xtampza ER, or OxyContin. If none are formulary, approve.

4. Individuals ≥ 11 years and < 18 years of age: approve if the individual has tried OxyContin, if formulary. If Oxycontin is non-formulary, approve.

Page 36 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Ozobax baclofen oral 1. Approve if the individual has tried baclofen tablets or tizanidine tablets. solution 2. Approve if the individual is unable to or has difficulty swallowing tablets.

Palforzia peanut [Arachis 1. Approve Palforzia if the individual meets the following criteria (A, B, C, D, E, F, and hypogaea] G): allergen powder- A) The individual has a peanut allergy; AND dnfp for oral B) The individual meets ONE of the following (i or ii): administration i. Individual is 4 to 17 years of age; OR ii. Individual is ≥ 18 years of age AND has been previously started on therapy with Palforzia prior to becoming 18 years of age; AND C) The medication is prescribed by or in consultation with an allergist or immunologist; AND D) Per the prescriber, the individual has a history of an allergic reaction to peanut that met each of the following (i, ii, and iii): i. The individual demonstrated signs and symptoms of a significant systemic allergic reaction; AND Note: Signs and symptoms of a significant systemic allergic reaction include hives, swelling, wheezing, hypotension, and gastrointestinal symptoms. ii. This reaction occurred within a short period of time following a known ingestion of peanut or peanut-containing food; AND iii. The prescriber deemed this reaction significant enough to require a prescription for an epinephrine auto-injector; AND Note: Examples of epinephrine auto-injectors include EpiPen, EpiPen Jr., Auvi-Q, and generic epinephrine auto-injectors. E) The individual has a positive prick test (SPT) response to peanut with a wheal diameter ≥ 3 mm larger than the negative control; AND F) The individual has a positive in vitro test (i.e., a blood test) for peanut-specific IgE (psIgE) with a level ≥ 0.35 kUA/L; AND G) Per the prescriber, Palforzia will be used in conjunction with a peanut-avoidant diet.

Pazeo olopatadine 0.7% 1. Approve if the individual has tried three products from the following list (if three are ophthalmic formulary; or two if two are formulary; or one if one is formulary): Alocril, Alomide, solution cromolyn sodium 4% solution (generics), azelastine 0.05% solution (generics), Bepreve, epinastine 0.05% solution (Elestat, generics), Lastacaft, olopatadine 0.2% solution (Pataday, generics), olopatadine 0.1% solution (Patanol, generics), or Zerviate. If none are formulary, approve.

Pennsaid diclofenac sodium 1. Approve if the individual has tried, and according to the prescriber, has experienced topical solution inadequate efficacy OR significant intolerance with two products from the following 2.0% pump list (if two are formulary, or one if one is formulary): prescription diclofenac sodium topical 1% gel (Voltaren 1% gel, generics) or diclofenac sodium 1.5% topical solution (generics). If none are formulary, approve if the individual has tried over- the-counter Voltaren 1% gel.

Pertzye pancrelipase 1. Approve if the individual has tried three products from the following list (if three are delayed-release formulary, or two if two are formulary, or one if one is formulary): Creon, capsules Pancreaze, or Zenpep. If none are formulary, approve.

Page 37 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Pexeva paroxetine 1. Approve if the individual has tried four formulary SSRIs from the following list (if four mesylate tablets are formulary or three if three are formulary or two if two are formulary, or one if one is formulary): citalopram (Celexa, generics), fluvoxamine (generics) escitalopram (Lexapro, generics), fluoxetine (Prozac, generics), sertraline (Zoloft, generics), paroxetine HCl (Paxil, Paxil CR, generics), Viibryd, or Trintellix. If none are formulary, approve.

2. Individual is currently taking or has taken Pexeva at any time in the past: approve.

3. Suicidal ideation: approve.

Phesgo pertuzumab, 1. Approve if the individual has tried Perjeta intravenous AND one of the following: trastuzumab, and Herceptin, Herzuma, Kanjinti, Ogivri, Ontruzant, or Trazimera, if formulary. If hyaluronidase- Perjeta is non-formulary, approve. If none of Herceptin, Herzuma, Kanjinti, Ogivri, zzxf injection for Ontruzant, nor Trazimera are formulary, approve. subcutaneous use 2. Approve if the individual is unable to obtain and/or maintain intravenous access.

3. If the individual has already been started on therapy with Phesgo, approve.

Phexxi L-lactic acid, citric Approve if the individual meets one of the following criteria (1 or 2): acid, and potassium 1. Individual has tried or is unable to tolerate THREE other barrier methods of bitartrate vaginal contraception, such as diaphragms, , (over-the-counter), or gel sponges; OR

2. If according to the prescriber, these alternatives would not be as medically appropriate for the individual as the requested non-formulary drug.

Pifeltro doravirine tablets 1. Approve if the individual has tried one non-nucleoside reverse transcriptase inhibitor (NNRTI) or a NNRTI-containing product (e.g., Sustiva, Edurant, Delstrigo, Complera, Odefsey, Atripla, Symfi, Smyfi Lo).

2. Individuals already started on therapy with Pifeltro, approve.

Piqray alpelisib tablets 1. Approve for the diagnosis of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER-2)-negative, breast cancer if the individual has a known PIK3CA mutation, Piqray is used in combination with fulvestrant, and the individual has tried one of the following agents: a Cyclin-Dependent Kinase 4/6 Inhibitor (e.g., Ibrance [palbociclib], Kisqali [ribociclib], Kisqali Co-Pack [ribociclib, letrozole], Verzenio [abemaciclib]), an aromatase inhibitor (e.g., letrozole, anastrozole, ), tamoxifen, or toremifene.

2. Approve for the diagnosis of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER-2)-negative, breast cancer if the individual has a known PIK3CA mutation and the individual has already been started on Piqray.

Plenvu polyethylene 1. Approve if the individual meets one of the following criteria (a, b, or c): glycol; a. Individual has tried PEG3350 powder packet (Moviprep, generics). If electrolytes; PEG3350 powder packet (Moviprep, generics) are non-formulary, approve; OR ascorbic acid b. If PEG3350 powder packet (generic of Moviprep) is unavailable; OR powder for c. Individuals with phenylketonuria. solution Approval duration: 1 month

Page 38 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Pliaglis and lidocaine 7% and 1. Approve if the individual has tried and cannot use two of the following, if two are lidocaine 7% and tetracaine 7% formulary (or one if only one is formulary): lidocaine and prilocaine cream tetracaine 7% cream cream (generics), lidocaine cream (generics, multiple strengths), Livixil Pak, Relador Pak, (brand) Relador Pak Plus, DermacinRx Prizopak, Lidopril. If none are formulary, approve.

Pradaxa dabigatran 1. Approve if the individual has tried one of Eliquis, Savaysa, or Xarelto, if one is etexilate mesylate formulary [documentation required]. If none are formulary, approve Pradaxa. capsules 2. Individual is less than (<) 18 years of age: approve.

3. Individuals currently receiving Pradaxa for treatment of thrombosis (e.g., [DVT] or pulmonary embolism [PE]): approve.

4. Individuals currently receiving Pradaxa for prophylaxis of DVT or PE after orthopedic surgery (e.g., hip or knee replacement surgery): approve.

Pred Mild prednisolone 1. Approve if the individual has tried two formulary ophthalmic corticosteroids from the acetate 0.12% following list (if two are formulary; or one if one is formulary): dexamethasone ophthalmic (generics), Maxidex, Durezol, loteprednol etabonate (Lotemax, generics), Lotemax suspension SM, Inveltys, fluorometholone (FML Liquifilm, generics), FML Forte/S.O.P., Flarex, or prednisolone (Pred Forte, Omnipred, generics). If none are formulary, approve.

2. If the individual has elevated intraocular pressure (IOP) or glaucoma after a trial of another corticosteroid (i.e., topical, inhaled, oral, ophthalmic): approve if the individual has tried one product from the following list (if one is formulary): fluorometholone (FML Liquifilm, generics), loteprednol etabonate (Lotemax, generics), Lotemax SM, Inveltys, Flarex, FML Forte/S.O.P., or Durezol. If none are formulary, approve.

Pregenna beta carotene, 1. Direct the individual to generic prenatal vitamins. ascorbic acid, cholecalciferol, .alpha.-tocopherol acetate, pyridoxine hydrochloride, biotin, folic acid, levomefolate , cyanocobalamin, calcium carbonate, magnesium oxide, ferrous bisglycinate, and potassium iodide tablet

Pregnyl chorionic 1. Approve if the individual has tried one product from the following list (if one is gonadotropin formulary): chorionic gonadotropin, Novarel or Ovidrel. If none are formulary, 10,000 unit approve. powder for intramuscular 2. For a diagnosis of cryptorchidism or hypogonadism, approve if the individual has injection tried chorionic gonadotropin or Novarel, if formulary. If neither are formulary, approve.

Page 39 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form 3. Individuals with a latex allergy: approve if the individual has tried Novarel, if formulary. If Novarel is non-formulary, approve.

4. For a diagnosis related to infertility or induction of ovulation, approve a one-time fill if the individual may be at risk of missing the optimal administration timeframe window of the product (in order to avoid disruption of the current fertility medication cycle).

Premarin conjugated 1. Approve if the individual has tried and, according to the prescriber, has experienced estrogens tablets inadequate efficacy OR significant intolerance with four products (or three if three are formulary, or two if two are formulary, or one if one is formulary) from the following list: estradiol tablets (Estrace, generics), Menest tablets, Enjuvia tablets, or Cenestin tablets. If none are formulary, approve.

Premphase conjugated 1. Approve if the individual has tried and, according to the prescriber, has experienced estrogens//medrox inadequate efficacy OR significant intolerance with four products (or three if three yprogesterone are formulary, or two if two are formulary, or one if one is formulary) from the tablets following list: Prempro, Femhrt (including generics of Femhrt: Jinteli, Fyavolv, norethindrone-ethinyl estradiol), Activella (including generics of Activella: Mimvey, Amabelz, and estradiol-norethindrone), or Bijuva. If none are formulary, approve.

Note: A brand and any generic of a product would count as one alternative. For example, if Mimvey and Amabelz are both formulary, it would count as one alternative.

Prempro conjugated 1. Approve if the individual has tried and, according to the prescriber, has experienced estrogens/ inadequate efficacy OR significant intolerance with three products (or two if two are medroxyprogester formulary, or one if one is formulary) from the following list: Femhrt (including one tablets generics of Femhrt: Jinteli, Fyavolv, norethindrone-ethinyl estradiol), Activella (including generics of Activella: Mimvey, Amabelz, and estradiol-norethindrone), or Bijuva. If none are formulary, approve.

Note: A brand and any generic of a product would count as one alternative. For example, if Mimvey and Amabelz are both formulary, it would count as one alternative.

Prezcobix darunavir and 1. Approve if the individual has tried one protease inhibitor (PI) or a PI-containing cobicistat tablets product (e.g., Aptivus, Reyataz, Crixivan, Viracept, Norvir, Invirase, Lexiva, Prezista, Evotaz, Kaletra).

2. If the individual, according to the prescriber, needs to begin antiretroviral therapy urgently, approve.

3. Approve if the individual has been started on Prezcobix.

Prilosec oral omeprazole 1. Approve if the individual has tried five proton pump inhibitors (PPIs). suspension delayed-release oral suspension Note: Examples of PPIs include rabeprazole delayed-release (DR) tablets (Aciphex, generics), Aciphex Sprinkle DR capsules or authorized generic, Dexilant DR capsules, esomeprazole DR capsules (Nexium, generics), Nexium DR packet (granules for oral suspension), pantoprazole DR tablets (Protonix, generics), Protonix suspension (granules), lansoprazole DR capsules (Prevacid, generics), lansoprazole orally disintegrating tablets (Prevacid SoluTab, generics), omeprazole DR capsules, omeprazole/sodium bicarbonate capsules (Zegerid, generics), or omeprazole/sodium bicarbonate packet (Zegerid, generics).

Page 40 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form 2. Individuals < 18 years of age OR individuals who have difficulty swallowing tablets/capsules: Approve if the individual has tried two proton pump inhibitors (PPIs).

3. Individuals < 1 year of age: approve if the individual has tried Nexium DR packet (granules for oral suspension), if formulary. If Nexium DR packet (granules for oral suspension), is non-formulary, approve.

Note: The requested agent would NOT count as a trial of an alternative.

Primlev tablet oxycodone- 1. Direct individual to use oxycodone-acetaminophen. acetaminophen

ProAir Digihaler albuterol sulfate 1. Approve if the individual has tried one product from the following list, if formulary: inhalation powder albuterol HFA (ProAir HFA, generics), ProAir Respiclick, albuterol HFA (Proventil HFA, generics), Ventolin HFA, albuterol HFA inhaler (authorized generics to Ventolin HFA), Xopenex HFA, or levalbuterol HFA inhaler. If none are formulary, approve.

2. Individuals who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried ProAir Respiclick, if formulary. If ProAir Respiclick is non-formulary, approve.

ProAir Respiclick albuterol sulfate 1. Approve if the individual has tried one product from the following list, if formulary: inhalation powder albuterol HFA (ProAir HFA, generics), ProAir Digihaler, albuterol HFA (Proventil HFA, generics), Ventolin HFA, albuterol HFA inhaler (authorized generics to Ventolin HFA), Xopenex HFA, or levalbuterol HFA inhaler. If none are formulary, approve.

2. Individuals who are unable to coordinate breath and actuation with a metered-dose inhaler (MDI): approve if the individual has tried ProAir Digihaler, if formulary. If ProAir Digihaler is non-formulary, approve.

Proctofoam-HC pramoxine 1. Approve if the individual has tried and, according to the prescriber, has experienced hydrochloride inadequate efficacy OR a significant intolerance with pramoxine-hydrocortisone hydrocortisone cream. acetate aerosol, foam

Procysbi cysteamine 1. Approve if the individual meets the following criteria (A, B, C, and D): bitartrate delayed- A. Individuals with nephropathic cystinosis; AND release capsules B. According to the prescriber, the diagnosis was confirmed by one of the and granule following (i or ii): packets i. Genetic testing confirmed a mutation of the CTNS gene; OR ii. White blood cell cystine concentration above the upper limit of the normal reference range for the reporting laboratory; AND C. The individual will not be using Cystagon and Procysbi concurrently; AND D. The individual has tried Cystagon, if formulary. If Cystagon is non-formulary, approve.

Prolate solution oxycodone and 1. Approve if the individual has tried and cannot take oxycodone-acetaminophen acetaminophen tablets. oral solution 2. Approve if the individual is unable to swallow or has difficulty swallowing tablets.

Page 41 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Prolia denosumab 1. Approve if individual has tried one of the following products: an oral or intravenous injection for bisphosphonate (e.g., alendronate [Fosamax, Fosamax Plus D, generics], subcutaneous use ibandronate tablets [Boniva, generics], alendronate oral solution, Binosto, risedronate [Actonel, Atelvia, generics, zoledronic acid [Reclast, generics], ibandronate injection [Boniva, generics]), a teriparatide product (i.e., Forteo, teriparatide), Tymlos, or Evenity.

2. Individuals with severe renal impairment (e.g., creatinine clearance < 35 mL/min) or chronic kidney disease (CKD): approve.

3. Individuals who have had an osteoporotic fracture or a fragility fracture: approve.

4. Individuals who cannot swallow/have difficulty tablets, cannot remain in an upright position (post oral bisphosphonate administration), or have a history of a gastrointestinal medical condition (e.g., esophageal lesions, esophageal ulcers, or abnormalities of the esophagus that delay esophageal emptying [stricture, achalasia]): approve.

5. Treatment of bone loss (to increase bone mass) in individuals at high risk for fracture receiving androgen deprivation therapy (e.g., Lupron Depot [leuprolide for depot suspension], Eligard [leuprolide acetate for injectable suspension] or has undergone bilateral orchiectomy) for nonmetastatic prostate cancer: approve.

6. Treatment of bone loss (to increase bone mass) in individuals at high risk for fracture receiving adjuvant aromatase inhibitor therapy (e.g., anastrozole [Arimidex, generics], letrozole [Femara, generics], and exemestane [Aromasin, generics]) for breast cancer: approve.

Pulmicort Flexhaler budesonide 1. 1. Approve if the individual has tried four formulary alternatives from the following inhalation powder list (if four are formulary, or three if three are formulary, or two if two are formulary, or one if only one is formulary): Alvesco, Arnuity Ellipta, Asmanex HFA, Asmanex Twisthaler, Flovent Diskus, Flovent HFA, ArmonAir Digihaler, or Qvar RediHaler. If none are formulary, approve. a. If the individual is < 12 years of age, approve if the individual has tried three formulary alternatives from the following list (if three are formulary, or two if two are formulary, or one if only one is formulary): Arnuity Ellipta, Asmanex Twisthaler, Asmanex HFA, Flovent Diskus, Flovent HFA, or Qvar RediHaler. If none are formulary, approve. i. If the individual is < 12 years of age and is unable to coordinate breath and actuation with an inhaler, approve if the individual has tried two formulary alternatives from the following list (if two are formulary or one if only one is formulary): Armuity Ellipta, Asmanex Twisthaler, Flovent Diskus, or Qvar RediHaler. If none are formulary, approve.

2. If the individual is unable to coordinate breath and actuation with an inhaler, approve if the individual has tried two formulary alternatives from the following list (if two are formulary or one if only one is formulary): Arnuity Ellipta, Asmanex Twisthaler, ArmonAir Digihaler, Flovent Diskus, or Qvar RediHaler. If none are formulary, approve.

Note: Asmanex HFA and Asmanex Twisthaler would count as one alternative. Flovent Diskus and Flovent HFA would count as one alternative.

Page 42 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Pylera bismuth subcitrate 1. Approve if the individual meets ONE of the following (A or B): potassium, A. The individual has tried and, according to the prescriber, has experienced metronidazole inadequate efficacy OR significant intolerance with two different regimens of plus tetracycline single-entity products (e.g., clarithromycin + amoxicillin + proton pump inhibitor capsules [e.g., omeprazole, lansoprazole]; bismuth subcitrate + tetracycline + metronidazole + proton pump inhibitor [e.g., omeprazole, lansoprazole ]); OR B. The individual has tried and, according to the prescriber, has experienced inadequate efficacy OR significant intolerance with any TWO pre-packaged products (e.g., amoxicillin/clarithromycin/lansoprazole [Prevpac, generics], Omeclamox-Pak, Helidac, or Talicia).

Approval duration: 1 month

Qbrelis lisinopril oral 1. Approve if the individuals has tried lisinopril tablets (Prinivl, Zestril, generics), if solution formulary. If lisinopril tablets (Prinivil, Zestril, generics) are non-formulary, approve.

2. Approve if the individual cannot swallow or has difficulty swallowing tablets.

Qdolo tramadol 1. Approve if the individual has tried tramadol tablets. hydrochloride oral 2. Approve if the individual cannot swallow or has difficulty swallowing tramadol solution tablets.

Qelbree viloxazine 1. Approve if the individual has tried one product from the following list, if formulary: extended-release atomoxetine (Strattera, generics), guanfacine extended-release (Intuniv, generics), capsules or clonidine extended-release (Kapvay, generics). If none are formulary, approve.

2. If the individual is unable to swallow or has difficulty swallowing tablets, approve.

Qinlock ripretinib tablets Gastrointestinal stromal tumor: 1. Approve if the individual has been previously treated with at least three other kinase inhibitors, one of which was imatinib.

Note: Examples of kinase inhibitors are imatinib (Gleevec), Sutent, Stivarga, Nexavar, Votrient, Tasigna, Sprycel.

2. Approve if the individual has already been started on therapy with Qinlock.

Qnasl beclomethasone 1. Approve if the individual has tried five nasal steroids from the following list, if dipropionate nasal formulary (or four if four are formulary or three if three are formulary or two if two aersol are formulary or one if one is formulary): fluticasone propionate spray, Beconase AQ, mometasone nasal spray (Nasonex, generics), flunisolide nasal spray (generics), Omnaris, or Zetonna.

Note: Over-the-counter (OTC) nasal steroids would count as a trial of an alternative.

Qtern dapagliflozin/ 1. Approve if the individual has tried, and according to the prescriber, has experienced saxagliptin tablets inadequate efficacy OR a significant intolerance with both Glyxambi and Steglujan, if formulary. If one if formulary, try one, if neither are formulary, approve if the individual has tried and, according to the prescriber, has experienced inadequate efficacy OR a significant intolerance with three formulary SGLT-2 inhibitors (or two if two are formulary or one if one is formulary) AND three formulary DPP-4 inhibitors (or two if two are formulary or one if one is formulary). SGLT-2 inhibitors: Farxiga, Invokana, Jardiance, Steglatro. DPP-4 inhibitors: Januvia, Nesina, Onglyza, Tradjenta.

Page 43 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: If the individual has tried a combination product containing a DPP-4 inhibitor or an SGLT-2 inhibitor, this would count as a trial of the respective product. A trial of the request agent would NOT count toward this requirement.

RediTrex methotrexate 1. Approve if the individual has tried Otrexup or Rasuvo, if formulary. If neither are injection for formulary, approve if, according to the prescriber, the individual and caregiver are subcutaneous unable to administer methotrexate injection (NOT including RediTrex, Otrexup, or use; 7.5 mg, Rasuvo). 10 mg, 12.5 mg, 15 mg, 17.5 mg, 20 mg, 22.5 mg, 25 mg

Relafen DS nabumetone 1. Approve if the individual has tried five prescription-strength NSAIDs. 1,000 mg tablets Note: For example: nabumetone (generics), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

Reltone ursodiol capsules 1. Approve if the individual has tried generic ursodiol capsules or tablets. 200 mg, 400 mg 2. Approve, if according to the prescriber, the individual is unable to achieve the appropriate dosage requirement with ursodiol capsules.

Rhopressa netarsudil 1. Approve if the individual meets the following criteria (A, B, and C): ophthalmic A. Individual has tried one ophthalmic prostaglandin product; AND solution 0.02% Note: Examples of ophthalmic prostaglandin products include: latanoprost ophthalmic solution (Xalatan, generics), travoprost ophthalmic solution (generics), bimatoprost 0.03% ophthalmic solution (generics), Lumigan, Vyzulta, Xelpros, or Zioptan.

B. Individual has tried one ophthalmic beta-blocker product; AND

Note: Examples of ophthalmic beta-blockers products include: levobunolol solution, timolol maleate solution (Istalol, generics), betaxolol ophthalmic solution, Betopic S, carteolol opthalmic solution, timolol (Timoptic, generics), Timoptic in Ocudose, timolol gel-forming solution (Timoptic XE, generics).

C. Individual has tried either one ophthalmic alpha-adrenergic agonists or an ophthalmic carbonic anhydrase inhibitor.

Note: Examples of ophthalmic alpha-adrenergic agonists include: Alphagan P, brimonidine solution (Alphagan, generics), apraclonidine solution.

Page 44 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: Examples of ophthalmic carbonic anhydrase inhibitors include: Azopt, dorzolamide (Trusopt, generics).

Note: A combination ophthalmic agent containing the requested drug products, would count as a trial of the respective alternatives.

Rocklatan netarsudil/latanopr 1. Approve if the individual has tried latanoprost ophthalmic solution (Xalatan, ost ophthalmic generics) AND Rhopressa, if Rhopressa is formulary. solution 2. If Rhopressa is non-formulary, approve if the individual meets the following criteria (A, B, and C): A. Individual has tried one ophthalmic prostaglandin product; AND

Note: Examples of ophthalmic prostaglandin products include: latanoprost ophthalmic solution (Xalatan, generics), travoprost ophthalmic solution (generics), bimatoprost 0.03% ophthalmic solution (generics), Lumigan, Vyzulta, Xelpros, or Zioptan.

B. Individual has tried one ophthalmic beta-blocker product; AND

Note: Examples of ophthalmic beta-blockers products include: levobunolol solution, timolol maleate solution (Istalol, generics), betaxolol ophthalmic solution, Betopic S, carteolol opthalmic solution, timolol (Timoptic, generics), Timoptic in Ocudose, timolol gel-forming solution (Timoptic XE, generics).

C. Individual has tried either one ophthalmic alpha-adrenergic agonists or an ophthalmic carbonic anhydrase inhibitor.

Note: Examples of ophthalmic alpha-adrenergic agonists include: Alphagan P, brimonidine solution (Alphagan, generics), apraclonidine solution.

Note: Examples of ophthalmic carbonic anhydrase inhibitors include: Azopt, dorzolamide (Trusopt, generics).

Note: A combination ophthalmic agent containing the requested drug products, would count as a trial of the respective alternatives.

Rukobia fostemsavir 1. Human Immunodeficiency Virus (HIV) infection in heavily treatment-experienced extended-release individuals with multidrug-resistant HIV-1 infection: Approve if the individual meets tablets the following criteria (A, B, and C): A. The individual is ≥ 18 years of age; AND B. According to the prescriber, the individual is failing a current antiretroviral regimen for Human Immunodeficiency Virus; AND C. According the prescriber, the individual has exhausted at least FOUR antiretroviral classes defined as elimination of all antiretrovirals within a given class due to demonstrated or projected resistance to the agent(s) in that class OR due to significant intolerability.

Saizen/SaizenPrep somatropin Growth hormone deficiency (GHD) in children, Turner syndrome, GHD in adults, Prader injection Willi syndrome, Idiopathic short stature in children, Children with chronic kidney disease, Short Stature Homeobox-Containing Gene deficiency, Children Born Small for Gestational Age or with Intrauterine Growth Restriction, Noonan syndrome, Short bowel syndrome: 1. Approve if the individual has tried five of the following (if five are formulary, or four if four are formulary, or three if three are formulary, or two if only two are formulary, or one if only one is formulary): Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ, Omnitrope, or Zomacton. If none are formulary, approve.

Page 45 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Sandostatin LAR octreotide 1. Approve if the individual has tried Somatuline Depot, if formulary. If Somatuline Depot injectable Depot is non-formulary, approve. suspension 2. Individual with meningioma: approve.

3. Individual with thymoma/thymic carcinoma: approve.

4. If the individual has already been started on Sandostatin LAR Depot therapy, approve.

Savaysa edoxaban tablets 1. Approve if the individual has tried one of the following, if one is formulary: Pradaxa, Xarelto, or Eliquis [documentation required]. If none are formulary, approve.

2. Individuals currently receiving Savaysa for treatment of thrombosis (e.g., deep vein thrombosis [DVT] or pulmonary embolism [PE]): approve.

3. Individuals using Savaysa for treatment of DVT or PE associated with cancer: approve if the individual has tried Eliquis [documentation required], if formulary. If Eliquis is non-formulary, approve.

4. Individuals currently receiving Savaysa for prophylaxis of DVT or PE after orthopedic surgery (e.g., hip replacement surgery): approve.

Semglee insulin glargine 1. Approve if the individual has tried four formulary products from the following list (if injection four are formulary, or three if three are formulary or two if two are formulary or one if one is formulary): Basaglar, Lantus, Toujeo, Levemir, or Tresiba. If none are formulary, approve.

2. Individuals with Type 1 diabetes- approve if the individual has tried three formulary products from the following list (if three are formulary, or two if two are formulary, or one if one is formulary): Basaglar, Lantus, Toujeo, or Tresiba. If none are formulary, approve.

3. Individuals with Type 1 diabetes who are currently maintained on Semglee- approve if the individual has tried two formulary product from the following list (if two are formulary, or one if one is formulary): Basaglar, Lantus, or Toujeo. If neither are formulary, approve. Signifor LAR pasireotide IM 1. Individuals with acromegaly: approve if the individual has tried one of Sandostatin injection LAR Depot or Somatuline Depot, if one is formulary. If neither are formulary, approve.

2. Individuals with Cushing’s disease: approve if the individual has tried Signifor (not LAR). If Signifor (not LAR) is non-formulary, approve.

Siklos hydroxyurea 1. Approve is the individual has tried Droxia, if formulary. If Droxia is non-formulary, tablets approve.

2. If the individual requires Siklos 100 mg or 1,000 mg tablets to achieve a dosage that cannot be achieved with the available strengths of Droxia, approve.

3. If the individual cannot swallow or has difficulty swallowing Droxia capsules, approve.

Sitavig acyclovir buccal 1. Approve if the individual has tried two of the following: acyclovir capsules/tablets, tablets famciclovir tablets (generics), valacyclovir tablets (Valtrex, generics), Denavir 1% cream, Xerese 5%/1% cream, acyclovir 5% cream (Zovirax 5% cream, generics), or over-the-counter (OTC) Abreva 10% cream.

Page 46 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Slynd Approve if the individual meets one of the following criteria (1 or 2): tablet 1. Individual has tried one progesterone-only contraceptive containing norethindrone; OR Examples of progesterone-only contraceptives containing norethindrone include Ortho Micronor, Camila, Deblitane, Errin, Nora-BE, norethindrone, Heather, Jencycla, Lyza, Norlyroc, Sharobel.

2. If according to the prescriber, these alternatives would not be as medically appropriate for the individual as the requested non-formulary drug. sofosbuvir/velpatas sofosbuvir/velpata 1. Individual is directed to use Epclusa. If Epclusa is non-formulary, approve. vir (Authorized svir tablets 400 generic for Epclusa) mg/100 mg tablets Approval duration: 24 weeks 400 mg/100 mg tablets

Sorilux and calcipotriene foam 1. Approve if the individual has tried calcipotriene solution, if formulary. If authorized generic calcipotriene solution is non-formulary, approve. 2. Approve if the individual has tried calcipotriene cream or ointment. 3. If the individual is using the requested medication for plaque psoriasis and is between the ages ≥ 4 and < 18 years of age, approve.

Spravato esketamine nasal 1. For the diagnosis of Treatment-Resistant Depression: approve if the individual spray meets the following criteria (A, B, and C): A. The individual is ≥ 18 years of age; AND B. The individual meets both of the following (i and ii): i. The individual has demonstrated nonresponse (≤ 25% improvement in depression symptoms or scores) to at least two different antidepressants, each from a different pharmacologic class; AND Note: Different pharmacologic classes of antidepressants include selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs], tricyclic antidepressants [TCAs], bupropion, mirtazapine, etc. ii. Each antidepressant was used at therapeutic dosages for at least 6 weeks in the current episode of depression, according to the prescriber; AND C. Individual is concomitantly receiving at least one oral antidepressant.

2. Major Depressive Disorder with Acute Suicidal Ideation or Behavior: approve if the individual meets the following criteria (A, B, and C): A. The individual is ≥ 18 years of age; AND B. The individual has major depressive disorder that is considered to be severe, according to the prescriber; AND C. The individual is concomitantly receiving at least one oral antidepressant.

Note: Antidepressants may include, but are not limited to, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), mirtazapine, and bupropion.

3. For the diagnosis of Treatment-Resistant Depression OR Major Depressive Disorder with acute suicidal ideation or behavior: approve if the individual has already started therapy with Spravato.

Sprix and ketorolac 1. Approve if the individual has tried five prescription-strength, oral NSAIDs. authorized generic tromethamine nasal spray Note: Examples include: etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics), indomethacin (generics).

Page 47 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

2. Approve for individuals with difficulty swallowing or for individuals who cannot swallow.

Stribild elvitegravir/ 1. Approve if the individual has tried Biktarvy, if formulary. If Biktarvy is non-formulary, cobicistat/ approve. emtricitabine/ tenofovir tablets 2. Approve if the individual has tried one integrase strand transfer inhibitor (INSTI) or an INSTI-containing product (e.g., Genvoya, Tivicay, Triumeq, Juluca, Isentress or Intress-HD).

3. Individuals already started on therapy with Stribild: approve. Striverdi Respimat olodaterol 1. Approve if the individual has tried Serevent Diskus, if formulary. If Serevent Diskus inhalation spray is non-formulary, approve.

2. Individuals who have a low inspiratory flow rate and are unable to use a dry-powder inhaler (DPI): approve.

Suprep magnesium 1. Approve if the individual has tried one other bowel evacuant product (e.g., peg- sulfate; potassium electrolyte solution, Colyte, GaviLyte, Golytely, Nulytely, TriLyte). sulfate; sodium sulfate solution 2. If, per the prescriber, the individual requires a low volume bowel preparation, approve if the individual meet one of the following criteria (a, b, c, d, or e): a. Individual has tried PEG3350 powder packet (Moviprep, generics). If PEG3350 powder packet (Moviprep, generics) are non-formulary, approve; OR b. If PEG3350 powder packet (generic of Moviprep) is unavailable; OR c. The individual is less than 18 years of age; OR d. Individuals with phenylketonuria; OR e. Individuals with glucose-6-phosphate dehydrogenase deficiency.

Approval duration: 1 month

Sutab sodium sulfate, 1. Approve if the individual meet one of the following criteria (a, b, c, or d): magnesium a. Individual has tried PEG3350 powder packet (Moviprep, generics). If sulfate, and PEG3350 powder packet (Moviprep, generics) are non-formulary, approve; potassium OR chloride tablets b. If PEG3350 powder packet (generic of Moviprep) is unavailable; OR c. Individuals with phenylketonuria; OR d. Individuals with glucose-6-phosphate dehydrogenase deficiency.

Approval duration: 1 month

Tavalisse fostamatinib 1. Approve if the individual has tried two of the following products: Promacta, Nplate, disodium or Doptelet (if two are formulary or one if one is formulary). If none are formulary, hexahydrate approve. tablets 2. Approve if the individual has been started on Tavalisse.

Tepmetko tepotinib tablets Non-Small Cell Lung Cancer (NSCLC) with mesenchymal-epithelial transition (MET) exon 14 skipping alterations: 1. Approve if the individual has tried Tabrecta. If Tabrecta is non-formulary, approve. 2. Approve if the individual has already been started on Tepmetko.

Page 48 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Thyquidity levothyroxine 1. Approve if the individual has tried five formulary levothyroxine products from the sodium oral following list (if five are formulary or four if four are formulary or three if three are solution formulary or two if two are formulary or one if one is formulary): levothyroxine (Synthroid, generics), Levoxyl (generics), Unithroid (generics), Levo-T (generics), Euthyrox (generics), or Tirosint capsules. If none are formulary, approve.

2. If the individual cannot swallow or has difficulty swallowing, approve if the individual has tried Tirosint oral solution, if formulary. If Tirosint oral solution is non-formulary, approve.

Timoptic in timolol maleate 1. Approve if the individual has tried and, according to the prescriber, has experienced Ocudose 0.25% and 0.5% inadequate efficacy OR significant intolerance with four products from the following ophthalmic list: timolol ophthalmic solution (Timoptic, generics), levobunolol ophthalmic solution solution (Betagan, generics), timolol once-daily (Istalol, generics), timolol gel- forming solution (Timoptic XE, generics), betaxolol ophthalmic solution (generics), Betoptic S, carteolol opthalmic solution (generics), if four are formulary (or three if three are formulary or two if two are formulary or one if one is formulary). If none are formulary, approve.

2. Approve if the individual has a known sensitivity to a preservative or when use of a preservative-free is advisable.

Tirosint levothyroxine oral 1. Approve if the individual has tried five formulary levothyroxine products from the solution following list (if five are formulary or four if four are formulary or three if three are formulary or two if two are formulary or one if one is formulary): levothyroxine (Synthroid, generics), Levoxyl (generics), Unithroid (generics), Levo-T (generics), Euthyrox (generics), or Tirosint capsules. If none are formulary, approve.

2. If the individual cannot swallow or has difficulty swallowing, approve if the individual has tried Thyquidity oral solution, if formulary. If Thyquidity is non-formulary, approve.

Tirosint and levothyroxine 1. Approve if the individual has tried five formulary levothyroxine products from the authorized generic capsules following list (if five are formulary or four are formulary or three if three are formulary or two if two are formulary or one if one is formulary): levothyroxine (Synthroid, generics), Levoxyl (generics), Unithroid (generics), Levo-T (generics), Euthyrox (generics), or Tirosint oral solution. If none are formulary, approve.

Tivorbex and indomethacin, 1. Approve if the individual has tried five prescription-strength, oral NSAIDs. authorized generic submicronized capsules Note: Examples include: indomethacin (generics), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

TobraDex ST tobramycin 1. Approve if the individual has tried tobramycin-dexamethasone ophthalmic 0.3%/dexamethas suspension (Tobradex, generics), if formulary. If tobramycin-dexamthasone one 0.05% ophthalmic suspension (Tobradex, generics) are non-formulary, approve. ophthalmic suspension 2. For the treatment of currently active eye infections: approve in individuals already receiving TobraDex ST to complete the course of therapy.

Page 49 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Tolsura itraconazole 1. Approve if the individual has tried one of itraconazole capsules (Sporanox, capsules generics) or itraconazole oral solution (Sporanox liquid, generics).

NOTE: A trial of either the conventional intraconazole capsules or intraconazole solution would count toward meeting criteria regardless of the formulary status of the product.

2. Individual has been started on a current course of therapy with Tolsura (for a non- oncychomycosis diagnosis): approve to complete the current course.

3. Deny: If the individual is requesting Tolsura for a diagnosis of onychomycosis.

NOTE: If the individual is requesting Tolsura for a diagnosis of onychomycosis, the request should be denied regardless of what the individual has tried for the current condition or if the individual has already been started on the product.

Tradjenta linagliptin tablets 1. Approve if the individual has tried two products from the following list (if two are formulary, or one if only one is formulary): alogliptin tablets (Nesina, generics), Onglyza, or Januvia. If none are formulary, approve.

2. Individuals with a history of heart failure (HF) or a history of renal impairment: Approve if the individual has tried Januvia, if formulary. If Januvia is non-formulary, approve Tradjenta.

Treximet sumatriptan/ Approve if the individual has tried naproxen AND sumatriptan tablets (Imitrex, generics), naproxen sodium if formulary. If sumatriptan tablets (Imitrex, generics) are non-formulary, approve. tablets NOTE: A trial of the requested agent would NOT count toward meeting this requirement.

Trinaz ascorbic acid, 1. Direct the individual to generic prenatal vitamins. cholecalciferol, thiamine hydrochloride, riboflavin, pyridoxal phosphate anhydrous, folic acid, methylcobalamin, calcium carbonate, ferrous gluconate, and potassium iodide tablet, film coated

Tudorza Pressair aclidinium 1. Approve if the individual has tried one product from the following list (if one is bromide inhalation formulary): Incruse Ellipta, Spiriva HandiHaler, or Spiriva Respimat. If none are powder formulary, approve.

Twirla levonorgestrel and Approve if the individual meets one of the following criteria (1 or 2): ethinyl estradiol 1. Individual has tried five other contraceptive agents (e.g., oral contraceptive tablets, transdermal Xulane [contraceptive patch], Annovera [contraceptive ring]), NuvaRing or generics system [contraceptive ring]); OR

Note: A trial of five different oral contraceptive agents would meet the requirement.

Page 50 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form 2. Approve if according to the prescriber, these alternatives would not be as medically appropriate for the individual as the requested non-formulary drug.

Tyblume levonorgestrel 0.1 Approve if the individual meets one of the following criteria (1 or 2): mg and ethinyl 1. Individual has tried four other oral contraceptive agents; OR estradiol 0.02 mg 2. If according to the prescriber, these alternatives would not be as medically tablets appropriate for the individual as the requested non-formulary drug. Udenyca pegfilgrastim-cbqv 1. Approve if the individual meets BOTH of the following (a and b): injection 1. The individual has tried four of the following, if four are formulary (or three if three are formulary or two if two are formulary or one if one is formulary): Neulasta, Fulphila, Ziextenzo, or Nyvepria; AND

Note: If none are formulary, approve.

2. Individual cannot continue to use each of the formulary alternative(s) due to a formulation difference in the inactive ingredient(s) [e.g., differences in stabilizing agent, buffering agent, and/or surfactant] which, according to the prescriber, would result in a significant allergy or serious adverse reaction.

2. Individuals who have initiated therapy with Udenyca and requires further medication to complete the current cycle of chemotherapy: approve. Upneeq oxymetazoline 1. No exceptions are recommended. Due to insufficient clinical efficacy data, approval hydrochloride is not recommended for Upneeq. 0.1% ophthalmic solution Veltassa patiromer powder 1. Approve if the individual has tried Lokelma, if formulary. If Lokelma is non- for suspension formulary, approve.

Veltin clindamycin 1. Approve if the individual has tried BOTH a clindamycin- AND a - containing phosphate and product (for example, Ziana, generic clindamycin/tretinoin, Retin-A, generic tretinoin gel tretinoin, Cleocin-T, generic clindamycin).

Ventolin HFA albuterol sulfate 1. Approve if the individual has tried one product from the following list, if formulary: inhalation aerosol albuterol HFA (ProAir HFA, generics), albuterol HFA (Proventil HFA, generics), ProAir Respiclick, ProAir Digihaler, albuterol HFA inhaler (authorized generic to Ventolin HFA), Xopenex HFA, or levalbuterol HFA inhaler. If none are formulary, approve.

2. Individuals < 12 years of age or individuals who have a low inspiratory flow rate and are unable to use a dry powder inhaler (DPI): approve if the individual has tried one product from the following list, if formulary: albuterol HFA (ProAir HFA, generics), albuterol HFA (Proventil HFA, generics), albuterol HFA inhaler (authorized generic to Ventolin HFA), Xopenex HFA, or levalbuterol HFA inhaler. If none are formulary, approve.

Verdeso desonide foam 1. Approve if the individual has tried and, according to the prescriber, has experienced inadequate efficacy OR significant intolerance with five unique, generic prescription- strength topical corticosteroid products.

Note: Examples of topical steroid products include: desonide, alclometasone dipropionate, betamethasone valerate, fluocinolone acetonide, triamcinolone, flurandrenolide, hydrocortisone butyrate.

Page 51 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: The five products must be chemically unique (i.e., a trial of desoximetasone 0.05% and 0.25% would NOT fulfill the requirement).

Vesicare LS solifenacin 1. Approve if the individual has tried one oxybutynin-containing product (e.g., succinate oral oxybutynin immediate-release tablets, oxybutynin extended-release tablets, suspension oxybutynin solution/).

2. Individual is < 5 years of age: approve.

Victoza liraglutide (rDNA 1. Approve if the individual has tried two formulary alternatives from the following list origin) injection (or one if only one is formulary): Adlyxin, Trulicity, Byetta, Bydureon BCise, or Ozempic [documentation required]. If none are formulary, approve.

NOTE: Bydureon BCise and Byetta count as one alternative.

2. Approve if the individual is less than 18 years of age.

3. If the individual, according to the prescriber, has established cardiovascular disease OR at least two risk factors for cardiovascular disease, approve if the individual has tried Ozempic and Trulicity [documentation required], if formulary (or one if one is formulary). If neither are formulary, approve.

4. Individuals with stage 3 chronic kidney disease (CKD) or renal impairment (i.e., estimated creatinine clearance [CrCl] < 30 mL/min): approve if the individual has tried two formulary alternatives from the following list: Trulicity or Ozempic [documentation required], if formulary (or one if one is formulary). If neither are formulary, approve.

Approval duration: 2 years

Viibryd vilazodone tablets 1. Approve if the individual has tried four formulary SSRIs from the following list (if four are formulary or three if three are formulary or two if two are formulary, or one if one is formulary): citalopram (Celexa, generics), fluvoxamine (generics), escitalopram (Lexapro, generics), fluoxetine (Prozac, generics), sertraline (Zoloft, generics), paroxetine HCl (Paxil, Paxil CR, generics), Pexeva, or Trintellix. If none are formulary, approve.

2. Individual is currently taking or has taken Viibryd at any time in the past: approve.

3. Suicidal ideation: approve.

Vivlodex meloxicam 1. Approve if the individual has tried five prescription-strength, oral NSAIDs. capsules Note: Examples include: meloxicam (Mobic, generics), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), diclofenac (Voltaren XR, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

Winlevi clascoterone 1. Approve if the individual has tried, and according to the prescriber has inadequate cream 1% efficacy OR significant intolerance with both topical a topical retinoid-containing product AND a topical -containing product.

Page 52 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Note: Examples of topical include: clindamycin topical solution/gel, erythromycin topical solution/gel.

Note: Examples of topical retinoid products include tretinoin cream (Retin-A cream, generics), tretinoin gel (Retin-A gel, generics).

Wynzora calcipotriene/ 1. Approve if the individual has tried and, according to the prescriber has experienced betamethasone inadequate efficacy OR significant intolerance with five generic prescription- dipropionate strength topical corticosteroid products (e.g., betamethasone dipropinate, 0.005%/ 0.064% clobetasol propionate, diflorasone diacetate) AND a calcipotriene-containing topical cream product (e.g., calcipotriene cream).

Xadago safinamide tablets 1. Approve if the individual has tried two products from the following list, if formulary (or one if one is formulary): selegiline tablets, selegiline capsules (Eldepryl, generics), rasagiline tablets (Aziliect, generics), or Zelapar. If none are formulary, approve.

2. Individuals already started on Xadago, approve.

Xatmep methotrexate oral 1. Approve if the individual cannot swallow or has difficulty swallowing oral solution methotrexate tablets.

2. Approve if the individual’s dose cannot be obtained using whole methotrexate tablets.

Xelpros latanoprost 1. Approve if the individual has tried two formulary alternatives from the following list 0.005% (or one if only one is formulary): latanoprost ophthalmic solution (Xalatan, ophthalmic generics), bimatoprost 0.03% ophthalmic solution (generics), Lumigan, travoprost (Travatan Z, generics), Zioptan or Vyzulta. If none are formulary approve.

2. Individual has a benzalkonium chloride sensitivity: approve if the individual has tried Zioptan or travoprost (Travatan Z, generics), if formulary. If neither is formulary, approve.

Ximino and minocycline ER 1. Approve if the individual has tried minocycline extended-release tablets (Solodyn, authorized generic capsule generics), if formulary. If none are formulary, approve

Xolegel ketoconazole 2% 1. Approve if the individual has tried four topical antifungals (e.g., naftifine 1% or 2% gel cream or 1% gel (Naftin, generics), Naftin 2% gel, Lotrimin Ultra [over-the-counter {OTC}], clotrimazole 1% cream [OTC formulation], econazole 1% cream, Ecoza 1% foam, ketoconazole 2% cream or foam [Extina, generics], Oxistat 1% lotion, oxiconazole 1% cream (Oxistat, generics), Ertaczo 2% cream, Exelderm 1% cream or solution, ciclopirox 0.77% cream or gel [generics], Luzu 1% cream, Mentax 1% cream).

Xopenex HFA levalbuterol 1. Approve if the individual has tried one formulary albuterol containing inhaler from inhalation aerosol the following list: albuterol HFA (Proventil HFA, generics), Ventolin HFA, albuterol HFA inhaler (authorized generic for Ventolin HFA), albuterol HFA (ProAir HFA, generics), ProAir Respiclick, ProAir Digihaler, if one is formulary. If none are formulary, approve.

2. Individuals < 12 years of age or individuals who have a low inspiratory flow rate and are unable to use a dry powder inhaler (DPI): approve if the individual has tried one product from the following list (if one is formulary): albuterol HFA (ProAir HFA, generics), Ventolin HFA, albuterol HFA inhaler (authorized generic for Ventolin HFA), albuterol HFA (Proventil HFA, generics). If none are formulary, approve.

Page 53 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Xpovio selinexor tablets 1. Multiple Myeloma: Approve if the individual meets one of the following (i, ii, or iii): i. Individual has tried at least four prior regimens for multiple myeloma; OR ii. Individual meets both of the following (a and b): a) Individual has tried at least one prior regimen for multiple myeloma; AND b) The medication will be taken in combination with bortezomib; OR iii. Individual meets both of the following (a and b): a) Individual has tried at least one prior regimen for multiple myeloma; AND b) The medication will be taken in combination with Darzalex (daratumumb infusion), Darzlaex Faspro (daratumumab and hyaluronidase-fihj injection), or Pomalyst (pomalidomide capsules).

Note: Examples include bortezomib/Revlimid (lenalidomide capsules)/dexamethasone, Kyprolis (carfilzomib infusion) / Revlimid/ dexamethasone, Darzalex (daratumumab injection)/bortezomib or Kyprolis/dexamethasone, or other regimens containing a proteasome inhibitor, immunomodulatory drug, and/or anti-CD38 monoclonal antibody.

2. Diffuse Large B-Cell Lymphoma: approve if the individual has been treated with at least two prior systemic therapies.

3. Multiple Myeloma, Diffuse Large B-Cell Lymphoma: If the individual has already been started on Xpovio, approve.

Xtampza ER oxycodone 1. Approve if the individual has tried three other oral long-acting opioid products. extended-release For example: morphine sulfate controlled-release/extended-release capsules or capsules (with tablets [MS Contin, generics; Kadian, generics for some strengths], hydromorphone DETERx) extended-release tablets [Exalgo, generics], oxymorphone extended-release, Nucynta ER, Zohydro ER, OxyContin, oxycodone ER tablets [generics], Hysingla ER, Arymo ER, or MorphaBond.

2. Individual is intolerant or allergic to morphine: approve if the individual has tried one product from the following list (if one is formulary): Nucynta ER, Zohydro ER, Hysingla ER, oxycodone ER tablets (generics), or OxyContin. If none are formulary, approve.

3. Individual has renal insufficiency: approve if the individual has tried one product from the following list (if one is formulary): Nucynta ER, Zohydro ER, Hysingla ER, or oxycodone ER tablets (generics), OxyContin. If none are formulary, approve.

Yosprala and aspirin and 1. Approve if the individual has tried aspirin AND at least five proton pump inhibitors authorized generic omeprazole (e.g., omeprazole [Prilosec, generics], rabeprazole tablets [Aciphex, generics], delayed-release lansoprazole [Prevacid, generics], esomeprazole [Nexium, generics], pantoprazole tablets [Protonix, generics]).

Zegerid capsules omeprazole/ 1. Approve if the individual has tried five proton pump inhibitors (PPIs). sodium bicarbonate Note: Examples of PPIs include rabeprazole delayed-release (DR) tablets capsules (Aciphex, generics), Aciphex Sprinkle DR capsules or authorized generic, Dexilant DR capsules, esomeprazole DR capsules (Nexium, generics), Nexium DR packet (granules for oral suspension), pantoprazole DR tablets (Protonix, generics), Protonix suspension (granules), lansoprazole DR capsules, lansoprazole oral disintegrating tablets (Prevacid Solutab, generics), omeprazole DR capsules (Prilosec, generics), or Prilosec DR suspension.

Note: The requested agent would NOT count as a trial of an alternative.

Page 54 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Zegerid packets omeprazole/ 1. Approve if the individual has tried five proton pump inhibitors (PPIs). sodium bicarbonate Note: Examples of PPIs include rabeprazole delayed-release (DR) tablets powder for oral (Aciphex, generics), Aciphex Sprinkle DR capsules or authorized generics, Dexilant suspension DR capsules, esomeprazole DR capsules (Nexium, generics), Nexium DR packet (packets) (granules for oral suspension), pantoprazole DR tablets (Protonix, generics), Protonix suspension (granules), lansoprazole DR capsules, lansoprazole oral disintegrating tablets (Prevacid Solutab, generics), omeprazole DR capsules (Prilosec, generics), or Prilosec DR suspension.

Note: The requested agent would NOT count as a trial of an alternative.

Zelapar selegiline orally 1. Approve if the individual has tried one product from the following list, if formulary (or disintegrating one if one is formulary): selegiline tablets, selegiline capsules (Eldepryl, generics), tablets rasagiline tablets (Azilect, generics), or Xadago. If none are formulary, approve.

2. Approve if the individual cannot swallow or has difficulty swallowing selegiline tablets.

Zetonna ciclesonide nasal 1. Approve if the individual has tried five nasal steroids from the following list, if aerosol formulary (or four if four are formulary or three if three are formulary or two if two are formulary or one if one is formulary): fluticasone propionate spray, Beconase AQ, mometasone nasal spray (Nasonex, generics), flunisolide nasal spray (generics), Omnaris, or Qnasl.

Note: Over-the-counter (OTC) nasal steroids would count as a trial of an alternative.

Zipsor diclofenac 1. Approve if the individual has tried five prescription-strength, oral NSAIDS. potassium capsule Note: Examples include: diclofenac (Voltaren XR, generics), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried. zolmitriptan nasal zolmitriptan nasal 1. Direct the individual to Zomig nasal spray (brand), if formulary. If Zomig nasal spray spray (authorized spray (brand) is non-formulary, approve if the individual has tried one product from the generic of Zomig following list (if one is formulary): sumatriptan nasal spray (Imitrex Nasal Spray, nasal spray) generics), Onzetra Xsail, or Tosymra Nasal Spray. If none are formulary, approve.

2. Direct the individual to Zomig nasal spray (brand), if formulary. If Zomig nasal spray (brand) is non-formulary, approve if the individual is 12 to 17 years of age.

Zomacton (formerly somatropin Growth hormone deficiency (GHD) in children, Turner syndrome, GHD in adults, Prader Tev-Tropin) injection Willi syndrome, Idiopathic short stature in children, Children with chronic kidney disease, Short Stature Homeobox-Containing Gene deficiency, Children Born Small for Gestational Age or with Intrauterine Growth Restriction, Noonan syndrome, Short bowel syndrome: 1. Approve if the individual has tried five of the following (if five are formulary, or four if four are formulary, or three if three are formulary, or two if only two are formulary, or one if only one is formulary): Genotropin, Humatrope, Norditropin Flexpro, Nutropin AQ, Omnitrope, or Saizen. If none are formulary, approve.

Page 55 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review Non-Covered Chemical Name Exception Criteria Product and Dosage Form Zorvolex and diclofenac 1. Approve if the individual has tried five prescription-strength, oral NSAIDS. authorized generic capsules Note: Examples include: diclofenac (Voltaren XR, generics), etodolac (generics), flurbiprofen (Ansaid, generics), ibuprofen (e.g., Motrin, generics), ketoprofen (generics), meloxicam (Mobic, generics), nabumetone (generics), naproxen (e.g., Naprosyn, Naprelan, generics), oxaprozin (Daypro, generics), piroxicam (Feldene, generics), indomethacin (generics).

Note: Over-the-counter (OTC) NSAIDs would count if prescription-strength doses were used.

Note: Five unique NSAIDs should be tried.

Zyclara 2.5% and imiquimod 2.5% 1. Approve if the individual has tried imiquimod 5% cream (Aldara, generics), if 3.75% and and 3.75% cream formulary. If imiquimod 5% cream (Aldara, generics) is non-formulary, approve. authorized generic 3.75% Zylet tobramycin 1. Approve if the individual has tried one of tobramycin-dexamethasone ophthalmic 0.3%/loteprednol suspension (Tobradex, generics) or TobraDex ST, if formulary. If neither are non- etabonate 0.5% formulary, approve. ophthalmic suspension 2. Individuals < 2 years of age, approve.

3. For the treatment of currently active eye infections: approve in individuals already receiving Zylet to complete the course of therapy.

Conditions Not Covered

Any other exception is considered not medically necessary.

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Page 56 of 56 Cigna National Formulary Coverage Policy: Medical Necessity Criteria for Products Requiring Non-Preferred Coverage Review