Pharmacy Prior Authorization Criteria

Central California Alliance for Health

August 2019

Notice of Nondiscrimination and Accessibility

Discrimination is Against the Law Central California Alliance for Health (the Alliance) complies with Federal civil rights and nondiscrimination laws to make sure all members have access to its programs and services. This means that the Alliance does not exclude or treat members differently because of race, color, national origin, age, disability, or sex.

The Alliance provides services, at no cost, to help members communicate with us. • Members with a disability can ask for: ○ A trained sign language interpreter, and ○ Written information in large print, audio, easy to use electronic formats and other formats.

• Members whose primary language is not English can ask for: ○ A trained language interpreter, and ○ Information written in a language they can understand.

If you need these services, contact the Alliance Member Services Department at (800)700-3874 or if you believe that the Alliance did not provide these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance in any of these ways:

Phone: 1 (800) 700-3874, ext. 5816 Website: https://www.ccah-alliance.org/Complaints.html Fax: (831) 430-5579 Email: [email protected] Mail: Grievance Department 1600 Green Hills Road, Suite 101 Scotts Valley, CA 95066

If you need help filing a grievance, our Member Service Representatives and Grievance Coordinators can help you. Contact the Alliance Member Services Department at (800) 700-3874 or Grievance Department at (800)700-3874, ext. 5816. For the Hearing or Speech Assistance Line, call (800) 735-2929 (TTY: Dial 7-1-1).

You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights in any of these ways:

Phone: (800)368-1019 (TTY: Dial (800)537-7697) Website: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Email: [email protected] Mail: U.S. Department of Health and Human Services, Office for Civil Rights 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Forms: https://www.hhs.gov/ocr/complaints/index.html

Last Revision: November 4, 2016

LANGUAGE ASSISTANCESI

LANGUAGE ASSISTANCE CONTINUED

Alliance Contact Information

Address Santa Cruz County Monterey County Office Merced County Office Main Office1600 Green Hills Road, 950 East Blanco Road, 530 West 16th Street, Suite 101 Suite 101 Suite B Scotts Valley, CA 95066-4981 Salinas, CA 93901-3400 Merced, CA 95340-4710 (831) 430-5500 (831) 755-6000 (209) 381-5300 Hours: M-F, 8 a.m.- 5 p.m. Hours: M-F, 8 a.m.- 5 p.m. Hours: M-F, 8 a.m.- 5 p.m.

Department Phone Directory

Automated System (831) 430-5501 Authorizations – Pharmacy (831) 430-5507 Authorizations – Non-Pharmacy (831) 430-5506 Status Requests for Non-Pharmacy (831) 430-5511 Care Management (831) 430-5512 Claims Inquiries (831) 430-5503 EDI Support Line (831) 430-5510 Health Education (831) 430-5580 Member Services (831) 430-5505 Provider Services (831) 430-5504

Department Fax Numbers

Administration (831) 430-5852 Claims (831) 430-5858 Finance (831) 430-5853 Health Services PA and RAFs (831) 430-5850 Member Services (831) 430-5856 Pharmacy Authorizations (831) 430-5851 Provider Services (831) 430-5857

Alliance Website Resources Various resources can be found on the Central California Alliance for Health’s Pharmacy Department website:

Alliance Provider Portal To save paper and increase efficiency, providers may submit pharmacy prior authorizations through the Alliance Provider Portal (Portal). If you have questions, please contact the Provider Services Web & EDI Specialist at (831) 430-5518.

Prior Authorization Form All Alliance lines of business (Medi-Cal and IHSS) are required to use a standardized Prior Authorization Form to request prior authorizations.

Hepatitis C virus (HCV) Checklist Use this resource for HCV medication requests, i.e. Zepatier, Epclusa, etc. (PDF)

Prior Authorization Information Request for Chemotherapy & Injectable Drugs Use this form for chemotherapy, HCPCS J-code requests, and other IV medication request administered by the physician/hospital. (PDF)

High Dose Opioid Regimen Checklist Use this form for opioid drugs that exceed our quantity limits. (PDF)

Pharmacy Opioid Policies Policy 403-1121 – Quantity Limits for Opioid Medications Policy 403-1139 – Opioid Utilization Review Policy 403-1140 – Opioid Refill Policy

Synagis Statement of Medical Necessity These Synagis documents discuss criteria for Synagis and how to obtain a prior authorization. For providers who wish to administer Synagis in their office, the Statement of Medical Necessity form is required to be submitted along with the prior authorization request. The Alliance will cover Synagis for members who meet Conditions of Usage listed in Synagis Policy 403-1120. – Synagis Statement of Medical Necessity – Policy 403-1120 Synagis Policy

Diplomat Specialty Pharmacy Alliance mandates use of Diplomat Specialty Pharmacy for dispensing all specialty medications. Diplomat can be reached by phone at (877) 977-9118 and by fax at (800) 550-6272.

Forward

Central California Alliance for Health (The Alliance), with direction from the Pharmacy & Therapeutics (P&T) Committee, has developed this formulary to be used by Alliance providers and members. The Medi-Cal List of Contract Drugs has not been in use by the Alliance since January 1, 1997.

The P&T committee will continue to update and revise this formulary based on quality of care considerations and sound pharmacoeconomic principles. The Alliance’s contract with the State of California requires mandatory generic substitution whenever an equivalent product is available. By Alliance policy, the only drugs not requiring mandatory generic substitution are Coumadin, Dilantin, and Lanoxin. However, clinicians may prescribe a Brand Name drug with a “do not substitute” order when there is clinical justification for doing so. In the latter case, a Prior Authorization must be submitted to the Alliance for consideration prior to dispensing the medication to an Alliance member.

The Formulary is a list of medication available to Central California Alliance for Health members under their pharmacy benefit. All drugs are listed by their generics names and the most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name and by therapeutic drug category. In situations where an FDA-approved generic equivalent is available, brand names are listed for reference purposes only, and do no denote coverage for the brand.

Formulary Terms 5-Day Emergency Fills Emergency authorizations for Prior Authorizations outside of Central California Alliances’ normal business hours may be requested from MedImpact at (800) 788-2949. MedImpact may authorize up to a 5 day supply of medication, pending further authorization by Central California Alliance for Health. MedImpact is available 24/7. Central California Alliance for Health will also authorize a retroactive Prior Authorization allowing the pharmacy to dispense up to a 5 day supply of a non-formulary drug in an emergency situation. Central California Alliance for Health does not require that the situation meet any legal (i.e., pharmacy law) definition of “emergency” -- it is the judgment of the dispensing pharmacist that determines the need for emergency authorization in order to avoid pain, suffering, severe emotional distress, or worsening of any medical condition that could result in the need for emergency medical treatment.

Brand Name Unless otherwise stated, the brand names shown in the formulary guide are non-formulary when an equivalent generic is approved by the FDA. Brand names used in this formulary guide are representative only, for ease of drug recognition by providers. Generic products must be dispensed whenever possible, as required by the Formulary Utilization Management Initiative (refer to State’s Medi-Cal program).

Carve-Out Drugs (Excluded Drugs) The following drugs are covered by State Medi-Cal:

All antiretroviral drugs except Retrovir (zidovudine), and Videx (didanosine). All antipsychotics, antimania, MAO inhibitors and antiparkinson anticholinergic drugs used for side effects. Drugs to treat ED and opioid detoxification. All blood factors and coagulation factors. Certain drugs for the treatment of Hepatitis B.

These are Prescription services that are not included in the Alliances’ scope of coverage, but are covered (or covered with Prior Authorization) by State Medi-CaI Fee-For-Service program. These drugs remain a potential benefit for eligible Alliance members through State Medi-Cal, but the Alliance is not financially responsible and all claims for these drugs (including secondary copays) must be reimbursed through the State Medi-Cal program.

These drugs are non-formulary but, with the exception of ED drugs, are covered by the Alliance for the Medi-Cal Access program and IHSS.

Please contact State Medi-Cal at 1-800-541-555 or go to https://learn.medi-cal.ca.gov/Resources/eTARNewsTips.aspx

Code 1 Restriction Code 1 medications are formulary, but their use is limited to a specific medical condition, failure/intolerance to 1st line therapy, member’s place of residence, or other stipulated restriction(s). Although Code 1 restricted drugs do not require a Prior Authorization when the Code 1 restriction is met, pharmacy providers must maintain documentation that the drug is being dispensed according to the Code 1 restriction. Any other use of the drug is considered non- formulary and requires a Prior Authorization. To facilitate filling of a Code 1 prescription, prescribers should write the member’s diagnosis, and any other Code 1 criteria if met, on the prescription.

Formulary Terms (Continued) Dollar Amount Limit Central California Alliance for Health has an online adjudication limit of $1,000 for any single claim, for most drugs. Claims submitted for more than $1,000 will require a Prior Authorization, even if on formulary. Compound prescription claims using formulary ingredients have a $100 limit, with a Prior Authorization required on claims that exceed $100.

Dual Eligible Members A dual eligible member is a Medi-Cal member who is also eligible for Medicare, whether or not they are actually enrolled in Medicare. Medi-Cal is always secondary to Medicare, thus if patient is eligible for Medicare, Medicare must be billed prior to billing Central California Alliance for Health. Dual eligible individuals are required to join a Medicare prescription drug plan, and there is a process by which CMS auto-enrolls members into Medicare upon becoming eligible. However, if a member is not yet enrolled in Medicare, but is eligible for Medicare, there is a process by which pharmacies can enroll patients in Part D at Point-of-Sale (LINET program, administered by Humana). Medications that are excluded from the members Medicare plan may be submitted directly to Central California Alliance for Health. Please note that medication that are excluded from the Members Medicare may also be exempt from Medi-Cal &/or Central California Alliance for Health’s benefits. Medications that are non- formulary on member’s Part D (but not excluded) must go through the Prior Authorization procedures with the Part D plan rather than Central California Alliance for Health. Pharmacies may submit a Prior Authorization to Central California Alliance for Health for consideration of Part B copays; Central California Alliance for Health is federally prohibited from paying any Part D copays or deductibles. eCOB Electronic coordination of benefits. The ability to transmit & adjudicate electronically (online) the portion of the primary insurance claim that is the patient’s responsibility, to the secondary insurance. If the medication is non- formulary or non-preferred with the primary insurance, a prior auth. should be sought with the primary before submitting a PRIOR AUTHORIZATION to Central California Alliance for Health. Per CMS Federal regulations, PHC is not responsible for any Part D copays, deductibles or “donut hole” (gap) amounts.

Excluded Drugs Medications that have been excluded from Part D by Federal CMS regulation and are typically not a covered benefit by Medicare D plans. Excluded Drugs include: drugs covered exclusively by Part A or B, OTCs, Rx vitamin & mineral supplements (except niacin & fluoride products), cough & cold agents, fertility agents, agents for weight gain/loss (except megestrol), agents for cosmetic use. Drugs which are excluded from PART D coverage per CMS may be eligible for coverage through the member’s secondary Medi-Cal (Central California Alliance for Health) coverage, depending on the drugs’ Central California Alliance for Health formulary status (eg, some drugs which are excluded from CMS for Part D are also excluded from Central California Alliance for Health coverage).

Formulary Note that additional restrictions may apply to formulary medications. A formulary agent may be subject to dollar limit, age, quantity, or other limitations which necessitate a PA despite formulary status.

Medical Supplies The pharmacy department will review authorization requests for blood glucose meters, test strips, lancets, syringes, needles and sharps containers. All other requests for medical supplies will need to be sent to the Authorization department. The fax number for the Authorization department is (831) 430-5850.

Formulary Terms (Continued) Prior Authorization A prior authorization request form for Central California Alliance for Health services.

To facilitate prompt determination of a Prior Authorization (PA), and to minimize the need for communication between the prescriber, the pharmacy, and Central California Alliance for Health staff, prescribers are encouraged to include the following information, as appropriate: Diagnosis: Prior Authorization must have an accurate diagnosis (preferably with specific ICD-10) provided by the physician. The diagnosis info must be specific for the patient & drug in question. Dispensing pharmacy staff is asked NOT to complete this section on the Prior Authorization without checking with the prescriber, as many drugs have multiple indications & the Dx should never be assumed based on a common use. An incorrect Dx may cause further delay of the review process. Other Formulary Medications tried and nature of the failure. Clinical Justification for the use of a non-formulary drug, including relevant lab results and medical history.

Prior Authorizations submitted to Central California Alliance for Health without the above information may be denied due to insufficient information for clinical review. If denied due to insufficient information, the request may be resubmitted with a new completed Prior Authorization form & the required information at any time, since the new submission is treated as a new Prior Authorization.

Over the Counter Medications (OTC’s) A prescription is required for both formulary OTC claims and non-formulary OTC requests.

Quantity Limit A drug may be limited to a maximum daily, monthly, yearly or lifetime usage.

Secondary Insurance When a Member has more than one medical &/or prescription insurance, one is assigned as the primary and the other is secondary—meaning reimbursement for services is the responsibility of the primary insurance first. The secondary is billed only after the primary. A secondary insurance may utilize its own formulary restrictions. State funded programs are always secondary to any private or federal insurance plans—i.e., they are the payers of last resort. All reimbursement issues should be resolved with the primary insurance before submitting a Prior Authorization to Central California Alliance for Health – this includes using the allowed day’s supply, using the primary’s formulary preferred agents, obtaining prior auth. from the primary for non-preferred or non-formulary items, etc.

If the Member’s commercial insurance does not cover a medication, a Prior Authorization must be submitted to the commercial primary insurance first. If the Prior Authorization is denied an appeal must be submitted and denied prior to submitting a request directly to Central California Alliance for Health with a copy of both denials from the primary insurance.

If the Member has a commercial primary insurance, Central California Alliance for Health will pay for the remaining copay balance due. Central California Alliance for Health requires verbal or written notification of the amount that the primary insurance paid.

Formulary Terms (Continued) Step Therapy Online approval without a Prior Authorization requires prior treatment with prerequisite drug therapy. Member must have had a previous trial of one or more designated 1st line agent(s) paid by MedImpact within a designated time frame in order for claim to adjudicate without a Prior Authorization. Prior Authorizations submitted for STEP agents are needed when there is no qualifying claim in the claim history look-back period; in the event that a Prior Authorization is needed for a STEP item, additional criteria may have been established by P & T, over & above what is equal to the electronic step edit.

Nutritional Supplements The Alliance covers oral nutritional supplements and enteral formulas for Medi-Cal eligible members when medically necessary.

A prior authorization will need to be submitted via the Alliance Portal or by fax to the Alliance Pharmacy Department at (831)430-5851.

Please include the following when submitting a Prior Authorization: Copy of prescribing provider’s prescription Completed Prior Authorization request form Recent chart notes that address medical justification as to why the member is unable to meet his/her nutritional needs with standard or fortified foods Growth charts for pediatric members or relevant weight history for adult members

Conditions that may necessitate oral nutritional supplements or enteral formulas include, but are not limited to: Increased metabolic needs Cow’s milk allergy/intolerance to standard formulas in infancy Preterm birth Cancer with significant weight loss Decubitus ulcers ESRD on HD or PD Severe swallowing or chewing difficulty Conditions impairing digestion and absorption Failure to Thrive Underweight status or unintended weight loss defined by the Medi-Cal guidelines

The Alliance will not authorize oral nutrition supplements when used for convenience or preference of the member or provider.

All requests will be reviewed for medical necessity by the Alliance’s Registered Dietitian (RD).

For a list of covered products, please see the Medi-Cal Enteral Formulary, available here.

The Alliance’s Enteral Nutrition policy can be accessed here.

For additional information regarding the criteria for authorization, please contact Tony Nannini, RD at (831) 430- 4117.

Date: September 2017 GTC: ALLERGY: 1Z Brand Name: DYMISTA Generic Name: 137 mcg azelastine/ 50 mcg fluticasonenasal spray Criteria: Diagnosis of allergic rhinitis AND tried and failure of formulary alternatives Fluticasone 50mcg nasal spray and Azelastine 137 mcg nasal spray used concurrently

Quantity Limits:

Date: GTC: ALLERGY: 1Z Brand Name: OPTIVAR Generic Name: azelastine opthalmic drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen ophthalmic drops (OTC)

Quantity Limits: 1 bottle/rx

Date: September 2016 GTC: ALLERGY: 1Z Brand Name: QNSAL Generic Name: beclomethasone dipropionate hfa aerosol, beclomethasone QNASL CHILDREN dipropionate nasal spray BECONASE AQ Criteria: Diagnosis of allergic rhinitis AND has inadequate response, intolerable side effect, or contraindication to both fluticasone nasal spray and Nasacort OTC

Quantity Limits:

Date: September 2016 GTC: ALLERGY: 1Z Brand Name: RHINOCORT AQUA Generic Name: budesonide nasal spray (rx) Criteria: Use Rhinocort Allergy 32MCG Spray (OTC)

Quantity Limits:

Date: July 2018 GTC: ALLERGY: 1Z Brand Name: ZYRTEC CAPSULE Generic Name: cetirizine capsule

Criteria: Diagnosis of upper respiratory allergies AND trial and failure of cetirizine tablets

Quantity Limits:

Date: September 2017 GTC: ALLERGY: 1Z Brand Name: ZYRTEC CHEWABLE TABLETS Generic Name: cetirizine chew tablet Criteria: Diagnosis of upper respiratory allergies AND trial and failure of cetirizine rapdis OR loratadine rapdis AND trial and failure of loratidine solution OR cetirizine solution

Quantity Limits:

Date: September 2016 GTC: ALLERGY: 1Z Brand Name: OMNARIS Generic Name: ciclesonide nasal spray ZETONNA ciclesonide hfa aerosol Criteria: Diagnosis of allergic rhinitis AND patient has inadequate response, intolerable side effect or contraindication to both fluticasone nasal spray AND Nasacort OTC

Quantity Limits:

Date: September 2017 GTC: ALLERGY: 1Z Brand Name: CLARINEX Generic Name: desloratadine tablets Criteria: Diagnosis of upper respiratory allergies AND trial and failure of Loratadine, Cetirizine and Levocetirizine*

Quantity Limits:

Date: September 2017 GTC: ALLERGY: 1Z Brand Name: ALLEGRA Generic Name: fexofenadine tablet Criteria: Diagnosis of upper respiratory allergies AND trial and failure of Loratadine OR Cetirizine

Quantity Limits:

Date: GTC: ALLERGY: 1Z Brand Name: VERAMYST Generic Name: fluticasone furoate nasal spray Criteria: Diagnosis of allergic rhinitis AND has inadequate response, intolerable side effect or contraindication to both fluticasone nasal spray AND Nasacort OTC

Quantity Limits:

Date: September 2017 GTC: ALLERGY: 1Z Brand Name: XYZAL Generic Name: levocetirizine tablets Criteria: Diagnosis of upper respiratory allergies AND trial and failure of loratadine or cetirizine

Quantity Limits:

Date: July 2018 GTC: ALLERGY: 1Z Brand Name: CLARITIN CAPSULES Generic Name: loratadine capsule

Criteria: Diagnosis of upper respiratory allergies AND trial and failure of loratadine tablets

Quantity Limits:

Date: July 2018 GTC: ALLERGY: 1Z Brand Name: NASONEX Generic Name: mometasone nasal spray Criteria: If patient has inadequate response, intolerable side effect or contraindication to generic fluticasone nasal spray, Nasacort OTC or Budesonide

Quantity Limits:

Date: GTC: ALLERGY: 1Z Brand Name: PATANASE Generic Name: olopatadine nasal spray Criteria: Diagnosis of allergic rhinitis AND has inadequate response, intolerable side effect, or contraindication to formulary alternative azelastine nasal spray.

Quantity Limits: 1 bottle/month

Date: GTC: ALLERGY: 1Z Brand Name: NASACORT AQ Generic Name: triamcinolone nasal spray (rx) Criteria: Use Nasacort Allergy 24HR Spray (OTC)

Quantity Limits:

Date: October 2018 GTC: ANTI- NEOPLASTICS: 0F Brand Name: FDA-APPROVED ONCOLOGY DRUGS Generic Name: fda-approved oncology drugs

Criteria: Diagnosis of cancer AND prescribed by hematologist/oncologist AND use FDA-approved indications and Medi-Cal guidelines and/or in regimens consistent with NCCN Guidelines

FDA-approved Oncology Drugs: abiraterone acetate, ado-trastuzumab emtansine, afatinib dimaleate, aldesleukin, amifostine (Ethyol), asparaginase (Erwinaze), bendamustine, bevacizumab, Bexarotene, bleomycin sulfate, bortezomib, bosutinib, busulfan, cabazitaxel, capecitabine, carboplatin, carfilzomib, carmustine (BiCNU), ceritinib, cetuximab, cisplatin, cladribine, crizotinib, cyclophosphamide, cytarabine, dabrafenib, mesylate, dacarbazine, dasatinib, daunorubicin HCL, denileukin diftitox, docetaxel, doxorubicin HCL, enzalutamide, epirubicin HCL, eribulin mesylate, erlotinib HCL, estramustine phosphate sodium, etoposide, everolimus, exemestane, floxuridine, fulvestrant, gemcitabine HCL, goserelin acetate, hydroxyurea, idelalisib, ifosfamide, ifosfamide/ mesna, imatinib mesylate, Inotuzumab ozogamicin (Besponsa), ipilimumab, irinotecan HCL, ixabepilone, lapatinib, ditosylate, letrozole, leuprolide acetate, lomustine, mechlorethamine HCL, megestrol acetate, melphalan, mitomycin, mitotane, mitoxantrone HCL, nilotinib HCL, nivolumab, obinutuzumab, ofatumumab, olaparib, oxaliplatin, paclitaxel, paclitaxel nanoparticle albumin bound (nabpaclitaxel-Abraxane), palbociclib, panobinostat, panitumumab, pazopanib HCL, pegaspargase, pemetrexed disodium, pentostatin, pertuzumab, plicamycin, porfimer sodium, ramucirumab, regorafenib, rituximab, sorafenib tosylate, streptozocin, sunitinib malate, tamoxifen citrate, temozolomide, teniposide, thiotepa, topotecan HCL, trametinib dimethyl sulfoxide, trastuzumab, tretinoin, vandetanib, vinblastine sulfate, vismodegib, vorinostat, ziv-aflibercept

Quantity Limits:

Date: March 2018 GTC: ANTI- NEOPLASTICS: 0F Brand Name: RITUXAN Generic Name: rituximab Criteria: Diagnosis of rheumatoid arthritis AND has been evaluated by a rheumatologist AND has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine) OR Has severe active rheumatoid arthritis

Quantity Limits: IV: 1000mg on days 1 and 15. May retreat every 24 weeks.

Date: January 2019 GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: BONJESTA ER Generic Name: doxylamine succinate/vitamin b6 Criteria: Nausea and vomiting due to pregnancy AND an adequate trial of 2 weeks of OTC doxylamine and pyridoxine

Quantity Limits:

Date: June 2016 GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: DICLEGIS Generic Name: doxylamine/pyridoxine Criteria: Nausea and vomiting due to pregnancy AND an adequate trial of 2 weeks of OTC doxylamine and pyridoxine

Quantity Limits: Max 30 tablets per dispensing and max of 4 dispensings in a 12 month period

Date: GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: MARINOL Generic Name: dronabinol Criteria: Diagnosis of anorexia associated with weight loss in patients with AIDS

Quantity Limits: 2 tablets/day Max: 20mg/day

Date: September 2017 GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: SANCUSO Generic Name: granisetron 3.1mg/24 hour patch Criteria: Prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy for up to 5 consecutive days AND tried and failed or intolerant to at least one oral 5-HT3 antagonists: generic granisetron, generic ondansetron, Aloxi, Anzemet AND tried and failed or intolerant to Emend OR Patient unable to tolerate oral dosage forms

Quantity Limits: 1 patch per cycle

Date: September 2017 GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: AKYNZEO Generic Name: netupitant/apalonosetron 300-0.5mg capsule Criteria: Prevention of nausea and vomiting in patients receiving highly emetogenic chemotherapy AND tried and failed or intolerant to at least one oral 5-HT3 antagonists (generic granisetron, generic ondansetron, Aloxi, Anzemet) AND tried and failed or intolerant to Emend

Quantity Limits: QL: 1 Capsule per cycle

Date: September 2017 GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: ZUPLENZ Generic Name: ondansetron 4mg film Criteria: Prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy OR Prevention of nausea and vomiting associated with radiotherapy in patients receiving total body irradiation, single high-dose fraction to abdomen, or daily fractions to the abdomen AND tried and failed or intolerant to at least one oral 5-HT3 antagonists: generic granisetron, generic ondansetron, Aloxi, Anzemet AND tried and failed or intolerant to Emend

Quantity Limits: 10 films per cycle

Date: June 2016 GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: ALOXI Generic Name: palonosetron Criteria: Prevention of nausea and vomiting due to chemotherapy AND trial and failure of ondansetron

Quantity Limits: Up to 0.25mg/5ml per cycle

Date: GTC: ANTIEMESIS/ANTIVERTIGO: 0Q Brand Name: TRANSDERM-SCOP Generic Name: scopolamine patch Criteria: Prevention of chemotherapy-induced nausea/vomiting AND tried and failed Meclizine OR Dimenhydrinate AND tried 1 of the following: ondansetron, prochlorperazine, or metoclopramide

Quantity Limits: 3 patches/ Rx For chemotherapy-induced, quantity sufficient to last through treatment 1 fill per request EXCEPT 12 fills for chemotherapy induced

Date: June 2018 GTC: ASTHMA: 1X Brand Name: TRELEGY ELLIPTA Generic Name: (fluticasone/umeclidinium/vilanterol) Criteria: Diagnosis of severe COPD AND had been stabilized on a triple therapy with ICS inhaler, LABA inhaler and LAMA inhaler OR Diagnosis of severe COPD AND has been stabilized on dual therapy (LAMA/LABA, LAMA/ICS, LABA/ICS) AND now requiring the third inhaler (LAMA, LABA, or ICS) AND prescribed by a pulmonologist

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: TUDORZA PRESSAIR Generic Name: aclidinium Criteria: Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative Atrovent HFA or Incruse Ellipta

Quantity Limits:

Date: September 2016 GTC: ASTHMA: 1X Brand Name: PROVENTIL HFA Generic Name: albuterol Criteria: Diagnosis of bronchospasm, asthma, COPD AND has inadequate response, intolerable side effect, or contraindication to Ventolin HFA, ProAir HFA, or ProAir Respiclick

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: OPTIVAR Generic Name: albuterol sulfate tablets Criteria: Diagnosis of bronchospasm, asthma AND has inadequate response, intolerable side effect, or contraindication to Albuterol syrup and Albuterol sulfate ER 12hrs Tablets

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: VOSPIRE Generic Name: albuterol sulfate tablets er 12hr Criteria: Diagnosis of bronchospasm, asthma AND has inadequate response, intolerable side effect, or contraindication to Albuterol syrup

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: BROVANA NEBULIZATION Generic Name: arformoterol

Criteria: Diagnosis of COPD AND has inadequate response or intolerable side effect to formulary Striverdi and Serevent Diagnosis of asthma AND symptoms are inadequately controlled on long-term maintenance treatment which includes an inhaled corticosteroid (ICS) AND has inadequate response or intolerable side effect to 2 preferred LABA (Striverdi, and Serevent) OR Member unable to use inhaler

Quantity Limits:

Date: June 2018 GTC: ASTHMA: 1X Brand Name: SYMBICORT Generic Name: budesonide/formoterol

Criteria: Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to formulary alternative fluticasone/salmeterol (AirDuo) in ≥12 years of age

Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to preferred alternative generic Advair (Fluticasone/Salmeterol and Wixela Inhub) in <12 years of age

Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative generic Advair (Fluticasone/Salmeterol (AG for Advair Diskus) and Wixela Inhub (ANDA for Advair Diskus)

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: ALVESCO Generic Name: ciclesonide Criteria: Diagnosis of asthma AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives such as QVAR, Pulmicort, Arnuity, Flovent, ArmonAir, Asmanex

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: BREO ELLIPTA Generic Name: fluticasone furoate/vilanterol

Criteria: Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to formulary alternative fluticasone/salmeterol (AirDuo) in ≥12 years of age

Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to preferred alternative generic Advair (Fluticasone/Salmeterol and Wixela Inhub) in <12 years of age

Quantity Limits:

Date: June 2018 GTC: ASTHMA: 1X Brand Name: AIRDUO RESPICLICK Generic Name: fluticasone/salmeterol (BRAND ONLY) Criteria: Diagnosis of asthma AND has inadequate response or intolerable side effects to generic AirDuo.

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: ADVAIR HFA Generic Name: fluticasone/salmeterol

Criteria: Diagnosis of Asthma AND Has inadequate response, intolerable side effect or contraindication to formulary alternative fluticasone/salmeterol (AirDuo) in ≥12 years of age

Diagnosis of Ashtma AND Has inadequate response, intolerable side effect or contraindication to formulary alternative generic Advair (Fluticasone/Salmeterol and Wixela Inhub) in <12years of age

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: ADVAIR DISKUS Generic Name: fluticasone/salmeterol wixela inhub

Criteria: Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to formulary alternative fluticasone/salmeterol (AirDuo) in ≥12 years of age OR Diagnosis of COPD

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: PERFOROMIST Generic Name: formoterol NEBULIZATION Criteria: Diagnosis of COPD AND has inadequate response or intolerable side effect to formulary Striverdi and Serevent Diagnosis of asthma AND symptoms are inadequately controlled on long-term maintenance treatment which includes an inhaled corticosteroid (ICS) AND has inadequate response or intolerable side effect to 2 preferred LABA (Striverdi, and Serevent) OR Member unable to use inhaler

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: LONHALA MAGNAIR VIALS Generic Name: glycopyrrolate 25 mcg/1ml vial

Criteria: Diagnosis of COPD, including chronic bronchitis and/or emphysema AND has inadequate response or intolerable side effect to ipratropium solution (Atrovent) or ipratropium/albuterol solution (Duoneb) AND has inadequate response or intolerable side effect to Seebri Neohaler AND has inadequate response or intolerable side effect to one other long acting anticholingeric medications such as: Tudorza, Spiriva, Incruse, Utibron, Anoro Ellipta, Bevespi, Stiolto

Quantity Limits: 60 mL per fill. 1 vial (25 mcg) inhaled twice daily May approve x 3

Date: July 2018 GTC: ASTHMA: 1X Brand Name: SEEBRI NEOHALER Generic Name: glycopyrrolate

Criteria: Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative Atrovent HFA or Incruse Ellipta

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: UTIBRON NEOHALER Generic Name: glycopyrrolate/indacaterol Criteria: Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative Combivent or Bevespi

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: ARCAPTA NEOHALER Generic Name: indacaterol

Criteria: Diagnosis of COPD AND has inadequate response or intolerable side effect to formulary Striverdi Diagnosis of asthma AND symptoms are inadequately controlled on long-term maintenance treatment which includes an inhaled corticosteroid (ICS) AND has inadequate response or intolerable side effect to Striverdi

Quantity Limits:

Date: September 2016 GTC: ASTHMA: 1X Brand Name: XOPENEX SOLUTION Generic Name: levalbuterol Criteria: Diagnosis of bronchospasm, asthma, COPD AND has inadequate response, intolerable side effect, or contraindication to albuterol nebulized solution

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: NUCALA Generic Name: mepolizumab

Criteria: Diagnosis of severe persistent asthma with an eosinophilic phenotype AND symptoms are inadequately controlled with max dose of inhaled corticosteroids in combination with long acting beta-agonists OR Anti-leukotrienes OR Theophylline

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: METAPROTERENOL SULFATE TABLETS Generic Name: metaproterenol sulfate tablets Criteria: Diagnosis of bronchospasm, asthma AND has inadequate response, intolerable side effect, or contraindication to albuterol syrup

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: DULERA Generic Name: mometasone/formoterol

Criteria: Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to formulary alternative fluticasone/salmeterol (AirDuo) in ≥12 years of age

Diagnosis of Asthma AND has inadequate response, intolerable side effect or contraindication to preferred alternative generic Advair (Fluticasone/Salmeterol and Wixela Inhub) in <12 years of age

Quantity Limits:

Date: September 2016 GTC: ASTHMA: 1X Brand Name: SINGULAIR Generic Name: montelukast oral granules Criteria: Montelukast oral granules are formulary for patients < 2yo. If > 2yo, approve if diagnosis of asthma, allergic rhinitis AND has inadequate response or intolerable side effect to formulary montelukast chewables or montelukast tablets

Quantity Limits:

Date: October 2018 GTC: ASTHMA: 1X Brand Name: XOLAIR Generic Name: omalizumab 150mg subcutaneous vial Criteria: Diagnosis of moderate to severe persistent asthma in patients 6 years to 11 years: • Positive skin test or in vitro reactivity to a perennial aeroallergen • Symptoms are inadequately controlled with max doses of inhaled corticosteroids • Pre-treatment serum IgE level between 30 and 1300 IU/ml Diagnosis of moderate to severe persistent asthma in patients 12 years and older: • Positive skin test or in vitro reactivity to a perennial aeroallergen • Symptoms are inadequately controlled with max doses of inhaled corticosteroids • Pre-treatment serum IgE level between 30 and 700 IU/ml Diagnosis of chronic idiopathic urticaria (CIU) in patients 12 years and older: • Must have the presence of urticaria (hives) on most days of the week, for a duration of longer than six weeks AND • Trial and failure of the following: • At least two H1 antihistamines (loratadine, cetirizine, fexofenadine) • H1 antihistamine in combination with H2 (ranitidine, famotidine) OR • H1 antihistamine in combination with Leukotriene modifier (Singulair)

Quantity Limits:

Date: October 2018 GTC: ASTHMA: 1X Brand Name: CINQAIR Generic Name: reslizumab 100mg/10ml vial

Criteria: Diagnosis of severe asthma with an eosinophilic phenotype AND eosinophil count greater than or equal 400 cells/mcL within past 30 days AND used in combination with a corticosteroid inhaler and long acting beta2-agonist AND inadequate control of asthmatic symptoms after a minimum of 3 months of ONE of the following: inhaled corticosteroids & long acting beta2 agonist OR Inhaled corticosteroids & long acting muscarinic antagonist AND only administered by a healthcare professional with appropriate medical support to manage anaphylaxis and monitored for an appropriate period of time after infusion

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: DALIRESP Generic Name: roflumilast Criteria: Diagnosis of COPD AND has inadequate response or intolerable side effect to trial of two formulary alternatives among: generic Airduo, Symbicort , Breo Ellipta , Dulera and Atrovent , Spiriva, and Stirverdi

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: SEREVENT Generic Name: salmeterol

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: TERBUTALINE SULFATE TABLETS Generic Name: terbutaline sulfate tablets Criteria: Diagnosis of bronchospasm, asthma AND has inadequate response, intolerable side effect, or contraindication to albuterol syrup and albuterol sulfate ER 12hrs tablets

Quantity Limits:

Date: September 2017 GTC: ASTHMA: 1X Brand Name: THEO-24 Generic Name: theophylline 24 h er capsules .

Criteria: Diagnosis of asthma or COPD AND tried/failed Theophylline ER 12H tablets OR Theophylline ER 24 hours tablets

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: SPIRIVA HANDIHALER Generic Name: tiotropium

Criteria: Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative Atrovent HFA or Incruse Ellipta

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: SPIRIVA RESPIMAT Generic Name: tiotropium

Criteria: Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative Atrovent HFA or Incruse Ellipta (May approve for asthma)

Quantity Limits:

Date: July 2018 GTC: ASTHMA: 1X Brand Name: STIOLTO RESPIRMAT Generic Name: tiotropium/olodaterol

Criteria: Diagnosis of COPD AND has inadequate response, intolerable side effect or contraindication to preferred alternative Combivent or Bevespi

Quantity Limits:

Date: September 2016 GTC: ASTHMA: 1X Brand Name: ACCOLATE Generic Name: zafirlukast Criteria: Diagnosis of asthma AND has inadequate response, intolerable side effect, or inability to use formulary montelukast chewables or tablets

Quantity Limits:

Date: GTC: AUTONOMIC NERVOUS SYSTEM DISORDERS: 2D Brand Name: RAZADYNE Generic Name: galantamine oral tablet RAZADYNE ER galantamine oral solution extended-release capsule Criteria: Diagnosis of Alzheimer's dementia AND Mini Mental State Examination (MMSE) score <23 OR an equivalent score on another screening test AND trial and failure of donepezil or medical justification why they cannot be used. Razadyne oral solution or ER capsule requires T/F of Razadyne tablets or medical justification why tablets cannot be used.

Quantity Limits: IR: 2 tablets/day Soln: 6mL/day ER: 1 capsule/day

Date: September 2016 GTC: AUTONOMIC NERVOUS SYSTEM DISORDERS: 2D Brand Name: NAMENDA Generic Name: memantine oral tablet NAMENDA XR memantine oral solution extended-release capsule

Criteria: Diagnosis of Alzheimer's dementia AND trial and failure of donepezil or medical justification why they cannot be used Namenda oral solution or ER capsules requires trial and failure of Namenda tablets or medical justification why tablets cannot be used.

Quantity Limits: IR: 2 tablets/day Soln: 10mL/day ER: 1 capsule/day

Date: September 2017 GTC: AUTONOMIC NERVOUS SYSTEM DISORDERS: 2D Brand Name: NAMZARIC Generic Name: memantine/donepezil 1-10/14/10, 7-10mg, 14-10mg, 21- 10mg, 28-10mg Criteria: Diagnosis of moderate to severe Alzheimer disease AND documentation from the member Rx profile or clinician progress notes that the member has had a previous trial of generic memantine and generic donepezil (administered as separate agents) in the last 180 days AND medical justification why the member cannot continue the generics as separate agents

Quantity Limits: 1 capsule per day

Date: GTC: AUTONOMIC NERVOUS SYSTEM DISORDERS: 2D Brand Name: EXELON Generic Name: rivastigmine oral capsule rivastigmine oral solution transdermal patch Criteria: Diagnosis of mild-moderate Alzheimer's dementia or mild-moderate dementia associated with Parkinson’s disease AND Mini Mental State Examination (MMSE) score <23 OR an equivalent score on another screening test For Alzheimer’s dementia, T/F of donepezil or medical justification why they cannot be used Exelon patch or oral solution requires T/F of Exelon capsules or medical justification why capsules cannot be used

Quantity Limits: 2 capsules/day Up to 6 mL/day 1 patch/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: APLENZIN ER Generic Name: bupropion hbr er tablet

Criteria: Diagnosis of depression or Seasonal Affective Disorder (SAD) AND has inadequate response, intolerable side effect, or contraindication to 2 formulary antidepressants such as: fluoxetine, paroxetine, sertraline, citalopram, escitalopram , venlafaxine, duloxetine AND trial of bupropion IR, bupropion SR or bupropion XL at a dose of 300mg per day for SAD or 450mg for depression AND submission of medical records documenting: • details of failure/intolerance to bupropion formulation tried AND • which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: FORFIVO XL Generic Name: bupropion hcl 450mg oral tablet Criteria: Diagnosis of depression AND has inadequate response, intolerable side effect, or contraindication to 2 formulary antidepressants such as: fluoxetine, paroxetine, sertraline, citalopram, escitalopram, venlafaxine, duloxetine AND trial of bupropion IR, bupropion SR, or bupropion XL at a dose of 450mg per day AND submission of medical records documenting: • details of failure/intolerance to bupropion formulation tried AND • which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: ANAFRANIL Generic Name: clomipramine hcl oral capsule

Criteria: Diagnosis of obsessive-compulsive disorder AND has inadequate response, intolerable side effect, or contraindication to 3 formulary antidepressants such as: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, duloxetine, venlafaxine, bupropion AND submission of medical records documenting: • details of failure/intolerance to each drug AND • which attempts were taken to resolve these

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: NORPRAMIN Generic Name: desipramine hcl oral tablet Criteria: Has inadequate response, intolerable side effect, or contraindication to 2 formulary tricyclic antidepressants (TCA) such as: amitriptyline, imipramine HCl tablet, nortriptyline AND submission of medical records documenting: • details of failure/intolerance to each drug AND • which attempts were taken to resolve these

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: KHEDEZLA ER Generic Name: desvenlafaxine er tablet

Criteria: Trial of desvenlafaxine succinate ER tablet (generic for Pristiq)* AND submission of medical records documenting: • details of failure/intolerance to desvenlafaxine succinate ER tablet (generic for Pristiq)* AND • which attempts were taken to resolve these *Prior Authorization required

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: PRISTIQ ER Generic Name: desvenlafaxine succinate er tablet Criteria: Has inadequate response, intolerable side effect, or contraindication to 1 formulary antidepressant such as: fluoxetine, sertraline, citalopram, escitalopram, duloxetine AND trial of venlafaxine IR tablet or venlafaxine ER capsule formulation at dose ≥ 150mg/day AND submission of medical records documenting: • details of failure/intolerance to venlafaxine formulation tried AND • which attempts were taken to resolve these

Quantity Limits: 50mg: 1 tablet/day 100mg: 4 tablets/day

Date: September 2016 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: IRENKA Generic Name: duloxetine 40mg delayed-release oral capsule Criteria: Diagnosis of depression AND has inadequate response, intolerable side effect, or contradiction to 2 capsules per day of formulary Duloxetine 20mg, to achieve same 40mg/day dosage

Quantity Limits: 1 capsule/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: LUVOX CR Generic Name: fluvoxamine maleate cr capsule Criteria: Has inadequate response, intolerable side effect, or contraindication to 2 formulary antidepressants such as: fluoxetine, paroxetine, sertraline, citalopram, escitalopram, venlafaxine, duloxetine AND trial of fluvoxamine immediate-release (IR) formulation AND submission of medical records documenting: • details of failure/intolerance to fluvoxamine IR AND • which attempts were taken to resolve these

Quantity Limits: 2 capsules/day Max: 300mg/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: TOFRANIL-PM Generic Name: imipramine pamoate oral capsule

Criteria: Has inadequate response, intolerable side effect, or contraindication to 2 formulary tricyclic antidepressants (TCA) such as: amitriptyline, nortriptyline AND trial of imipramine HCl tablet AND submission of medical records documenting: • details of failure/intolerance to imipramine HCl tablet • which attempts were taken to resolve these

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: FETZIMA ER Generic Name: levomilnacipran hcl sa 24h capsule FETZIMA 20-40 TITRATION PACK levomilnacipran hcl 20-40mg sa 24h dosepack

Criteria: Diagnosis of major depression AND has inadequate response, intolerable side effect, or contraindication to 4 formulary antidepressants such as: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, duloxetine, venlafaxine, bupropion AND submission of medical records documenting: • details of failure/intolerance to each drug AND • which attempts were taken to resolve these

Quantity Limits: 1 capsule/day Dose Pack: 1x authorization for titration

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: REMERON Generic Name: mirtazapine 7.5mg oral tablet

Criteria: Inadequate response to formulary strength of mirtazapine (such as ½ tablet of 15mg strength) OR medical justification for necessity of 7.5mg over the above formulary alternative.

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: REMERON SOLTAB Generic Name: mirtazapine orally disintegrating tablet Criteria: Patient has a documented inability to swallow tablets OR inadequate response to formulary mirtazapine immediate-release tablets.

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: PAXIL CR Generic Name: paroxetine hcl er tablet

Criteria: Diagnosis of depression AND has inadequate response, intolerable side effect, or contraindication to 2 formulary antidepressants such as: fluoxetine, sertraline, citalopram, escitalopram, venlafaxine, duloxetine AND trial of paroxetine HCl immediate-release (IR) formulation AND submission of medical records documenting: • details of failure/intolerance to paroxetine HCl IR AND • which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: PEXEVA Generic Name: paroxetine mesylate oral tablet

Criteria: Diagnosis of depression AND has inadequate response, intolerable side effect, or contraindication to 2 formulary antidepressants such as: fluoxetine, sertraline, citalopram, escitalopram, venlafaxine, duloxetine AND trial of paroxetine HCl immediate-release (IR) formulation AND trial of paroxetine HCl ER formulation* AND submission of medical records documenting: • details of failure/intolerance to paroxetine HCl IR and paroxetine ER AND • which attempts were taken to resolve these *Prior Authorization Required

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: BRISDELLE Generic Name: paroxetine mesylate 7.5mg oral capsule Criteria: Diagnosis of moderate to severe vasomotor symptoms associated with menopause AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives such as: fluoxetine, sertraline, citalopram, escitalopram, venlafaxine, gabapentin, clonidine AND trial of paroxetine HCl immediate- release (IR) formulation AND submission of medical records documenting: • details of failure/intolerance to paroxetine HCl IR AND • which attempts were taken to resolve these

Quantity Limits:

Date: September 2016 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: VENLAFAXINE ER TABLET Generic Name: venlafaxine extended-release oral tablet Criteria: Diagnosis of depression AND has inadequate response, intolerable side effect, or contradiction to formulary Venlafaxine ER capsules For 225mg ER tablet: Has inadequate response, intolerable side effect, or contradiction to formulary Venlafaxine ER 150mg capsule with Venlafaxine ER 75mg capsule, to achieve same 225mg/day dosage

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: VIIBRYD Generic Name: vilazodone hcl oral tablet VIIBRYD 10-20 STARTER PACK vilazodone hcl 10-20mg oral tablet dosepack

Criteria: Diagnosis of major depression AND has inadequate response, intolerable side effect, or contraindication to 3 formulary antidepressants such as: fluoxetine, sertraline, citalopram, escitalopram, paroxetine, duloxetine, venlafaxine, bupropion AND submission of medical records documenting: • details of failure/intolerance to each drug AND • which attempts were taken to resolve these

Quantity Limits: 1 tablet/day Starter Kit: 1x authorization for titration

Date: October 2018 GTC: BEHAVIORAL HEALTH - ANTIDEPRESSANTS: 0N Brand Name: TRINTELLIX Generic Name: vortioxetine hbr oral tablet

Quantity Limits: 1 tablet/day

Date: December 2016 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: XANAX Generic Name: alprazolam immediate-release tablet

Criteria: Diagnosis of anxiety or panic disorder AND has inadequate response, intolerable side effect, or contraindication to the formulary alternatives clonazepam and lorazepam AND member is not currently taking any opiate medications (such as hydrocodone/APAP, Tylenol w/codeine, oxycodone/APAP, morphine sulfate ER, etc.) AND member is not concurrently taking carisoprodol

Quantity Limits: 3 tablets/day

Date: September 2017 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: DYANAVEL XR Generic Name: amphetamine oral solution 2.5mg/ml Criteria: Diagnosis is Attention Deficit Hyperactivity Disorder (ADHD) AND has inadequate response, intolerable side effect, or contraindication to 2 formulary ADHD stimulant medications (1 from each class such as a methylphenidate product and a mixed amphetamine product) OR Patient has swallowing difficulties and has inadequate response, intolerable side effect or contraindication to 1 formulary medications that can be sprinkled on soft food (Generic Ritalin LA, Metadate CD and Adderall XR) and oral solution (methylphenidate) AND supporting documentation that member is unable to swallow solid oral dosage forms of medication (ex. tablets, capsules)

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: NUVIGIL Generic Name: armodafinil oral tablet

Criteria: Diagnosis of narcolepsy or Shift Work Sleep Disorders or Diagnosis of obstructive sleep apnea AND submission of chart notes and relevant test results (such as sleep study) AND inadequate response, intolerable side effect, or contraindication to modafinil AND details of failure/intolerance to modafinil AND which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: September 2016 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: KAPVAY Generic Name: clonidine extended-release oral tablet Criteria: Diagnosis of Attention Deficit Hyperactivity Disorder(ADHD) or Attention Deficit Disorder (ADD) AND has inadequate response, intolerable side effect, or contraindication to 1 formulary non-stimulant medication (guanfacine IR dosed twice daily OR clonidine IR dosed twice daily OR guanfacine ER dosed once daily)

Quantity Limits: 1 tablet/day

Date: GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: FOCALIN/FOCALIN XR Generic Name: dexmethylphenidate Criteria: Diagnosis of Attention Deficit Hyperactivity Disorder(ADHD) or Attention Deficit Disorder (ADD) AND has inadequate response, intolerable side effect, or contraindication to 2 formulary ADHD stimulant medications (1 from each class such as a methylphenidate product and a mixed amphetamine product) AND for XR requests, has inadequate response, intolerable side effect, or contraindication to dexmethylphenidate IR

Quantity Limits: Focalin: 2 tablets/day Focalin XR: 1 capsule/day

Date: September 2017 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: ADZENYS XR-ODT Generic Name: dextroamphetamin/amphetamine 3.1, 6.3, 9.4, 12.5, 15.7 and 18.8mg tablet Criteria: Diagnosis is Attention Deficit Hyperactivity Disorder(ADHD) AND has inadequate response, intolerable side effect, or contraindication to 2 formulary ADHD stimulant medications (1 from each class such as a methylphenidate product and a mixed amphetamine product) OR Patient has swallowing difficulties and has inadequate response, intolerable side effect or contraindication to 1 formulary medications that can be sprinkled on soft food (Generic Ritalin LA, Metadate CD and Adderall XR) and oral solution (methylphenidate)

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: SILENOR Generic Name: doxepin hcl oral tablet

Criteria: Potential causes of sleep disturbances have been addressed (e.g., inappropriate sleep hygiene and sleep environment issues or treatable medical/psychological causes of chronic insomnia) AND inadequate response, intolerable side effect, or contraindication to 3 formulary agents such as diphenhydramine, trazodone, zolpidem IR, eszopiclone, zaleplon AND • details of failure/intolerance to each agent AND • which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: VYVANSE ORAL CAPSULE, VYVANSE CHEWABLE TABLET Generic Name: lisdexamfetamine oral capsule, lisdexamfetamine chewable tablet

Criteria: Diagnosis of Attention Deficit Hyperactivity Disorder(ADHD) or Attention Deficit Disorder (ADD) AND must be greater than 6 years of age AND has inadequate response, intolerable side effect, or contraindication to 2 formulary ADHD stimulant medications (1 product from the methylphenidate class and 1 from the amphetamine class) OR If there is concern about substance abuse, a trial and failure of a non-stimulant alternative Diagnosis of Binge Eating Disorder AND prescribed by psychiatrist AND has inadequate response, intolerable side effect, or contraindication to 2 formulary agents such as SSRIs (fluoxetine, sertraline, citalopram, escitalopram, paroxetine), topiramate, or zonisamide

Quantity Limits: 1 capsule/day, 1 chew tab/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: COTEMPLA XR-ODT TABLET Generic Name: methylphenidate extended-release orally disintegrating tablet

Criteria: Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) AND must be greater than 6 years of age AND failure/inability to swallow methylphenidate tablet or capsule AND trial of methylphenidate solution (5mg/5ml or 10mg/5ml) or formulation that can be sprinkled on soft food (such as generic Ritalin LA, Metadate CD)

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: QUILLICHEW ER CHEWABLE TABLET Generic Name: methylphenidate hcl chewable er tab

Quantity Limits: 1 chewable tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: QUILLIVANT XR SUSPENSION Generic Name: methylphenidate hydrochloride oral suspension, extended release Criteria: Diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) AND must be greater than 6 years of age AND failure/inability to swallow methylphenidate tablet or capsule AND trial of methylphenidate solution (5mg/5ml or 10mg/5ml) or formulation that can be sprinkled on soft food (such as generic Ritalin LA, Metadate CD)

Quantity Limits:

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: DAYTRANA Generic Name: methylphenidate transdermal patch

Quantity Limits: 1 patch/day

Date: July 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: NUPLAZID Generic Name: pimavanserin Criteria: Diagnosis of Parkinson’s disease psychosis AND patient has the presence of hallucinations or delusions (which may include illusions or a false sense of presence) on a recurrent or continuous basis for at least 1 month AND must not have dementia-related psychosis AND must have tried to discontinue or reduce the dose of any medication(s) that may cause or contribute to hallucinations and delusions or provide clinical rationale indicating why dose reduction or discontinuation of applicable medications would not be appropriate AND must be prescribed by or in consultation with a neurologist, psychiatrist, or geriatrician

Quantity Limits: 2 tablets/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: ROZEREM Generic Name: ramelteon 8mg oral tablet Criteria: Potential causes of sleep disturbances have been addressed (e.g., inappropriate sleep hygiene and sleep environment issues or treatable medical/psychological causes of chronic insomnia) AND inadequate response, intolerable side effect, or contraindication to 3 formulary agents such as diphenhydramine, trazodone, zolpidem IR, eszopiclone, zaleplon AND • details of failure/intolerance to each agent AND • which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: September 2017 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: XYREM Generic Name: sodium oxybate 500mg/ml Criteria: Cataplexy associated with Narcolepsy (all below criteria must be met) • Patient must be older than 16 (safety and effectiveness not established in children under 16) • Patient must have a documented diagnosis of narcolepsy • Patient must have cataplexy requiring treatment • Patient has tried three (3) of the following: modafinil, Nuvigil*, a tricyclic antidepressant (TCA) [e.g., amitriptyline, imipramine HCL tablet], a selective serotonin reuptake inhibitor (SSRI) [e.g., fluoxetine, sertraline, paroxetine], or venlafaxine • Xyrem is being prescribed by a neurologist or sleep specialist physican Excessive Daytime Sleepiness associated with Narcolepsy (all below criteria must be met) • Patient must be older than 16. (Safety and effectiveness not established in children under 16.) • Patient must have a documented diagnosis of narcolepsy • Patient must have excessive daytime sleepiness as defined by Epworth Sleepiness Scale (ESS) score greater than or equal to 10. • Patient must have had an intolerance to, or treatment failure of an adequate trial of 3 of the following: amphetamine based stimulant, methylphenidate based stimulant, Provigil® (modafanil) or Nuvigil* (armodafanil) • Xyrem is being prescribed by a neurologist or sleep specialist physician * Prior Authorization Required

Quantity Limits: A quantity limit of 540ml per month will apply.

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: BELSOMRA Generic Name: suvorexant oral tablet

Criteria: Potential causes of sleep disturbances have been addressed (e.g. inappropriate sleep hygiene and sleep environment issues or treatable medical/psychological causes of chronic insomnia) AND inadequate response, intolerable side effect, or contraindication to 3 formulary agents such as diphenhydramine, trazodone, zolpidem IR, eszopiclone, zaleplon AND details of failure/intolerance to each agent AND which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: AMBIEN CR Generic Name: zolpidem extended-release tablet

Criteria: Potential causes of sleep disturbances have been addressed (e.g., inappropriate sleep hygiene and sleep environment issues or treatable medical/psychological causes of chronic insomnia) AND inadequate response, intolerable side effect, or contraindication to zolpidem immediate release (IR) AND details of failure/intolerance to Zolpidem IR AND which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: BEHAVIORAL HEALTH - OTHER: 2L Brand Name: INTERMEZZO Generic Name: zolpidem tartrate 1.75mg sublingual tab zolpidem tartrate 3.5mg sublingual tab

Criteria: Potential causes of sleep disturbances have been addressed (e.g., inappropriate sleep hygiene and sleep environment issues or treatable medical/psychological causes of chronic insomnia) AND inadequate response, intolerable side effect, or contraindication to 3 formulary agents such as diphenhydramine, trazodone, zolpidem IR, eszopiclone, zaleplon AND details of failure/intolerance to each agent AND which attempts were taken to resolve these

Quantity Limits: 1 tablet/day

Date: December 2016 GTC: CARDIOVASCULAR DISEASE - ARRHYTHMIA: 0H Brand Name: MULTAQ Generic Name: dronedarone Criteria: Diagnosis of paroxysmal or persistent atrial fibrillation AND has contraindication or inadequate response to amiodarone

Quantity Limits: 2/day

Date: October 2018 GTC: CARDIOVASCULAR DISEASE - ARRHYTHMIA: 0H Brand Name: RYTHMOL SR Generic Name: propafenone hcl er (12h) 225mg, 325mg, 425mg capsule Criteria: Diagnosis of paroxysmal atrial fibrillation/flutter associated with disabling symptoms in patients without structural heart disease AND has contraindication or inadequate response to propafenone immediate release tablets

Quantity Limits: 2/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: TEKTURNA Generic Name: aliskiren hemifumarate oral tablet 150mg, 300mg

Criteria: Diagnosis of hypertension AND has inadequate response, intolerable side effect, or contraindication to 2 formulary ARBs or ACE-I with or without hydrochlorothiazide as separate agents

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: LETAIRIS Generic Name: ambrisentan Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class II or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to PDE-5 inhibitors (sildenafil OR tadalafil*) *Prior Authorization Required

Quantity Limits: 1 tablet/day

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: AZOR Generic Name: amlodipine besylate, olmesartan medoxomil oral tablet TRIBENZOR 5mg-20mg, 5mg-40mg, 10mg-20mg, 10mg-40mg olmesartan medoxomil, amlodipine besylate, hydrochlorothiazide oral tablet 20mg-5mg-12.5mg, 40mg-5mg-12.5mg, 40mg-5mg-25mg, 40mg-10mg- 12.5mg, 40mg-10mg-25mg

Criteria: Diagnosis of Hypertension AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives such as: • Amlodipine/valsartan (with or without hydrochlorothiazide as separate agent) • Amlodipine as a separate agent with losartan, irbesartan, telmisartan , losartan HCT, valsartan HCT, irbesartan HCT

Quantity Limits:

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: EXFORGE HCT Generic Name: amlodipine besylate, valsartan, hydrochlorothiazide oral tablet 5-160-12.5, 5-160-25, 10-160-12.5, 10-160-25, 10-320-25

Quantity Limits:

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: EDARBI Generic Name: azilsartan medoxomil oral tablet 40mg, 80mg EDARBYCLOR azilsartan medoxomil, chlorthalidone oral tablet 40mg-12.5mg, 40mg-25mg

Criteria: Diagnosis of hypertension AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives such as losartan, irbesartan, valsartan, telmisartan with or without chlorthalidone as separate agents

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: TRACLEER Generic Name: bosentan Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class II or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to PDE-5 inhibitors (sildenafil OR tadalafil*) *Prior Authorization Required

Quantity Limits: Initial dosage: 62.5 mg BID x 4 weeks ≥ 40 kg: up to 125mg BID <40 kg: 62.5 mg BID

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: ATACAND Generic Name: candesartan cilexetil oral tablet ATACAND HCT 4mg, 8mg, 16mg, 32mg candesartan cilexetil, hydrochlorothiazide oral tablet 16mg-12.5mg, 32mg-12.5mg, 32mg-25mg

Quantity Limits:

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: INSPRA Generic Name: eplerenone oral tablet 25mg, 50mg Criteria: Diagnosis of HTN or CHF AND has inadequate response, intolerable side effect, or contraindication to spironolactone

Quantity Limits:

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: TEVETEN Generic Name: eprosartan mesylate oral tablet 400mg, 600mg

Criteria: Diagnosis of hypertension AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives such as losartan, irbesartan, valsartan, telmisartan

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: VENTAVIS Generic Name: inhaled iloprost Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class III or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to an ERA (ambrisentan, bosentan, or macitentan)* *Prior Authorization Required

Quantity Limits: Max dose = 45 mcg/day (5 mcg 9 times per day)

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: TYVASO Generic Name: inhaled treprostinil Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class III or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to an ERA (ambrisentan, bosentan, or macitentan)* *Prior Authorization Required

Quantity Limits: Tyvaso inhalation Starter Kit (NDC 66302-0206- Tyvaso Inhalation Refill Kit (NDC= 66302-0206-

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: BIDIL Generic Name: isosorbide dinitrate/ hydralazine Criteria: Diagnosis of Heart Failure AND has inadequate response, intolerable side effect, or contraindication to isosorbide and hydralazine as separate agents

Quantity Limits: 6 tablets/day

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: FLOLAN Generic Name: iv epoprostenol Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class III or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to an ERA (ambrisentan, bosentan, or macitentan)* *Prior Authorization Required

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: VELETRI Generic Name: iv epoprostenol Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class III or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to an ERA (ambrisentan, bosentan, or macitentan)* *Prior Authorization Required

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: OPSUMIT Generic Name: macitentan Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class II or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to PDE-5 inhibitors (sildenafil OR tadalafil*) *Prior Authorization Required

Quantity Limits: 1 tablet/day

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: BYSTOLIC Generic Name: nebivolol Criteria: Diagnosis of hypertension AND has inadequate response, intolerable side effect, or contraindication to 2 formulary beta-blockers

Quantity Limits: 1 tablet/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: BENICAR Generic Name: olmesartan medoxomil oral tablet 5mg, 20mg, 40mg BENICAR HCT olmesartan medoxomil, hydrochlorothiazide oral tablet 20mg-12.5mg, 40mg- 12.5mg, 40mg-25mg

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: ADEMPAS Generic Name: riociguat Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) with NYHA-WHO Functional Class III or greater AND has been evaluated by a cardiologist or pulmonologist AND is being used in adjunct with OR has inadequate response, intolerable side effect, or contraindication to an ERA (ambrisentan, bosentan, or macitentan)* *Prior Authorization Required

Quantity Limits: 3 tablets/day

Date: October 2018 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: UPTRAVI Generic Name: selexipag oral tablet 200mcg, 400mcg, 600mcg, 800mcg, 1000mcg, 1200mcg, 1400mcg, and 1600mcg Criteria: Diagnosis of pulmonary arterial hypertension (PAH) WHO group 1 AND prescribed by a pulmonologist or cardiologist AND documented use of at least two medications that belong to any of the following pharmacologic classes: • A PDE-5 inhibitor such as sildenafil (revatio) or tadalafil (Adcirca) • A guanylate cyclase stimulator such as riociguat (Adempas) • An endothelin receptor antagonist such as ambrisentan (Letairis), macitentan (Opsumit), bosentan (Tracleer)

Quantity Limits: 2 tablets/day

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: REVATIO Generic Name: sildenafil Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) AND has been evaluated by a cardiologist or pulmonologist

Quantity Limits: 5mg OR 20mg 3 tablets/day OR 2 mL/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: ALDACTAZIDE 50-50 Generic Name: spironolactone, hydrochlorothiazide oral tablet 50mg-50mg Criteria: Diagnosis of hypertension or Edema AND has inadequate response, intolerable side effect, or contraindication to spironolactone HCTZ 25-25 at equivalent dose

Quantity Limits:

Date: GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: ADCIRCA Generic Name: tadalafil Criteria: Diagnosis of Pulmonary Arterial Hypertension (PAH) AND has been evaluated by a cardiologist or pulmonologist AND has inadequate response, intolerable side effect, or contraindication to sildenafil

Quantity Limits: 2 tablets/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - HYPERTENSION: 0G Brand Name: TWYNSTA Generic Name: telmisartan, amlodipine besylate oral tablet 40mg-5mg, 40mg-10mg, 80mg-5mg, 80mg-10mg Criteria: Diagnosis of Hypertension AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives such as: • Amlodipine/valsartan (with or without hydrochlorothiazide as separate agent) • Amlodipine as a separate agent with losartan, irbesartan, telmisartan , losartan HCT, valsartan HCT, irbesartan HCT

Quantity Limits:

Date: October 2018 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: PRALUENT PEN Generic Name: alirocumab prefilled autoinjector 75mg/ml and 150mg/ml Criteria: Diagnosis of Heterozygous familial hypercholesterolemia (HeFH): Diagnosis confirmed by one of the following: 1. Simon Broome diagnostic criteria for HeFH (definite) [example:genetic testing consistent with HeFH] 2. Dutch Lipid Network criteria for HeFH with a score of at least 6 AND • prescribed by a Cardiologist, Endocrinologist or Lipidologist AND • LDL-C level: greater than 70mg/dL (LDL level measured within past 6 months) while patient was on maximal drug treatment and dietary therapy for at least 8 weeks AND • has inadequate response, intolerable side effect, or contraindication to Repatha AND • concurrent drug regimen (applicable to all approvable indications) that meets one of the following in combination with ezetimibe for 8 weeks: • high intensity statin (i.e., atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily) • maximally tolerated dose of any statin, given that the patient cannot tolerate a high-intensity statin • complete statin intolerance: severe and intolerable adverse effects (e.g., CK increase to 10 time upper limit of normal, LFTs increase to 3 times upper limit of normal, rhabdomyolysis, severe muscle weakness leading to temporary disability, fall, or inability to use a major muscle group) occurring with trials of at least 2 separate statins and improvement with discontinuation • absolute statin contraindication (e.g., active, decompensated liver disease, nursing female, pregnancy or plans to become pregnant, hypersensitivity reaction) OR

History of ASCVD: Diagnosis supported by hospital admission, imaging study, or surgical procedure. - Examples of atherosclerotic cardiovascular disease include history of myocardial infarction or other acute coronary syndrome, coronary or other revascularization procedure, transient ischemic attack, or ischemic stroke, atherosclerotic peripheral arterial disease, or documented atherosclerotic disease such as coronary atherosclerosis, renal atherosclerosis, aortic aneurysm secondary to atherosclerosis, or carotid plaque with 50% or more stenosis AND prescribed by a Cardiologist, Endocrinologist or Lipidologist AND LDL-C level: greater than 70mg/dL (LDL level measured within past 6 months) while patient was on maximal drug treatment and dietary therapy for at least 8 weeks Has inadequate response, intolerable side effect, or contraindication to Repatha AND concurrent drug regimen (applicable to all approvable indications) that meets one of the following in combination with ezetimibe for 8 weeks: • high intensity statin (i.e., atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily) • maximally tolerated dose of any statin, given that the patient cannot tolerate a high-intensity statin • complete statin intolerance: severe and intolerable adverse effects (e.g., CK increase to 10 time upper limit of normal, LFTs increase to 3 times upper limit of normal, rhabdomyolysis, severe muscle weakness leading to temporary disability, fall, or inability to use a major muscle group) occurring with trials of at least 2 separate statins and improvement with discontinuation • absolute statin contraindication (e.g., active, decompensated liver disease, nursing female, pregnancy or plans to become pregnant, hypersensitivity reaction)

Renewal: • Achieve/maintain LDL-C reduction ≥30% (ASCVD, HeFH) or a reduction (HoFH) from baseline • Concurrent use with maximally tolerated statin therapy

Quantity Limits: 75mg subcutaneously every 2 weeks or 300mg every 4 weeks Max: 150mg every 2 weeks

Date: GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: WELCHOL Generic Name: colesevelam Criteria: Diagnosis of hypercholesterolemia AND has inadequate response, intolerable side effect or contraindication to 2 formulary statins including: simvastatin, atorvastatin, pravastatin, or lovastatin AND formulary fenofibrates including generic Lofibra, Tricor, or Lopid AND has inadequate response, intolerable side effect or contraindication to niacin and bulk cholestyramine

Quantity Limits:

Date: October 2018 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: REPATHA SYRINGE Generic Name: evolocumab 140mg/ml prefilled syringe REPATHA SURECLICK evolocumab 140mg/ml autoinjector REPATHA PUSHTRONEX evolocumab 420mg/3.5ml prefilled cartridge

Criteria: Diagnosis of Heterozygous familial hypercholesterolemia (HeFH): Diagnosis confirmed by one of the following: 1. Simon Broome diagnostic criteria for HeFH (definite) [example:genetic testing consistent with HeFH] 2. Dutch Lipid Network criteria for HeFH with a score of at least 6 AND • Prescribed by a Cardiologist, Endocrinologist or Lipidologist AND • LDL-C level: greater than 70mg/dL (LDL level measured within past 6 months) while patient was on maximal drug treatment and dietary therapy for at least 8 weeks AND • concurrent drug regimen (applicable to all approvable indications) that meets one of the following in combination with ezetimibe for 8 weeks: • high intensity statin (i.e., atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily) • maximally tolerated dose of any statin, given that the patient cannot tolerate a high-intensity statin • complete statin intolerance: severe and intolerable adverse effects (e.g., CK increase to 10 time upper limit of normal, LFTs increase to 3 times upper limit of normal, rhabdomyolysis, severe muscle weakness leading to temporary disability, fall, or inability to use a major muscle group) occurring with trials of at least 2 separate statins and improvement with discontinuation • absolute statin contraindication (e.g., active, decompensated liver disease, nursing female, pregnancy or plans to become pregnant, hypersensitivity reaction) OR Diagnosis of Homozygous familial hypercholesterolemia (HoFH): Diagnosis confirmed by one of the following: 1. Simon Broome criteria (definite) [example:genetic testing consistent with HoFH], Dutch Lipid Network criteria (score ≥8) 2. Clinical diagnosis (untreated LDL-C concentration > 500mg/dL together with either • xanthoma before 10 years of age OR • evidence of HoFH in both parents) AND • prescribed by a Cardiologist, Endocrinologist or Lipidologist AND • LDL-C level: greater than 70mg/dL (LDL level measured within past 6 months) while patient was on maximal drug treatment and dietary therapy for at least 8 weeks AND • concurrent drug regimen (applicable to all approvable indications): Meets one of the following in combination with ezetimibe for 8 weeks: • high intensity statin (i.e., atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily) • maximally tolerated dose of any statin, given that the patient cannot tolerate a high-intensity statin • complete statin intolerance: severe and intolerable adverse effects (e.g., CK increase to 10 time upper limit of normal, LFTs increase to 3 times upper limit of normal, rhabdomyolysis, severe muscle weakness leading to temporary disability, fall, or inability to use a major muscle group) occurring with trials of at least 2 separate statins and improvement with discontinuation • absolute statin contraindication (e.g., active, decompensated liver disease, nursing female, pregnancy or plans to become pregnant, hypersensitivity reaction) OR History of ASCVD: Diagnosis supported by hospital admission, imaging study, or surgical procedure. - Examples of atherosclerotic cardiovascular disease include history of myocardial infarction or other acute coronary syndrome, coronary or other revascularization procedure, transient ischemic attack, or ischemic stroke, atherosclerotic peripheral arterial disease, or documented atherosclerotic disease such as coronary atherosclerosis, renal atherosclerosis, aortic aneurysm secondary to atherosclerosis, or carotid plaque with 50% or more stenosis AND • prescribed by a Cardiologist, Endocrinologist or Lipidologist AND • LDL-C level: greater than 70mg/dL (LDL level measured within past 6 months) while patient was on maximal drug treatment and dietary therapy for at least 8 weeks • concurrent drug regimen (applicable to all approvable indications): Meets one of the following in combination with ezetimibe for 8 weeks: • high intensity statin (i.e., atorvastatin 40-80 mg, rosuvastatin 20-40 mg daily) • maximally tolerated dose of any statin, given that the patient cannot tolerate a high-intensity statin • complete statin intolerance: severe and intolerable adverse effects (e.g., CK increase to 10 time upper limit of normal, LFTs increase to 3 times upper limit of normal, rhabdomyolysis, severe muscle weakness leading to temporary disability, fall, or inability to use a major muscle group) occurring with trials of at least 2 separate statins and improvement with discontinuation • absolute statin contraindication (e.g., active, decompensated liver disease, nursing female, pregnancy or plans to become pregnant, hypersensitivity reaction)

Renewal Criteria: • Achieve/maintain LDL-C reduction ≥30% (ASCVD, HeFH) or a reduction (HoFH) from baseline • Concurrent use with maximally tolerated statin therapy

Quantity Limits: 140 mg per 2 weeks (ASCVD, HeFH) 420mg per 4 weeks (HoFH)

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: VYTORIN Generic Name: ezetimibe, simvastatin oral tablet 10mg-10mg, 10mg-20mg, 10mg-40mg, 10mg-80mg

Criteria: Diagnosis of hypercholesterolemia AND has inadequate response, intolerable side effect, or contraindication to formulary ezetimibe and simvastatin taken as separate agents

Quantity Limits:

Date: December 2016 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: TRILIPIX 135MG Generic Name: fenofibric acid FIBRICOR Criteria: Trial of all formulary fenofibrates including generic Lofibra, Tricor, and Lopid

Quantity Limits: 1/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: LESCOL Generic Name: fluvastatin sodium oral capsule LESCOL XL 20mg, 40mg fluvastatin sodium oral tablet, extended release 80mg Criteria: Diagnosis of hypercholesterolemia, hyperlipidemia, hypertriglyceridemia AND has contraindication or inadequate response to 2 formulary alternatives such as: • rosuvastatin • atorvastatin • lovastatin • pravastatin • simvastatin

Quantity Limits: 1/day

Date: GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: VASCEPA Generic Name: icosapent ethyl Criteria: Diagnosis of hypertriglyceridemia AND has inadequate response, intolerable side effect or contraindication to niacin AND has inadequate response, intolerable side effect or contraindication to one formulary fenofibrates (generic Lofibra, Tricor, or Lopid) AND a preferred omega-3 acid ethyl esters

Quantity Limits: Up to 4/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: ALTOPREV Generic Name: lovastatin er tablet 20mg, 40mg, 60mg Criteria: Diagnosis of hypercholesterolemia, hyperlipidemia, hypertriglyceridemia AND has contraindication or inadequate response to 2 formulary alternatives such as: rosuvastatin, atorvastatin, lovastatin, pravastatin, simvastatin

Quantity Limits: 1/day

Date: GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: ADVICOR Generic Name: niacin/lovastatin Criteria: Diagnosis of hypercholesterolemia or mixed dyslipidemia AND medical justification why formulary niacin ER 24hr and lovastatin cannot be used together as separate agents

Quantity Limits: 2/day

Date: GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: SIMCOR Generic Name: niacin/simvastatin Criteria: Diagnosis of hypercholesterolemia or hypertriglyceridemia AND medical justification why formulary niacin ER 24hr and simvastatin cannot be used together as separate agents

Quantity Limits: Max 2/day

Date: December 2017 GTC: CARDIOVASCULAR DISEASE - LIPID IRREGULARITY: 0J Brand Name: LIVALO Generic Name: pitavastatin oral tablet 1mg, 2mg, 4mg Criteria: Diagnosis of hypercholesterolemia, hyperlipidemia, hypertriglyceridemia AND has contraindication or inadequate response to 2 formulary alternatives such as: • rosuvastatin • atorvastatin • lovastatin • pravastatin • simvastatin

Quantity Limits: 1/day

Date: July 2018 GTC: COLD AND COUGH: 2A Brand Name: ZONATUSS Generic Name: benzonatate 150mg Criteria: Respiratory diagnosis requiring a cough suppresant AND trial and failure of benzonatate 100mg and 200mg

Quantity Limits:

Date: September 2017 GTC: COLD AND COUGH: 2A Brand Name: MUCINEX ER Generic Name: guaifenesin er 12h

Criteria: Respiratory Diagnosis requiring an expectorant AND trial and failure of Guaifenesin regular tablets AND Guaifenesin liquid

Quantity Limits:

Date: July 2018 GTC: COLD AND COUGH: 2A Brand Name: ROBITUSSIN AC Generic Name: guaifenesin with codeine liquid Criteria: Limited to use in adults 18 years or older. Use in children is no longer indicated or recommended.

Quantity Limits: 240ml per 30 day supply

Date: September 2017 GTC: COLD AND COUGH: 2A Brand Name: PHENYLEPHRINE/ PROMETHAZINE SYRUP Generic Name: phenylephrine/ promethazine syrup

Criteria: Respiratory diagnosis requiring antihistamine/decongestant combination AND trial and failure of 2 of the following: • phenylephrine/brompheniramine solution • phenylephrine/diphenhydramine liquid • pseudoephedrine/brompheniramine liquid

Quantity Limits:

Date: March 2017 GTC: CONTRACEPTION/OXYTOCICS: 1W Brand Name: NUVARING Generic Name: etonorgestrel/ethinyl estradiol vaginal ring Criteria: Has inadequate response, intolerable side effect, or contraindication to formulary oral contraceptive OR Patient has known adherence/compliance issues

Quantity Limits:

Date: March 2017 GTC: CONTRACEPTION/OXYTOCICS: 1W Brand Name: XULANE Generic Name: norelgestromin/ethinyl estradiol transdermal patch Criteria: Has inadequate response, intolerable side effect, or contraindication to formulary oral contraceptive OR Patient has known adherence/compliance issues

Quantity Limits:

Date: March 2018 GTC: DENTAL AND ORAL AGENTS: 2G Brand Name: EVOXAC Generic Name: cevimeline Criteria: Diagnosis of xerostomia (dry mouth) AND has inadequate response, intolerable side effect, or contraindication to pilocarpine tablets

Quantity Limits:

Date: GTC: DERMATOLOGY - ACNE: 0U Brand Name: DIFFERIN Generic Name: adapalene cream Criteria: Diagnosis of acne AND patient has inadequate response, intolerable side effect or contraindication to formulary alternatives BPO, topical clindamycin, tretinoin cream and adapalene 0.1% gel.

Quantity Limits:

Date: GTC: DERMATOLOGY - ACNE: 0U Brand Name: EPIDUO Generic Name: adapalene/ benzoyl peroxide Criteria: Diagnosis of acne AND has inadequate response, intolerable side effect, or contraindication to topical clindamycin, tretinoin cream, adapalene 0.1% gel, and BPO

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ACNE: 0U Brand Name: AZELEX 20% CREAM Generic Name: azelaic acid Criteria: Diagnosis of Acne AND has inadequate response, intolerable side effect, or contraindication to formulary tretinoin, adapalene 0.1% gel, Benzoyl peroxide, and topical clindamycin AND details of failure/intolerance to above alternatives AND which attempts were taken to resolve these

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ACNE: 0U Brand Name: FINACEA 15% FOAM Generic Name: azelaic acid Criteria: Diagnosis of Rosacea AND patient has inadequate response, intolerable side effect or contraindication to topical metronidazole 0.75% gel AND Azelaic Acid 15% gel* * Requires Prior Authorization

Quantity Limits:

Date: June 2018 GTC: DERMATOLOGY - ACNE: 0U Brand Name: FINACEA Generic Name: azelaic acid 15% gel and foam Criteria: Diagnosis of Rosacea AND patient has inadequate response, intolerable side effect or contraindication to topical metronidazole 0.75% gel AND Azelaic Acid 15% gel* * Requires Prior Authorization

Quantity Limits:

Date: GTC: DERMATOLOGY - ACNE: 0U Brand Name: AZELEX Generic Name: azelaic acid 20% cream Criteria: Diagnosis of Acne AND inadequate response, intolerable side effect, or contraindication to formulary tretinoin, adapalene 0.1% gel, Benzoyl peroxide, and topical clindamycin AND details of failure/intolerance to above alternatives AND which attempts were taken to resolve these

Quantity Limits:

Date: GTC: DERMATOLOGY - ACNE: 0U Brand Name: BENZACLIN Generic Name: benzoyl peroxide 5% + clindamycin 1% gel Criteria: Diagnosis of acne AND patient has inadequate response, intolerable side effect or contraindication to formulary alternatives as single ingredients BPO, topical clindamycin, tretinoin cream, and adapalene 0.1% gel

Quantity Limits:

Date: GTC: DERMATOLOGY - ACNE: 0U Brand Name: DUAC Generic Name: benzoyl peroxide 5% + clindamycin 1.2% gel NEUAC Criteria: Diagnosis of acne AND patient has inadequate response, intolerable side effect or contraindication to formulary alternatives as single ingredients BPO, topical clindamycin, tretinoin cream, and adapalene 0.1% gel

Quantity Limits:

Date: GTC: DERMATOLOGY - ACNE: 0U Brand Name: BENZAMYCIN Generic Name: benzoyl peroxide 5% + erythromycin 3% gel Criteria: Diagnosis of acne AND patient has inadequate response, intolerable side effect or contraindication to formulary alternatives as single ingredients BPO, topical clindamycin, tretinoin cream, and adapalene 0.1% gel

Quantity Limits:

Date: June 2018 GTC: DERMATOLOGY - ACNE: 0U Brand Name: MIRVASO Generic Name: brimonidine Criteria: Diagnosis of Rosacea AND patient has inadequate response, intolerable side effect or contraindication to formulary alternative metronidazole 0.75% gel and Finacea (azelaic acid 15% gel or foam)

Quantity Limits:

Date: June 2018 GTC: DERMATOLOGY - ACNE: 0U Brand Name: ACZONE Generic Name: dapsone Criteria: Diagnosis of acne AND has inadequate response, intolerable side effect, or contraindication to topical clindamycin, tretinoin cream, adapalene 0.1% gel, and BPO

Quantity Limits:

Date: June 2017 GTC: DERMATOLOGY - ACNE: 0U Brand Name: ABSORICA Generic Name: isotretinoin Criteria: Diagnosis of acne AND patient has inadequate response, intolerable side effect or contraindication topical tretinoin cream, benzoyl peroxide, topical clindamycin, and oral antibiotics AND inadequate response or intolerable side effect to any other oral isotretinoin product (e.g., Claravis, Zenatane, Myorisan) OR Diagnosis of cystic or nodular acne AND inadequate response or intolerable side effect to any other oral isotretinoin product (e.g., Claravis, Zenatane, Myorisan)

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ACNE: 0U Brand Name: ACCUTANE, AMNESTEEM, CLARAVIS MYORISAN, SOTRET, Generic Name: isotretinoin ZENATANE, ISOTRETINOIN Criteria: Diagnosis of Acne AND patient has inadequate response, intolerable side effect or contraindication topical tretinoin cream, benzoyl peroxide, topical clindamycin, and oral antibiotics OR Diagnosis of cystic or nodular acne

Quantity Limits:

Approvable x 6 months

Date: May 2019 GTC: DERMATOLOGY - ACNE: 0U Brand Name: AMNESTEEM, CLARAVIS, Generic Name: isotretinoin MYORISAN, ZENATANE Criteria: Diagnosis of Acne AND patient has inadequate response, intolerable side effect or contraindication topical tretinoin cream, benzoyl peroxide, topical clindamycin, and oral antibiotics OR Diagnosis of cystic or nodular acne

Quantity Limits:

Approvable x 6 months

Date: June 2018 GTC: DERMATOLOGY - ACNE: 0U Brand Name: SOOLANTRA Generic Name: ivermectin Criteria: Diagnosis of rosacea AND patient has inadequate response, intolerable side effect or contraindication to formulary alternative metronidazole 0.75% gel and Finacea (azelaic acid 15% gel or foam) OR Diagnosis of head lice AND has inadequate response, intolerable side effect, or contraindication to permethrin (Nix) and pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ACNE: 0U Brand Name: NORITATE 1% CREAM Generic Name: metronidazole Criteria: Diagnosis of Rosacea AND: - Has inadequate response(to at least 8 weeks of therapy), intolerable side effect, or contraindication to formulary metronidazole, azelaic acid 15% gel* and Soolantra* AND - details of failure/intolerance to each of the above alternatives AND which attempts were taken to resolve these

Quantity Limits:

Date: March 2018 GTC: DERMATOLOGY - ACNE: 0U Brand Name: NON-FORMULARY TOPICAL CORTICOSTEROID Generic Name: non-formulary topical corticosteroid Criteria: Diagnosis of atopic dermatitis, pruritus, psoriasis, etc. AND trial and failure of two formulary equipotent or higher potency corticosteroids BOLD = Formulary

Super-High Potency (Group 1) Super-High Potency (Group 2) Betamethasone dipropionate, augmented 0.05% (Diprolene AF) ointment Betamethasone dipropionate 0.05% (Diprosone) ointment Clobetasol Propionate 0.05 % (Temovate) ointment Desoximetasone 0.25% (Topicort) ointment Halobetasol Propionate 0.05 % ointment (Ultravate) Fluocinonide 0.05 % (Lidex) ointment Halcinonide 0.1% (Halog) ointment Clobetasol Propionate 0.05 % (Temovate) cream Clobetasol Propionate 0.05 % (Temovate-E) emmolient cream Amcinonide 0.1% cream Fluocinonide 0.1% cream Betamethasone dipropionate augmented 0.05% (Diprolene AF) cream Halobetasol Propionate 0.05 % cream (Ultravate) Desoximetasone 0.25% (Topicort) cream Fluocinonide 0.05 % (Lidex) cream anhydrous Betamethasone dipropionate, augmented 0.05% (Diprolene AF) lotion Halcinonide 0.1% (Halog) cream Clobetasol Propionate 0.05 % (Clobex) lotion Halobetasol Propionate 0.05 % (Ultravate) lotion Fluocinonide 0.05 % (Lidex) solution

Clobetasol Propionate 0.05 % (temovate, Cormax) solution Amcinonide 0.1% lotion Clobetasol Propionate 0.05 % gel (Temovate) Desoximetasone 0.05% (Topicort) gel Clobetasol Propionate 0.05 % Foam (Olux) Fluocinonide 0.05 % (Lidex) gel Clobetasol Propionate 0.05 % emmolient foam (Olux-E)

Clobetasol Propionate 0.05 % spray (Clobex) Cordran 4MCG/SQ CM (Flurandrenolide) tape

High potency (Group 3) Medium potency (Group 4) Amcinonide 0.1% ointment Fluocinolone Acetonide 0.025 % (Synalar) ointment Betamethasone Valerate 0.1 % (Valisone) ointment Flurandrenolide 0.05% (Cordran) ointment Fluticasone Propionate 0.005 % (Cultivate) ointment Hydrocortisone valerate 0.2% (Westcort) ointment Mometasone Furoate 0.1 % (Elocon) ointment Triamcinolone Acetonide 0.1 % (Kenalog) ointment Triamcinolone Acetonide 0.5 % (Kenalog) ointment Betamethasone dipropionate 0.05% (Diprosone) cream Clocortolone pivalate 0.1% cream Desoximetasone 0.05% (Topicort LP) cream Mometasone Furoate 0.1 % (Elocon) cream Diflorasone 0.05% (Florone) cream Triamcinolone Acetonide 0.1 % (Kenalog) cream Fluocinonide-E 0.05 % (Lidex-E) cream Triamcinolone Acetonide 0.5 % (Triderm, Aristocort HP) cream Mometasone Furoate 0.1 % (Elocon) solution

Betamethasone Valerate 0.12% (Luqix) Foam Sernivo 0.05% (Betamethasone dipropionate) Spray Triamcinolone Acetonide 0.2mg/2 second (Kenalog) spray

Lower-mid potency (group 5) Low Potency (group 6) Desopnide 0.05 % (DesOwen) ointment Alclometasone Dipropionate 0.05 % (Aclovate) ointment Hydrocortisone Butyrate 0.1 %(Locoid) ointment Prednicarbate 0.1 % (Dermatop) ointment Alclometasone Dipropionate 0.05% (Aclovate) cream Triamcinolone Acetonide 0.025 % (Kenalog) ointment Desonide 0.05% (DesOwen) cream Fluocinolone Acetonide 0.01% (Synalar) cream Betamethasone Valerate 0.1% (Beta-Val, Valisone) cream Triamcinolone Acetonide 0.025 % (Kenalog, Aristocort) cream Fluocinolone Acetonide 0.025 % (Synalar) cream Flurandrenolide 0.05 % (Cordran) cream Betamethasone Valerate 0.1% (Beta-Val, Valisone) lotion Fluticasone Propionate 0.05 % (Cutivate) cream Desonide 0.05 %(DesOwen) lotion Hydrocortisone Butyrate 0.1 % (Locoid, locoid lipocream) cream Triamcinolone Acetonide 0.025 % (Kenalog) lotion Hydrocortisone probutate 0.1% (Pandel) cream Hydrocortisone Valerate 0.2 % (Westcort) cream Fluocinolone Acetonide 0.01 % solution (Synalar) Prednicarbate 0.1 % (Dermatop) cream, emolient Fluocinolone Acetonide 0.01% (Derma-smooth/FS scalp) scalp oil Fluocinolone Acetonide 0.01% (Derma-smooth/FS body) body oil Betamethasone dipropionate 0.05% (Diprosone) lotion Fluradrenolide 0.05 % (Cordran) lotion Capex (fluocinolone) 0.01% shampoo Fluticasone Propionate 0.05 % (Cutivate) lotion Desonide 0.05 % (Verdeso) foam Hydrocortisone Butyrate 0.1 % (Locoid) lotion, spray, solution Triamcinolone Acetonide 0.1 % (Kenalog) lotion

Desonide 0.05 % (Desonate) gel

Least Potency (group 7) Hydrocortisone OTC ointment, cream, solution, lotion, foam Hydrocortisone OTC spray Quantity Limits: 6 fills for 1 year

Date: May 2019 GTC: DERMATOLOGY - ACNE: 0U Brand Name: RETIN A MICRO Generic Name: tretinoin microspheres gel Criteria: Diagnosis of Acne AND inadequate response, intolerable side effect, or contraindication to formulary tretinoin, adapalene 0.1% gel, Benzoyl peroxide, and topical clindamycin

Quantity Limits:

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: ZOVIRAX CREAM/OINTMENT Generic Name: acyclovir Criteria: For acyclovir 5% cream Diagnosis of recurrent Herpes Labialis AND has inadequate response, intolerable side effect, or contraindication to oral acyclovir and oral valacyclovir For acyclovir 5% ointment Diagnosis of Genital Herpes, and Herpes Simplex Virus AND has inadequate response, intolerable side effect, or contraindication to acyclovir and oral valacyclovir

Quantity Limits: 1 tube (up to 30g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: XERESE Generic Name: acyclovir/hydrocortisone Criteria: Diagnosis of recurrent Herpes Labialis AND has inadequate response, intolerable side effect, or contraindication to oral acyclovir with hydrocortisone 1% cream and oral valacyclovir with hydrocortisone 1% cream AND has inadequate response, intolerable side effect, or contraindication to concurrent use of acyclovir 5% cream* and formulary hydrocortisone 1% cream

Quantity Limits: 1 tube (5g) per fill

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: ULESFIA Generic Name: benzyl alcohol Criteria: Diagnosis of head lice AND inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits: 1 bottle (227mL) per fill 2 fills per treatment

Date: June 2018 GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: EURAX Generic Name: crotamiton Criteria: Diagnosis of scabies AND has inadequate response, intolerable side effect, or contraindication to permethrin cream

Quantity Limits:

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: JUBLIA Generic Name: efinaconazole Criteria: Diagnosis of onychomycosis AND has inadequate response, intolerable side effect, or contraindication to formulary topical ciclopirox AND has inadequate response, intolerable side effect, or contraindication to two formulary oral agents such as oral terbinafine, itraconazole, or fluconazole

Quantity Limits: 1 bottle (up to 8mL) per fill

Date: September 2016 GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: SKLICE Generic Name: ivermectin lotion Criteria: Diagnosis of head lice AND inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits: 1 bottle (117mL) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: EXTINA Generic Name: ketoconazole foam Criteria: Diagnosis of seborrheic dermatitis AND has inadequate response, intolerable side effect, or contraindication to ketoconazole shampoo

Quantity Limits: 1 bottle (up to 100g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: XOLEGEL Generic Name: ketoconazole gel Criteria: Diagnosis of seborrheic dermatitis AND has inadequate response, intolerable side effect, or contraindication to ketoconazole shampoo

Quantity Limits: 1 tube (45g) per fill 2 fills per treatment

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: LINDANE Generic Name: lindane Criteria: Lindane 1% lotion Diagnosis of scabies AND has inadequate response to two application of formulary permethrin 5% cream each about a week apart and two application of topical crotamiton each 24hr apart OR Intolerable side effect, of contraindication to permethrin or crotamiton Lindane 1% shampoo Diagnosis of head lice AND has inadequate response, intolerable side effect, or contraindication to permethrin (Nix) and pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits: 1 bottle (60mL) per fill 1 fill per request

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: LUZU Generic Name: luliconazole Criteria: Diagnosis of tinea pedis (athlete’s foot), tinea cruris (jock itch), or tinea corporis (ringworm) AND has inadequate response, intolerable side effect, or contraindication to at least three of formulary topical antifungal agents such as clotrimazole, econazole cream, ketoconazole, miconazole, terbinafine, or tolnaftate

Quantity Limits: 1 tube (60g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: NAFTIN Generic Name: naftifine gel & cream Criteria: Diagnosis of tinea pedis (athlete’s foot), tinea cruris (jock itch), or tinea corporis (ringworm) AND has inadequate response, intolerable side effect, or contraindication to at least three of formulary topical antifungal agents such as clotrimazole, econazole cream, ketoconazole, miconazole, terbinafine, or tolnaftate

Quantity Limits: 1 tube (up to 90g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: OXISTAT Generic Name: oxiconazole cream, lotion Criteria: Diagnosis of tinea pedis (athlete’s foot), tinea cruris (jock itch), or tinea corporis (ringworm) AND has inadequate response, intolerable side effect, or contraindication to at least three of formulary topical antifungal agents such as clotrimazole, econazole cream, ketoconazole, miconazole, terbinafine, or tolnaftate

Quantity Limits: 1 tube (up to 90g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: DENAVIR Generic Name: penciclovir Criteria: Diagnosis of herpes labialis AND has inadequate response, intolerable side effect, or contraindication to oral acyclovir and oral valacyclovir

Quantity Limits: 1 tube (5g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: ALTABAX Generic Name: retapamulin Criteria: Diagnosis of impetigo AND has inadequate response, intolerable side effect, or contraindication to mupirocin ointment

Quantity Limits: 1 tube (up to 30g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: ERTACZO Generic Name: sertaconazole Criteria: Diagnosis of tinea pedis (athlete’s foot) AND has inadequate response, intolerable side effect, or contraindication to at least three of formulary topical antifungal agents such as clotrimazole, econazole cream, ketoconazole, miconazole, terbinafine, or tolnaftate

Quantity Limits: 1 tube (60g) per fill

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: VEREGEN Generic Name: sinecatechins Criteria: Diagnosis of genital warts or perianal warts AND has inadequate response, intolerable side effect, or contraindication to formulary podofilox solution or imiquimod cream

Quantity Limits: 1 tube (30g) per fill

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: NATROBA Generic Name: spinosad Criteria: Diagnosis of head lice AND inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits:

Date: GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: KERYDIN Generic Name: tavaborole Criteria: Diagnosis of onychomycosis AND has inadequate response, intolerable side effect, or contraindication to formulary topical ciclopirox AND has inadequate response, intolerable side effect, or contraindication to two formulary oral agents such as oral terbinafine, itraconazole, or fluconazole

Quantity Limits: 1 bottle (up to 10mL) per fill

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: 0S Brand Name: OVIDE Generic Name: Criteria: Diagnosis of head lice AND Has inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: OS Brand Name: ULESFIA Generic Name: benzyl alcohol Criteria: Diagnosis of head lice AND Has inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: OS Brand Name: LOPROX 1% SHAMPOO Generic Name: ciclopirox Criteria: Diagnosis of seborrheic dermatitis of the scalp AND inadequate response, intolerable side effect, or contraindication to formulary preferred ketoconazole shampoo

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: OS Brand Name: CLINDAGEL 1% DAILY GEL Generic Name: clindamycin phosphate Criteria: Diagnosis of Acne AND inadequate response, intolerable side effect, or contraindication to 3 formulary preferred Clindamycin formulations such as: - Clindamycin phosphate 1% gel (generic for Cleocin-T) - Clindamycin phosphate 1% lotion - Clindamycin phosphate 1% solution - Clindamycin phosphate 1% swab AND details of failure/intolerance to above alternatives AND which attempts were taken to resolve these

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: OS Brand Name: SKLICE 0.5% LOTION Generic Name: ivermectin lotion Criteria: Diagnosis of head lice AND Has inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - ANTIINFECTIVE: OS Brand Name: NATROBA Generic Name: spinosad Criteria: Diagnosis of head lice AND Has inadequate response, intolerable side effect, or contraindication to 2 treatments course with permethrin (Nix) OR Pyrethrins plus piperonyl butoxide (Rid)

Quantity Limits:

Date: June 2018 GTC: DERMATOLOGY - ANTIINFLAMMATORY: 0R Brand Name: EUCRISA Generic Name: crisaborole Criteria: Diagnosis of mild to moderate atopic dermatitis AND has inadequate response, intolerable side effect or contraindication to Protopic or Elidel AND one of the following: • has inadequate response, intolerable side effect, or contraindication to 2 formulary topical steroids • condition affects sensitive body areas (e.g. genitals, face)

Quantity Limits: 1 tube = 60 g

Date: GTC: DERMATOLOGY - ANTIINFLAMMATORY: 0R Brand Name: FLECTOR PATCH Generic Name: diclofenac epolamine 1.3% (12h) transdermal patch Criteria: Diagnosis of acute pain AND has inadequate response, intolerable side effect, or contraindication to 3 formulary oral NSAIDs such as ibuprofen, naproxen, meloxicam, diclofenac, sulindac, nabumetone, or etodolac, AND has inadequate response, intolerable side effect or contraindication to generic Voltaren 1% topical gel

Quantity Limits: 2 patches/day

Date: GTC: DERMATOLOGY - ANTIINFLAMMATORY: 0R Brand Name: PENNSAID SOLUTION Generic Name: diclofenac sodium 2% pump Criteria: Diagnosis of pain or arthritis AND has inadequate response, intolerable side effect, or contraindication to 3 formulary oral NSAIDs such as: ibuprofen, naproxen, meloxicam, diclofenac, sulindac, nabumetone or etodolac AND has inadequate response, intolerable side effect or contraindication to generic Voltaren 1% topical gel

Quantity Limits: 2 bottles/fill

Date: June 2018 GTC: DERMATOLOGY - ANTIPURITIC DRUGS: 0T Brand Name: PRUDOXIN Generic Name: doxepin cream ZONALON Criteria: Diagnosis of moderate pruritus in adults with atopic dermatitis AND has inadequate response, intolerable side effect or contraindication 1 topical antihistamine (diphenhydramine) AND has inadequate response, intolerable side effect, or contraindication to 2 formulary high potency topical steroids Diagnosis of lichen simplex chronicus AND has inadequate response, intolerable side effect, or contraindication to 2 formulary high potency topical steroids

Quantity Limits: 1 tube = 45g

Date: GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: PANRETIN Generic Name: alitretinoin Criteria: Diagnosis of cutaneous lesions in patients with AIDS-related Kaposi’s sarcoma

Quantity Limits:

Date: GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: PANCRETIN Generic Name: alitretinoin Criteria: Diagnosis of cutaneous lesions in patients with AIDS-related Kaposi’s sarcoma

Quantity Limits:

Date: GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: DOVONEX Generic Name: calcipotriene topical cream, topical ointment, topical solution CALCITRENE Criteria: Diagnosis of plaque psoriasis AND inadequate response, intolerable side effect or contraindication to 2 formulary topical steroids, coal tar, or UV therapy OR medical justification why they cannot be used. For large areas (>3% BSA) please consider systemic therapy such as methotrexate, acitretin*, or cyclosporine*. *Prior Authorization Required

Quantity Limits:

Date: June 2017 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: SANTYL Generic Name: collagenase clostridium histolyticum 250 unit/gram topical ointment

Criteria: • Necessity for debridement of chronic dermal ulcers or severely burned areas • Documentation of the size and location of the wound • Prescribed by a specialist (surgeon, podiatrist, burn/wound care facility) • Other methods of debridement have been tried on the wound or the recipient has contraindications or intolerance to other methods of debridement

Quantity Limits: Approve a 14-day supply per fill with a max duration of 6 weeks.

Date: June 2018 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: SOLARAZE Generic Name: diclofenac sodium 3% gel Criteria: Diagnosis of Actinic Keratoses

Quantity Limits: 1 tube (100g)

Date: June 2018 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: DUPIXENT Generic Name: dupilumab Criteria: Diagnosis of severe atopic dermatitis AND moderate atopic dermatitis requires a trial and failure of 2 formulary corticosteroids AND Protopic AND Eucrisa Diagnosis of severe atopic dermatitis requires a trial and failure of a 2 formulary corticosteroids AND Protopic

Quantity Limits:

Date: March 2018 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: TREMFYA Generic Name: guselkumab Criteria: Diagnosis of moderate to severe plaque psoriasis AND psoriasis affects > 10% BSA or causes significant functional disability (palms, soles, genitalia, severe scalp psoriasis) AND has inadequate response, intolerable side effect, or contraindication to phototherapy if available) AND has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD

Quantity Limits: PsO: Induction: 100mg SQ at Wk: 0 Wk: 4 Maintenance: 100mg every 8 weeks

Date: June 2018 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: PRAMOSONE FOAM AND LOTION Generic Name: hydrocortisone/pramoxine Criteria: Diagnosis of anorectal inflammation (may include dermatisis, psoriasis, pruritus, swelling associated with hemorrhoids, proctitis, cryptitis, anal fisusres, postoperative pain and pruritus ani) AND has inadequate response, intolerable side effect, or contraindication to hydrocortisone/pramoxine cream

Quantity Limits:

Date: March 2018 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: TALTZ Generic Name: ixekizumab syringe, autoinjector Criteria: Diagnosis of moderate to severe plaque psoriasis AND psoriasis affects > 10% BSA OR causes significant functional disability (palms, soles, genitalia, severe scalp psoriasis) AND has inadequate response, intolerable side effect, or contraindication to phototherapy if available) AND has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD Diagnosis of psoriatic arthritis AND has been evaluated by a rheumatologist/dermatologist AND has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis)

Quantity Limits: PsO: Induction: 160mg x1, then 80mg every 2 weeks for 3 months. Maintenance: 80mg every 4 weeks. PsA with coexisting PsO: Induction:160mg x 1 Maintenance: 80mg every 4 weeks

Date: September 2016 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: ELIDEL Generic Name: pimecrolimus cream Criteria: Diagnosis of moderate to severe atopic dermatitis or vitiligo AND has inadequate response, intolerable side effect or contraindication to Protopic AND one of the following: • has inadequate response, intolerable side effect, or contraindication to 2 formulary topical steroids • condition affects sensitive body areas (e.g. genitals, face)

Quantity Limits: Initial approval: Approval x 3. Reauthorization: Re-asses by reviewing chart notes and progress notes. May approve x 6 again for 1 year total

Date: September 2016 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: PROTOPIC Generic Name: tacrolimus ointment Criteria: Diagnosis of moderate to severe atopic dermatitis or vitiligo AND has inadequate response, intolerable side effect, or contraindication to 2 formulary topical steroids OR Condition affects sensitive body areas (e.g. genitals, face)

Quantity Limits: Initial approval: Approval x 3. Reauthorization: Re-asses by reviewing chart notes and progress notes. May approve x 6 again for 1 year total.

Date: GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: TAZORAC Generic Name: tazarotene topical cream, topical gel Criteria: Diagnosis of psoriasis AND patient has inadequate response, intolerable side effect or contraindication to 2 formulary topical steroids, coal tar, or UV therapy OR For large areas (>3% BSA) please consider systemic therapy such as methotrexate, acitretin*, or cyclosporine*. Diagnosis of psoriasis AND patient has inadequate response, intolerable side effect or contraindication to formulary alternatives BPO, topical clindamycin and tretinoin cream. *Prior Authorization Required

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: COSENTYX Generic Name: Criteria: Diagnosis of moderate to severe plaque psoriasis AND - Psoriasis affects > 10% BSA or causes significant functional disability (Palms, soles, genitalia, severe scalp psoriasis) AND - Has inadequate response, intolerable side effect, or contraindication to phototherapy (if available) AND - Has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD (Sulfasalazine, Methotrexate, Leflunomide , Hydroxychloroquine, Cyclosporine) AND - Trial and failure of TALTZ Diagnosis of psoriatic arthritis AND - Has been evaluated by a rheumatologist/dermatologist AND - Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast* AND - Trial and failure of TALTZ OR Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis) AND trial and failure of TALTZ

Quantity Limits:

Date: May 2019 GTC: DERMATOLOGY - PSORIASIS/ECZEMA: 0V Brand Name: SILIQ Generic Name: Criteria: Diagnosis of moderate to severe plaque psoriasis AND: - Psoriasis affects > 10% BSA or causes significant functional disability (Palms, soles, genitalia, severe scalp psoriasis) AND - Has inadequate response, intolerable side effect, or contraindication to phototherapy (if available) AND - Has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD (Sulfasalazine, Methotrexate, Leflunomide, Hydroxychloroquine, Cyclosporine) AND trial and failure of TALTZ

Quantity Limits: PsO: Induction: 210mg at week 0, 1, 2. Maintenance: 210 every 2 weeks

Date: June 2018 GTC: DIABETES: 1E Brand Name: INVOKANA Generic Name: canagliflozin 100, 300mg tablets

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: QTERN Generic Name: dapagliflozin/saxagliptin 10‐5mg tablets

Criteria: Diagnosis of type 2 diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to Steglatro* and alogliptin * with compliance of at least 3 month each *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: NESINA Generic Name: alogliptin 6.25, 12.5, 25 mg tablet

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: KAZANO Generic Name: alogliptin/metformin 12.5-500mg, 12.5-1000mg

Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% after inadequate response to metformin with compliance of at least 3 months OR HbA1c > 7.5%

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: OSENI Generic Name: alogliptin-pioglitazone 12.5-15mg, 12.5-30mg, 12.5-45mg, 25- 15mg, 25-30mg, 25-45mg Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months OR HbA1c >7.5% and patient was co-prescribed metformin

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: REGRANEX Generic Name: becaplermin Criteria: Prescribed by wound specialist AND prescribed as treatment of lower extremity diabetic ulcers that extend into the subcutaneous tissue or beyond AND have an adequate blood supply AND wound is free of infection OR infection has been controlled by systemic antibiotics AND prescribed as an adjunct to good ulcer care practices including initial sharp debridement, pressure relief, and infection control.

Quantity Limits: Limit of 15gm per fill x 3 fills

Date: June 2018 GTC: DIABETES: 1E Brand Name: INVOKAMET Generic Name: canagliflozin-metformin 50‐500mg, 50‐1000mg, 150‐500mg, 150‐1000mg

Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND a trial and failure of preferred alternative Steglatro* with compliance for additional 3 months AND trial of metformin and canaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater AND trial of metformin and canaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents HbA1c >7.5% and patient was co-prescribed metformin AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater AND trial of metformin and canaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: INVOKAMET XR Generic Name: canagliflozin-metformin er 50‐500mg, 50‐1000mg, 150‐500mg, 150‐1000mg

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: CHLORPROPAMIDE Generic Name: chlorpropamide Criteria: Diagnosis of diabetes mellitus type 2 AND has inadequate response, intolerable side effect, or contraindication to 2 sulfonylurea containing formulary alternatives such as Glimepiride, Glipizide ER, Glyburide, Glyburide Micronized, Glyburide-metformin

Quantity Limits:

Date: May 2019 GTC: DIABETES: 1E Modiify PA Criteria Brand Name: FARXIGA Generic Name: dapagliflozin 5mg, 10mg tablets

Quantity Limits: 1 tablet/day

Date: June 2018 GTC: DIABETES: 1E Brand Name: XIGDUO XR Generic Name: dapagliflozin-metformin er 5‐500mg, 5‐1000mg, 10‐500mg, 10‐1000mg Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to Steglatro* with compliance of at least 3 month AND trial of metformin and dapaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: XULTOPHY Generic Name: degludec 100 units/1 ml/liraglutide 3.6 mg/1 ml

Criteria: Diagnosis of type 2 diabetes mellitus AND A1C >9% AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater OR patient tried and failed triple therapy (which included either Basaglar or Trulicity* with compliance for at least 3 months AND Soliqua for additional 3 months *Prior Authorization Required

Quantity Limits:

Date: GTC: DIABETES: 1E Brand Name: DIABETIC TEST STRIPS Generic Name: diabetic test strips

Criteria: Approve Non-formulary test strip if: - Patient is on a specific insulin pump and it will only operate with a certain brand of test strip - Formulary test strips are limited to 100 strips/month unless: - Patient is using insulin or - Patient is diagnosed with gestational diabetes

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: TRULICITY Generic Name: dulaglutide single dose pen 0.75mg/0.5ml, 1.5mg/0.5ml

Quantity Limits: Each pen is 0.5ml 4 pens/ month = 2ml/ month

Date: June 2018 GTC: DIABETES: 1E Brand Name: JARDIANCE Generic Name: empagliflozin 10mg, 25mg tablets

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: GLYXAMBI Generic Name: empagliflozin/linagliptin 10‐5mg, 25‐5mg tablets Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND a trial and failure of preferred alternative Steglatro* and alogliptin* with compliance of 3 months each OR HbA1c>7.5% and patient was co-prescribed metformin AND documentation of established cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: SYNJARDY Generic Name: empagliflozin/metformin 5‐500mg, 12.5‐500mg, 12.5‐1000mg, 5‐1000mg

Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND a trial and failure of preferred alternative Steglatro* with compliance for additional 3 months AND trial of metformin and empaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater AND trial of metformin and empaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents HbA1c >7.5% and patient was co-prescribed metformin AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater AND trial of metformin and empaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: SYNJARDY XR Generic Name: empagliflozin/metformin er 5‐1000mg, 10‐1000mg, 12.5‐ 1000mg, 25‐1000mg

Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND a trial and failure of preferred alternative Steglatro* with compliance for additional 3 months AND trial of metformin and empaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents HbA1c >6.5% after inadequate response, intolerable side effect, or contraindication to metformin with compliance of at least 3 months AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater AND trial of metformin and empaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents HbA1c >7.5% and patient was co-prescribed metformin AND documentation of established Cardiovascular disease such as coronary artery disease (CAD) , angina, myocardial infarction, stroke, heart failure, cardiomyopathy, arrhythmia, peripheral artery disease, thromboembolic disease, and venous thrombosis, chronic kidney disease of stage 3 or greater AND trial of metformin and empaglifolozin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: STEGLATRO Generic Name: ertugliflozin 5mg, 15mg tablets

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: SEGLUROMET Generic Name: ertugliflozin/metformin 2.5-500mg, 2.5-1000mg, 7.5-500mg, 7.5-1000mg Criteria: Diagnosis of diabetes mellitus type 2 AND trial of metformin and Steglatro* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: STEGLUJAN Generic Name: ertugliflozin+sitagliptin5-100mg, 15-100mg

Criteria: Diagnosis of type 2 diabetes AND - Compliance to metformin therapy AND - Inadequate response, intolerable side effect, or contraindication to Steglatro* and alogliptin * with compliance of at least 3 month each *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: BYETTA Generic Name: exenatide 5mcg/dose (1.2ml pen), 10mcg/dose (2.4ml pen), 60 doses per pen

Criteria: Diagnosis of type 2 diabetes AND HbA1c >6.5% AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to Trulicity* with compliance of at least 3 month *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: BYDUREON Generic Name: exenatide microspheres 2mg single dose pen or vial

Quantity Limits: 4 vials per month

Date: June 2018 GTC: DIABETES: 1E Brand Name: SOLIQUA Generic Name: glargine 100 units/1 ml/lixisenatide 33 mcg / 1 ml 3ml x 5 pens

Criteria: Diagnosis of type 2 diabetes mellitus AND A1C >9 OR Patient tried and failed triple therapy (which included either basaglar or Trulicity* with compliance for at least 3 months *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: LANTUS VIALS Generic Name: glargine 10ml vials Criteria: Diagnosis of uncontrolled diabetes (HbA1C>7%) AND has inadequate response, intolerable side effect, or contraindication Basaglar Kwikpen

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: GLIPIZIDE-METFORMIN Generic Name: glipizide-metformin Criteria: Diagnosis of diabetes mellitus type 2 AND trial of formulary alternative glyburide-metformin AND trial of glipizide and metformin administered as separate agents AND medical justification why the member cannot continue glipizide + metformin as separate agents

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: APIDRA Generic Name: glulisine 100 units/ml 10ml vial, 3ml x5 solostar pen Criteria: Diagnosis of Type 1 or Type 2 diabetes AND inadequate response, intolerable side effect to Admelog vial or Admelog Solostar

Quantity Limits:

Date: June 2019 GTC: DIABETES: 1E Brand Name: FIASP Generic Name: insulin aspart (niacinamide) vial, flextouch

Criteria: Diagnosis of Type 1 or Type 2 diabetes AND inadequate response, intolerable side effect to Admelog vial or Admelog Solostar

Quantity Limits:

Date: May 2019 GTC: DIABETES: 1E Brand Name: NOVOLOG CARTRIDGE Generic Name: insulin aspart 3ml cartridge

Criteria: Diagnosis of type 1 or type 2 diabetes AND -Medical justification why Admelog cannot be used AND -To be used with refillable pens

Quantity Limits:

Date: June 2017 GTC: DIABETES: 1E Brand Name: TRESIBA FLEXTOUCH Generic Name: insulin degludec pen

Criteria: Diagnosis of uncontrolled diabetes (HbA1C>7%) AND has inadequate response, intolerable side effect, or contraindication Basaglar Kwikpen

Quantity Limits:

Date: June 2017 GTC: DIABETES: 1E Brand Name: LEVEMIR VIALS Generic Name: insulin detemir vials, insulin detemir pens LEVEMIR FLEXPEN Criteria: Diagnosis of uncontrolled diabetes (HbA1C>7%) AND has inadequate response, intolerable side effect, or contraindication Basaglar Kwikpen

Quantity Limits:

Date: June 2017 GTC: DIABETES: 1E Brand Name: LANTUS SOLOSTAR Generic Name: insulin glargine pen Criteria: Diagnosis of uncontrolled diabetes (HbA1C>7%) AND has inadequate response, intolerable side effect, or contraindication Basaglar Kwikpen

Quantity Limits:

Date: June 2017 GTC: DIABETES: 1E Brand Name: TOUJEO SOLOSTAR Generic Name: insulin glargine pen

Criteria: Diagnosis of uncontrolled diabetes (HbA1C>7%) AND has inadequate response, intolerable side effect, or contraindication Basaglar Kwikpen

Quantity Limits:

Date: March 2018 GTC: DIABETES: 1E (Changed- removed from the list of other pens) Brand Name: HUMALOG KWIKPEN, JR. KWIKPEN Generic Name: insulin lispro Criteria: Diagnosis of Type 1 or Type 2 diabetes AND inadequate response, intolerable side effect to Admelog vial or Admelog Solostar

Quantity Limits:

Date: June 2019 GTC: DIABETES: 1E Brand Name: HUMAPEN LUXURA HD Generic Name: insulin lispro

Criteria: Diagnosis of type 1 or type 2 diabetes AND -Medical justification why Admelog cannot be used OR -Requires half unit dosing

Quantity Limits: 1 pen/ year

Date: June 2019 GTC: DIABETES: 1E Brand Name: HUMALOG CARTRIDGE Generic Name: insulin lispro 3ml cartridge

Criteria: Diagnosis of type 1 or type 2 diabetes -Medical justification why Admelog cannot be used AND -To be used with refillable pens, or Disetronic D-TRON and D-TRON plus pumps

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: TRADJENTA Generic Name: linagliptin 5 mg tablet

Criteria: Diagnosis of type 2 diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to alogliptin* or alogliptin/metformin* or alogliptin/pioglitazone* with compliance of at least 3 month *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: JENTADUETO Generic Name: linagliptin/metformin 2.5-500mg, 2.5-850mg, 2.5-1000mg Criteria: Diagnosis of type 2 Diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to alogliptin* or alogliptin/metformin* or alogliptin/pioglitazone* with compliance of at least 3 month AND trial of metformin and linagliptin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits: 2 tabs/day

Date: June 2018 GTC: DIABETES: 1E Brand Name: JENTADUETO XR Generic Name: linagliptin/metformin er 2.5-1000mg, 5-1000mg Criteria: Diagnosis of type 2 Diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to alogliptin* or alogliptin/metformin* or alogliptin/pioglitazone* with compliance of at least 3 month AND trial of metformin and linagliptin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: VICTOZA Generic Name: liraglutide pen (18mg/3ml) 2 or 3 pack

Quantity Limits:

Date: May 2019 GTC: DIABETES: 1E Brand Name: HUMALOG Generic Name: lispro 100 unit/ml 10ml vial

Criteria: Diagnosis of Type 1 or Type 2 diabetes AND inadequate response, intolerable side effect to Admelog vial or Admelog Solostar

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: ADLYXIN Generic Name: lixisenatide starter pack (10mcg/dose 3ml pen & 20mcg/dose 3ml pen) maintenance pack (two 20mcg/dose 3ml pens

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: GLUMETZA Generic Name: metformin er (mod) 24 hour tablet 500mg, 1000mg Criteria: Diagnosis of diabetes mellitus type 2 AND prescribed by an Endocrinologist AND patient has tried at least 12 weeks of metformin ER (generic: Glucophage XR) AND patient has tried at least 12 weeks of metformin ER OSM (generic: Fortamet) AND submission of medical records (e.g. chart notes, laboratory values) documenting intolerance to generic Glucophage XR and generic Fortamet which were unable to be resolved with attempts to minimize the adverse effects (such as slower dose titration, dose reduction) AND FDA MedWatch report has been completed and submitted to report the adverse event with metformin ER (generic: Glucophage XR)

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: FORTAMET Generic Name: metformin er osm 24 hour tablet 500mg, 1000mg Criteria: Diagnosis of diabetes mellitus type 2 AND patient has tried at least 12 weeks of metformin ER (generic: Glucophage XR) AND submission of medical records (e.g. chart notes, laboratory values) documenting intolerance to metformin ER (generic: Glucophage XR) which is unable to be resolved with attempts to minimize the adverse effects (such as slower dose titration, dose reduction) AND FDA MedWatch report has been completed and submitted to report the adverse event with metformin ER (generic: Glucophage XR)

Quantity Limits:

Date: June 2017 GTC: DIABETES: 1E Brand Name: RIOMET Generic Name: metformin hcl solution Criteria: Documentation that the member is unable to swallow or has difficulty swallowing tablets containing metformin. Review of the member’s prescription claims history must show other liquid formulations

Quantity Limits:

Date: June 2017 GTC: DIABETES: 1E Brand Name: KORLYM Generic Name: mifepristone tablet Criteria: Initial Authorization: Korlym will be approved based on ALL of the following criteria: - Diagnosis of endogenous Cushing’s syndrome (i.e., hypercortisolism is not a result of chronic administration of high dose glucocorticoids) AND One of the following: - Diagnosis of type 2 diabetes mellitus - Diagnosis of glucose intolerance AND one of the following: - Patient has failed surgery - Patient is not a candidate for surgery AND patient must have failed or been intolerant to therapy with at least 2 formulary oral and injectable agents for type 2 diabetes mellitus AND must be prescribed by endocrinologist Authorization will be issued for 6 months. Reauthorization: Korlym reauthorization will be approved based on the following criterion: - Documentation of one of the following: - Patient has improved glucose intolerance while on Korlym therapy - Patient has stable glucose intolerance while on Korlym

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: GLYSET Generic Name: miglitol Criteria: Diagnosis of diabetes mellitus type 2 AND has inadequate response, intolerable side effect, or contraindication to formulary alternative acarbose

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: STARLIX Generic Name: nateglinide 60mg, 120 mg tablet Criteria: Diagnosis of diabetes mellitus type 2 AND has inadequate response, intolerable side effect, or contraindication to formulary alternative Repaglinide

Quantity Limits:

Date: June 2019 GTC: DIABETES: 1E Brand Name: NOVOPEN ECHO Generic Name: novopen echo Criteria: Diagnosis of type 1 or type 2 diabetes AND medical justification why Admelog cannot be used OR Requires half unit dosing

Quantity Limits: 1 pen/ year

Date: June 2018 GTC: DIABETES: 1E Brand Name: ACTOPLUS MET Generic Name: pioglitazone-metformin Criteria: Diagnosis of diabetes mellitus type 2 AND trial of pioglitazone and metformin administered as separate agents AND medical justification why patient cannot continue pioglitazone and metformin as separate agents

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: SYMLINPEN Generic Name: pramlintide Criteria: For the treatment of type 1 diabetes mellitus and type 2 diabetes mellitus who use mealtime insulin therapy AND failed to achieve desired glucose control despite optimal insulin therapy

Quantity Limits:

Date: June 2019 GTC: DIABETES: 1E Brand Name: AVANDIA Generic Name: rosiglitazone Criteria: Diagnosis of diabetes mellitus type 2 AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to pioglitazone with compliance of at least 3 months

Quantity Limits: 1 tablet/ day

Date: June 2018 GTC: DIABETES: 1E Brand Name: ONGLYZA Generic Name: saxagliptin 2.5, 5 mg tablets

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: KOMBIGLYZE XR Generic Name: saxagliptin/metformin er 2.5-500mg, 2.5-1000mg, 5-1000mg

Criteria: Diagnosis of type 2 Diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to alogliptin* or alogliptin/metformin* or alogliptin/pioglitazone* with compliance of at least 3 month AND trial of metformin and saxagliptin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: May 2019 GTC: DIABETES: 1E Brand Name: OZEMPIC Generic Name: semaglutide pens: 0.25 or 0.5 mg/ dose (2mg/1.5ml) 1 mg per dose (2mg/1.5ml)

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: JANUVIA Generic Name: sitagliptin 25, 50, 100 mg tablets

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: JANUMET Generic Name: sitagliptin/metformin 50-500mg, 50-1000mg

Criteria: Diagnosis of type 2 Diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to alogliptin* or alogliptin/metformin* or alogliptin/pioglitazone* with compliance of at least 3 month AND trial of metformin and sitagliptin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: June 2018 GTC: DIABETES: 1E Brand Name: JANUMET XR Generic Name: sitagliptin/metformin er 50-500mg, 50-1000mg, 100-1000mg

Criteria: Diagnosis of type 2 Diabetes AND compliance to metformin therapy AND inadequate response, intolerable side effect, or contraindication to alogliptin* or alogliptin/metformin* or alogliptin/pioglitazone* with compliance of at least 3 month AND trial of metformin and sitagliptin* administered as separate agents AND medical justification why the member cannot continue taking these as separate agents *Prior Authorization Required

Quantity Limits:

Date: May 2019 GTC: DIABETES: 1E Brand Name: NOVOLOG Generic Name:

Criteria: Diagnosis of Type 1 or Type 2 diabetes AND inadequate response, intolerable side effect to Admelog vial or Admelog Solostar

Quantity Limits:

Date: June 2018 GTC: EAR - GENERAL DISORDERS: 0Z Brand Name: DERMOTIC OIL Generic Name: fluocinolone oil Criteria: Diagnosis of chronic eczematous otitis externa

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EAR - GENERAL DISORDERS: 0Z Brand Name: COLY-MYCIN S Generic Name: Criteria: Has inadequate response, intolerable side effect, or contraindication to neomycin/polymyxin B/HC drops

Quantity Limits:

Date: May 2019 GTC: EAR - GENERAL DISORDERS: 0Z Brand Name: OTIPRIO Generic Name: Criteria: Diagnosis of bilateral otitis media with effusion undergoing tympanostomy tube placement AND patient is at least 6 months old OR Diagnosis of acute otitis externa AND patient is at least 6 months old AND has inadequate response, intolerable side effect, or contraindication to ciprofloxacin 0.2% drops

Quantity Limits:

Date: May 2019 GTC: EAR - GENERAL DISORDERS: 0Z Brand Name: OTOVEL Generic Name: Criteria: Diagnosis of acute otitis media with tympanostomy tubes (AOMT) AND patient is at least 6 months old

Quantity Limits:

Date: July 2018 GTC: ELECTROLYTE REGULATION: 1S Brand Name: AURYXIA Generic Name: ferric citrate Criteria: Management of hyperphosphatemia in CKD members on dialysis - Previous claims indicating a minimum 90-day trial of calcium acetate in the last 120 days Treatment of iron-deficiency anemia in CKD members - Previous claims indicating a minimum 90-day trial of formulary oral iron in the last 120 days - Medical justification why formulary oral iron tablets cannot be used with vitamin C

Quantity Limits: 12 tablets/ day

Date: September 2016 GTC: ELECTROLYTE REGULATION: 1S Brand Name: FOSRENOL Generic Name: lanthanum carbonate chewable tablet, oral powder packet Criteria: ESRD members who are unresponsive to calcium based phosphate binder therapy (formulary calcium acetate or calcium carbonate) in amounts exceeding 1,500mg total elemental calcium content. 1,500mg is provided by: - PhosLo 9/day OR - Tums E-X 750mg 5/day OR - When calcium based phosphorus binder are contraindicated

Quantity Limits:

Date: July 2018 GTC: ELECTROLYTE REGULATION: 1S Brand Name: VELTASSA Generic Name: patiromer Criteria: Diagnosis of hyperkalemia AND prescribed by appropriate specialist (nephrology, cardiology) AND 1 of the following: - Trial of sodium polystyrene sulfonate (SPS) - Has risk of developing constipation or impaction (e.g. chronic opioid use, underlying bowel disease) - Has risk for sodium or fluid overload (e.g. CHF)

Quantity Limits: 1 packet/ day 30 packets/ Rx

Date: September 2016 GTC: ELECTROLYTE REGULATION: 1S Brand Name: RENVELA Generic Name: sevelamer carbonate oral tablet, oral powder packet Criteria: CKD stage 5 members who are unresponsive to calcium based phosphate binder therapy (formulary calcium acetate or calcium carbonate) in amounts exceeding 1,500mg total elemental calcium content. 1,500mg is provided by: - PhosLo 9/day OR - Tums E-X 750mg 5/day OR - When calcium based phosphorus binder are contraindicated

Quantity Limits:

Date: September 2016 GTC: ELECTROLYTE REGULATION: 1S Brand Name: RENAGEL Generic Name: sevelamer hcl oral tablet Criteria: CKD stage 5 members who are unresponsive to calcium based phosphate binder therapy (formulary calcium acetate or calcium carbonate) in amounts exceeding 1,500mg total elemental calcium content. 1,500mg is provided by: - PhosLo 9/day OR - Tums E-X 750mg 5/day OR - When calcium based phosphorus binder are contraindicated AND trial and failure of Renvela (sevelamer carbonate) tablets

Quantity Limits:

Date: September 2017 GTC: ELECTROLYTE REGULATION: 1S

Brand Name: VELPHORO Generic Name: sucroferric oxyhydroxide 500mg chewable tablet Criteria: Diagnosis of hyperphosphatemia in patients with chronic kidney disease receiving dialysis AND trial and failure of calcium based phosphate binder (PhosLo, Tums) x 3 months. AND trial and failure of Renvela

Quantity Limits:

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: TYMLOS Generic Name: abaloparatide Criteria: ALL of the following are present: - Age 18 years or older - Female with postmenopausal osteoporosis, as indicated by 1 or more of the following - Femoral neck, spine, or total hip bone mineral density T-score minus 2.5 or less - Hip or vertebral fragility (ie, low-trauma) fracture in patient older than 50 years - T-score between −1.0 and −2.5 at the femoral neck or spine and a 10-yr probability of a hip fracture of ≥3% or a 10-yr probability of a major osteoporosis- related fracture of ≥20% - Failure of, inability to tolerate, or contraindication to oral bisphosphonates, IV bisphosphonates*, and Prolia* *Prior Authorization Required

Quantity Limits: 80mcg subcutaneously once daily

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: MIACALCIN INJECTION Generic Name: calcitonin injection Criteria: Patient using medication for one of the following: - Hypercalcemia with trial and failure of Zometa* - Paget’s disease with trial and failure of Reclast* AND disease is symptomatic (bone pain, hearing loss, bone deformities, fractures, arthritis) OR patient is at risk of complications from Paget’s disease (such as osteoarthritis, heart failure, kidney stones, fractures) *Prior Authorization Required

Quantity Limits: Hypercalcemia: 4 units/kg q12hr (may increase to max of 8 units/kg q6hr) Paget’s disease: 100 units daily (lower maint doses like 50 units 3x/wk may be sufficient)

Date: December 2017 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: SENSIPAR Generic Name: cinacalcet Criteria: Diagnosis of Primary hyperparathyroidism in adults who are unable to undergo parathyroidectomy and calcium levels are greater than 10.4 mg/dL OR Secondary hyperparathyroidism in adult CKD patients on dialysis and calcium level is greater than 8.4 and current intact parathyroid hormone levels are greater than 300 pg/ml3 and they have tried/failed one phosphate binder OR Hypercalcemia in adults with parathyroid cancer and current serum calcium levels are greater than 10mg/dL

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: XGEVA Generic Name: denosumab 120mg/1.7ml subcutaneous syringe

Criteria: Member using medication for one of the following: - Hypercalcemia of malignancy, bone metastases from solid tumors, or multiple myeloma with trial and failure of Zometa* - Giant cell tumor of bone (approve) *Prior Authorization Required

Quantity Limits: 120mg every 4 weeks. During the first month, may give an additional 120mg on Day 8 and Day 15.

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: PROLIA Generic Name: denosumab 60mg/ml subcutaneous syringe

Criteria: Documented osteoporosis in male or postmenopausal female, as indicated by 1 or more of the following - T-score less than -2.5 - History of osteoporotic fracture - T-score between −1.0 and −2.5 at the femoral neck or spine and a 10-yr probability of a hip fracture of ≥3% or a 10-yr probability of a major osteoporosis- related fracture of ≥20% AND inability to tolerate, or contraindication to, all of the following: - Oral bisphosphonates - IV bisphosphonates* - Raloxifene (only if postmenopausal female) - Androgen deprivation-induced bone loss in men with prostate cancer - Trial and failure of Zometa* - Aromatase inhibitor-induced bone loss in women with breast cancer - Trial and failure of at least two oral bisphosphonates and Zometa* *Prior Authorization Required

Quantity Limits: 60mg as a single dose, once every 6 months.

Date: GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: HECTOROL Generic Name: doxercalciferol Criteria: Diagnosis of secondary hyperparathyroidism due to chronic kidney disease (CKD)

Quantity Limits:

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: ORILISSA Generic Name: elagolix sodium 150mg, 200 mg tablet

Criteria: Member meets all of the following criteria: - Diagnosis of moderate to severe pain associated with endometriosis - Inadequate response, intolerable side effect, or contraindication to NSAIDs and oral contraceptives (at least 6 months trial) - Prescribed by appropriate specialist (such as endocrinologist or OB/GYN) - Member is at least 18 years of age - Member is not pregnant

Quantity Limits: 150 mg once daily for up to 24 months OR 200 mg twice daily for up to 6 months

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: SUPPRELIN LA Generic Name: histrelin acetate 50mg implant kit Criteria: Central precocious puberty (early-onset puberty): - Diagnosis of central precocious puberty confirmed by GnRH test or third-generation basal LH assay AND - Ages 2-11 years if female, ages 2-12 years if male AND member has advanced bone age (bone age at least 1 yr greater than chronological age) AND intracranial tumor has been ruled out AND onset of secondary sex characteristics occurred at: - Age < 8 years if female - Age < 9 years if male AND Trial and failure of Lupron Depot* *Prior Authorization Required Puberty suppression therapy for gender dysphoria: Patient has been diagnosed with gender dysphoria disorder by a qualified mental health professional AND the patient has exhibited the first physical changes of puberty (Tanner stage 2 or 3) AND trial and failure of Lupron Depot* *Prior Authorization Required

Quantity Limits: A single, subcutaneous 50mg implant, once every 12 months.

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: LUPRON DEPOT Generic Name: leuprolide acetate Criteria: DYSFUNCTIONAL UTERINE BLEEDING (off-label indication recommended by MCG guidelines) if Lupron is being used prior to planned endometrical ablation for definitive treatment AND other causes of symptoms or bleeding ruled out (e.g., by endometrical biopsy) ENDOMETRIOSIS (Lupron Depot 3.75 monthly and/or 11.25 every 3 months – with max treatment of 6 months) - Requires diagnosis of endometriosis with symptoms as indicated by dysmenorrhea, dyspareunia OR pelvic pain AND Must be 18 years or older AND prescribed by an appropriate specialist (such as endocrinologist or OB/GYN) AND if patient has inadequate response, intolerable side effect, or contraindication to Orilissa*, NSAIDs, and oral contraceptives (at least 6 months trial) *Prior Authorization Required FOR UTERINE LEIOMYOMAS (fibroids) (Lupron Depot 3.75 monthly and/or 11.25 every 3 months – with Max treatment of 3 months) - Diagnosis of uterine leiomyomas with symptoms as indicated by abnormal uterine bleeding, bulk-related symptoms (e.g., pelvic pain or pressure, dyspareunia, urinary symptoms) OR iron deficiency anemia - Must be 18 years or older AND other causes of symptoms or bleeding ruled out (e.g., by endometrial biopsy) BREAST CANCER (off-label indication recommended by MCG guidelines) (Lupron Depot 3.75 monthly and/or 11.25 every 3 months – with Max treatment of 24 months) - Palliative treatment of advanced disease AND patient is premenopausal or perimenopausal PROSTATE CANCER (Lupron Depot 7.5 monthly, 22.5 every 3 months, 30 every 4 months, and 45 mg every 6 months) - Locally advanced (T3b to T4) or metastatic disease OR clinically localized prostate cancer with intermediate risk of recurrence as indicated by 1 of the following: - T2a or lower, and aggressive histologic pattern (Gleason score of 7) - T2a or lower, and PSA 10 to 20 ng/mL (mcg/L) - T2b or T2c Clinically localized prostate cancer with high risk of recurrence as indicated by 1 of the following: - T2c or lower, and aggressive histologic pattern (Gleason score of 8 to 10) - T2c or lower, and PSA greater than 20 ng/mL (mcg/L) - T3a Central precocious puberty (early-onset puberty): Diagnosis of central precocious puberty confirmed by GnRH test or third-generation basal LH assay AND ages 2-11 years if female, ages 2-12 years if male AND member has advanced bone age (bone age at least 1 yr greater than chronological age) AND intracranial tumor has been ruled out AND onset of secondary sex characteristics occurred at: - Age < 8 years if female - Age < 9 years if male Puberty suppression therapy for gender dysphoria: Patient has been diagnosed with gender dysphoria disorder by a qualified mental health professional AND the patient has exhibited the first physical changes of puberty (Tanner stage 2 or 3)

Quantity Limits:

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: INCRELEX Generic Name: mecasermin Criteria: Severe primary IGF-1 deficiency: - At least 2 years of age - Basal IGF standard deviation score -3.0 or less - Height standard deviation score of -3.0 or less - Normal or elevated HGH level - Trial and failure of growth hormone* - Epiphyses not yet closed - No active or suspected neoplasia - No chronic treatment with pharmacologic doses of corticosteroids - No hypothyroidism - No malnutrition *Prior Authorization Required IGF-1 deficiency due to HGH gene deletion: - At least 2 years of age - HGH gene deletion associated with neutralizing antibodies to HGH - Epiphyses not yet closed - No active or suspected neoplasia - No chronic treatment with pharmacologic doses of corticosteroids - No hypothyroidism - No malnutrition

Quantity Limits: Initial: 0.04-0.08 mg/kg subcutaneous twice daily If tolerated for 7 days, may increase by 0.04 mg/kg/dose Max dose: 0.12 mg/kg twice daily

Date: GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: H.P. ACTHAR GEL Generic Name: repository corticotropin injection Criteria: Prescribed by Neurologist with diagnosis of acute MS flare up in adults AND - Currently on disease modifying therapy with adherence max doses of corticosteroids have been tried and failed during the current exacerbation, preferably trial of IV (e.g. methylprednisolone 500 to 1,000mg IV daily for 3-5 days) - A second opinion by an Alliance-identified American Board of Medical Specialties (ABMS) certified practitioner certified in the area of neurology may be required as well as assignment of an Alliance case manager (RN/MSW) to facilitate process in obtaining second opinion - Prescribed by Rheumatologist with diagnosis of any rheumatic disorder (RA, psoriatic arthritis, SLE, etc) - Max doses of corticosteroids have been tried and failed during the current exacerbation Diagnosis of any Nephrotic Syndrome - T/F corticosteroids (min 8 weeks) and if met, consult with Medical Director - Prescribed by Neurologist with diagnosis of infantile spasms - Less than 2 years of age - No CCS case

Quantity Limits: Maximum of 35mL in 28 days (each 5mL vial contains 400 units)

Date: GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: HUMAN GROWTH HORMONE: GENOTROPIN, HUMATROPE, Generic Name: somatropin NORDITROPIN, NORDIFLEX, NUTROPIN, NUTROPIN AQ, NUTROPIN DEPOT, SAIZEN, SEROSTIM, TEV-TROPIN, ZORBTIVE, OMNITROPE, GENOTROPIN, HUMATROPE, NORDITROPIN, NORDIFLEX, NUTROPIN, NUTROPIN AQ, NUTROPIN DEPOT, SAIZEN, SE Criteria: Please see Milliman Health Care Guidelines (MCG)

Quantity Limits:

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: FORTEO Generic Name: teriparatide 600mcg/2.4ml pen

Criteria: Must meet ALL numbered criteria for a given diagnosis Postmenopausal (female) osteoporosis: - Age 18 years or older - Female with postmenopausal osteoporosis, as indicated by 1 or more of the following - Femoral neck, spine, or total hip bone mineral density T-score of -2.5 or less - Hip or vertebral fragility (ie, low-trauma) fracture in patient older than 50 years - T-score between −1.0 and −2.5 at the femoral neck or spine and a 10-yr probability of a hip fracture of ≥3% or a 10-yr probability of a major osteoporosis- related fracture of ≥20% - Failure of, inability to tolerate, or contraindication to oral bisphosphonates, IV bisphosphonates*, Tymlos*, and Prolia*

*Prior Authorization Required

Male osteoporosis: - Age 18 years or older - Male with hypogonadal or primary osteoporosis, as indicated by 1 or more of the following - Femoral neck, spine, or total hip bone mineral density T-score -2.5 or less - Hip or vertebral fragility (ie, low-trauma) fracture in patient older than 50 years - T-score between −1.0 and −2.5 at the femoral neck or spine and a 10-yr probability of a hip fracture of ≥3% or a 10-yr probability of a major osteoporosis- related fracture of ≥20% - Failure of, inability to tolerate, or contraindication to oral bisphosphonates, IV bisphosphonates*, and Prolia* *Prior Authorization Required Chronic corticosteroid treatment: - Age 18 years or older - Chronic corticosteroid treatment, as indicated by ALL of the following - Daily dose equivalent to 7.5 mg or more of prednisone - Duration of therapy expected to be 1 or more of the following: - Three months or more in any patient with history of fragility (ie, low-trauma) fracture - Three months or more in male 50 years or older - Three months or more in postmenopausal female - Failure of, inability to tolerate, or contraindication to oral bisphosphonates, IV bisphosphonates*, and Prolia* *Prior Authorization Required

Quantity Limits: 20mcg subcutaneously once daily for up to 2 years

Date: January 2019 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: TRIPTODUR Generic Name: triptorelin im inj Criteria: Central precocious puberty (early-onset puberty): 1. Diagnosis of central precocious puberty confirmed by GnRH test or third-generation basal LH assay 2. Ages 2-11 years if female, ages 2-12 years if male 3. Member has advanced bone age (bone age at least 1 yr greater than chronological age) 4. Intracranial tumor has been ruled out 5. Onset of secondary sex characteristics occurred at: Age < 8 years if female Age < 9 years if male 6. Trial and failure of Lupron Depot* *Prior Authorization Required Puberty suppression therapy for gender dysphoria: 1. The patient has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria 2. Gender dysphoria emerged or worsened with the onset of puberty 3. Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment 4. The patient has exhibited the first physical changes of puberty (Tanner stage 2 or 3) 5. Trial and failure of Lupron Depot* *Prior authorization required

Quantity Limits: 22.5 mg IM inj once every 6 mo

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: Yutiq Generic Name: triptorelin im inj Criteria: Central precocious puberty (early-onset puberty): - Diagnosis of central precocious puberty confirmed by GnRH test or third-generation basal LH assay - Ages 2-11 years if female, ages 2-12 years if male - Member has advanced bone age (bone age at least 1 yr greater than chronological age) - Intracranial tumor has been ruled out - Onset of secondary sex characteristics occurred at: - Age < 8 years if female - Age < 9 years if male - Trial and failure of Lupron Depot* *Prior Authorization Required Puberty suppression therapy for gender dysphoria: - Patient has been diagnosed with gender dysphoria disorder by a qualified mental health professional - The patient has exhibited the first physical changes of puberty (Tanner stage 2 or 3) - Trial and failure of Lupron Depot* *Prior Authorization Required

Quantity Limits: 22.5 mg IM inj once every 6 mo

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: TRELSTAR DEPOT Generic Name: triptorelin pamoate intramuscular injection

Criteria: Medication is being used for the palliative treatment of prostate cancer

Quantity Limits:

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: ZOMETA Generic Name: zoledronic acid Criteria: Patient using medication for one of the following: - Hypercalcemia of malignancy - Multiple myeloma - Bone metastases from solid tumors - Prevention of skeletal related events in men with castration-resistant prostate cancer - Prevention of bone loss associated with aromatase inhibitor therapy for breast cancer in post-menopausal women or premenopausal women on adjuvant ovarian suppression AND trial and failure of oral bisphosphonate - Prevention of bone loss associated with androgen deprivation therapy in men with prostate cancer

Quantity Limits: 4 mg IV (dosing frequency will vary based on condition)

Date: October 2018 GTC: ENDOCRINE DISORDER – OTHER: 1I Brand Name: RECLAST Generic Name: zoledronic acid

Criteria: Osteoporosis in male or postmenopausal female: - T-score of < -2.5 OR history of osteoporotic fracture OR - T-score between −1.0 and −2.5 at the femoral neck or spine and a 10-yr probability of a hip fracture of ≥3% or a 10-yr probability of a major osteoporosis- related fracture of ≥20% AND trial and failure of (or intolerance to) two oral bisphosphonates (such as alendronate, ibandronate) AND trial and failure of raloxifene (only if post-menopausal female) Treatment or prevention of glucocorticoid-induced osteoporosis: - Trial and failure of (or intolerance to) two oral bisphosphonates (such as alendronate, ibandronate) Paget’s Disease: - Trial and failure of (or intolerance to) two oral bisphosphonates, OR extensive disease in which oral bisphosphonate would not be appropriate - Symptomatic disease (bone pain, hearing loss, bone deformities, fractures, arthritis) OR patient is at risk of complications from Paget’s disease (such as osteoarthritis, heart failure, kidney stones, fractures)

Quantity Limits: 5 mg IV once yearly Osteoporosis prevention in postmenopausal female: 5 mg IV once every 2 years Paget’s disease: 5 mg IV as a single dose

Date: December 2016 GTC: ENDOCRINE DISORDER – THYROID: 1G Brand Name: LEVOTHROID Generic Name: levothyroxine Criteria: Diagnosis of hypothyroidism AND has contraindication or inadequate response to generic levothyroxine

Quantity Limits:

Date: December 2016 GTC: ENDOCRINE DISORDER – THYROID: 1G Brand Name: LEVOXYL Generic Name: levothyroxine Criteria: Diagnosis of hypothyroidism AND has contraindication or inadequate response to generic levothyroxine

Quantity Limits:

Date: December 2016 GTC: ENDOCRINE DISORDER – THYROID: 1G Brand Name: SYNTHROID Generic Name: levothyroxine Criteria: Diagnosis of hypothyroidism AND has contraindication or inadequate response to generic levothyroxine

Quantity Limits:

Date: December 2016 GTC: ENDOCRINE DISORDER – THYROID: 1G Brand Name: TIROSINT Generic Name: levothyroxine capsules Criteria: Diagnosis of hypothyroidism AND has contraindication or inadequate response to generic levothyroxine AND 1 other agent in the same class (Armour Thyroid*, Levothroid*, Levoxyl*, Synthroid*, or liothyronine*) *Prior Authorization Required

Quantity Limits:

Date: December 2016 GTC: ENDOCRINE DISORDER – THYROID: 1G Brand Name: CYTOMEL Generic Name: liothyronine Criteria: Diagnosis of hypothyroidism AND has contraindication or inadequate response to generic levothyroxine

Quantity Limits:

Date: December 2016 GTC: ENDOCRINE DISORDER – THYROID: 1G Brand Name: ARMOUR THYROID Generic Name: thyroid, pork Criteria: Diagnosis of hypothyroidism AND has contraindication or inadequate response to at least 1 generic thyroid (Nature-Throid, NP Thyroid, Westhroid, Westhroid-P, WP Thyroid) formulary alternative

Quantity Limits:

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: LASTACAFT Generic Name: alcaftadine Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops AND olopatadine 0.1% ophthalmic drops* AND azelastine ophthalmic drops* *Prior Authorization Required

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: AZELASTINE DROPS Generic Name: azelastine drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops

Quantity Limits:

Date: June 2017 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: BEPREVE Generic Name: bepotastine 1.5% ophthalmic drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops AND olopatadine 0.1% ophthalmic drops* AND azelastine ophthalmic drops* *Prior Authorization Required

Quantity Limits: 1 bottle/rx

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: PROLENSA Generic Name: bromfenac 0.07% Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: PROLENSA Generic Name: bromfenac 0.07% drops Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac AND bromfenac 0.09% drops* *Prior authorization required

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: BROMSITE Generic Name: bromfenac 0.075% drops Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac AND bromfenac 0.09% drops* *Prior authorization required

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: BROMDAY Generic Name: bromfenac 0.09% Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: OXERVATE Generic Name: cenegermin-bkbj Criteria: Diagnosis of neurotrophic keratoconjunctivitis and member is 2 years of age or older AND member has been evaluated by an ophthalmologist AND member’s condition has continued to progress despite the use of artificial tears drops AND lubricating ophthalmic ointments AND member has tried alternative non-pharm options, including therapeutic soft contact lenses, amniotic membrane graft (Prokera), and tarsorrhaphy, or MD has considered them and feels they would not be appropriate

Quantity Limits: 8 boxes of #7 vials each for unilateral disease, or 16 boxes for bilateral disease Limit authorization to 8 weeks

Date: GTC: EYE - GENERAL DISORDERS: 1A Brand Name: RESTASIS Generic Name: cyclosporine 0.05% ophthalmic emulsion Criteria: Diagnosis of keratoconjunctivitis sicca or dry eye syndrome AND has inadequate response, intolerable side effect, or contraindication to artificial tears ophthalmic solutions and lubricating ophthalmic ointments.

Quantity Limits: 60 vials/month

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: CEQUA Generic Name: cyclosporine 0.09% drops Criteria: Diagnosis of keratoconjunctivitis sicca or dry eye syndrome AND has inadequate response, intolerable side effect, or contraindication to artificial tears ophthalmic solutions and lubricating ophthalmic ointments

Quantity Limits:

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: DEXYCU Generic Name: dexamethasone Criteria: Postoperative inflammation after cataract surgery AND dexterity issues that prevents member from using corticosteroid eye drops OR Medical justification why member cannot use corticosteroid eye drops

Quantity Limits: Dexamethasone 9% (equivalent to 517 mcg) as a single dose per eye per surgery

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: OZURDEX Generic Name: dexamethasone 0.7 mg intravitreal implant Criteria: Diagnosis of diabetic macular edema AND has inadequate response, intolerable side effect, or contraindication to anti-VEGF (bevacizumab*, ranibizumab*, aflibercept*) AND Inadequate response to intravitreal triamcinolone* OR Diagnosis of non-infective uveitis AND has inadequate response, intolerable side effect, or contraindication to a topical corticosteroid (such as prednisolone) AND inadequate response to intravitreal triamcinolone* *Prior authorization required

Quantity Limits:

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: DUREZOL Generic Name: difluprednate Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives (dexamethasone, prednisolone acetate, prednisolone sodium phosphate, fluorometholone)

Quantity Limits: 1 bottle/Rx

Date: June 2017 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ELESTAT Generic Name: epinastine 0.05% ophthalmic drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops

Quantity Limits: 1 bottle/rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: EPINASTINE DROPS Generic Name: epinastine drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops AND azelastine eye drops* *Prior authorization required

Quantity Limits:

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: RETISERT Generic Name: fluocinolone 0.59 mg intravitreal implant Criteria: Diagnosis of chronic non-infective uveitis AND has inadequate response, intolerable side effect, or contraindication to a topical corticosteroid (such as prednisolone) AND inadequate response to intravitreal triamcinolone* AND has inadequate response, intolerable side effect, or contraindication to Yutiq* *Prior authorization required

Quantity Limits:

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: FML FORTE Generic Name: fluorometholone 0.25% suspension Criteria: Diagnosis of ocular inflammation AND trial of one of formulary ophthalmic corticosteroids

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ZIRGAN Generic Name: ganciclovir ophthalmic gel Criteria: Diagnosis of keratitis related to herpes simplex virus AND trial and failure of trifluridine drops

Quantity Limits: Single 5 gm tube per Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: AVENOVA Generic Name: hypochlorous acid/sodium chloride spray Criteria: Member has foreign material on and around eyelid margin, associated with blepharitis, meibomian gland dysfunction (MGD), or dry eye AND member has tried eyelid cleansing with warm compresses, with insufficient effect OR member lacks the manual dexterity or necessary skill or judgment to do so safely

Quantity Limits:

Date: September 2016 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: XIIDRA Generic Name: lifitegrast 5% ophthalmic solution Criteria: Diagnosis of keratoconjunctivitis sicca or dry eye syndrome AND has inadequate response, intolerable side effect, or contraindication to artificial tears ophthalmic solutions and lubricating ophthalmic ointments.

Quantity Limits:

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ALOMIDE Generic Name: lodoxamide drops Criteria: Diagnosis of long-term ocular inflammation (such as seasonal allergic conjunctivitis) AND trial and failure of cromolyn sodium drops

Quantity Limits:

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ALREX Generic Name: loteprednol 0.2% suspension Criteria: Diagnosis of pain or inflammation in the eye AND intolerant of increase in intraocular pressure (IOP) such as glaucoma OR has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives (dexamethasone, prednisolone acetate, prednisolone sodium phosphate, fluorometholone)

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ALREX Generic Name: loteprednol 0.2% suspension Criteria: Diagnosis of seasonal allergic conjunctivitis AND trial and failure of ketotifen eye drops ($10/mo) AND trial and failure of cromolyn sodium drops ($16/mo)

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: LOTEMAX Generic Name: loteprednol 0.5% gel and suspension Criteria: Diagnosis of pain or inflammation in the eye AND intolerant of increase in intraocular pressure (IOP) such as glaucoma OR has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives (dexamethasone, prednisolone acetate, prednisolone sodium phosphate, fluorometholone)

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: LOTEMAX Generic Name: loteprednol 0.5% ointment Criteria: Diagnosis of pain or inflammation in the eye AND intolerant of increase in intraocular pressure (IOP) such as glaucoma OR Has inadequate response, intolerable side effect, or contraindication to 2 formulary alternatives (dexamethasone, prednisolone acetate, prednisolone sodium phosphate, fluorometholone)

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ALOCRIL Generic Name: nedocromil drops Criteria: Diagnosis of long-term ocular inflammation (such as seasonal allergic conjunctivitis) AND trial and failure of cromolyn sodium drops

Quantity Limits:

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: NEVANAC Generic Name: nepafenac 0.1% Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: NEVANAC Generic Name: nepafenac 0.1% drops Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac AND bromfenac 0.09% drops* *Prior authorization required

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ILEVRO Generic Name: nepafenac 0.3% Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ILEVRO Generic Name: nepafenac 0.3% drops Criteria: Diagnosis of pain or inflammation in the eye AND has inadequate response, intolerable side effect, or contraindication to formulary alternatives ketorolac AND diclofenac AND bromfenac 0.09% drops* *Prior authorization required

Quantity Limits: 1 bottle/Rx

Date: October 2018 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: JETREA Generic Name: ocriplasmin 1.25mg/ml intraocular vial

Criteria: Must have a diagnosis of symptomactic vitreomacular adhesion documented on Optical Coherence Tomography (OCT) AND must be prescribed by an retinal specialist, or an ophthalmologist AND must not have had a prior vitrectomy AND must not be receiving treatment in both eyes within 7 days of each other AND must not have a prior treatment with Jetrea on the affected eye

Quantity Limits: 1 injection per eye, per lifetime.

Date: September 2016 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: PATANOL Generic Name: olopatadine 0.1% ophthalmic drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops

Quantity Limits: 1 bottle/Rx

Date: June 2017 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: PATADAY Generic Name: olopatadine 0.2% ophthalmic drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops AND olopatadine 0.1% ophthalmic drops* AND azelastine ophthalmic drops* *Prior Authorization Required

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: PAZEO Generic Name: olopatadine 0.7% drops Criteria: Diagnosis of allergic conjunctivitis AND has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops AND azelastine ophthalmic drops* AND olopatadine 0.1% ophthalmic drops* AND olopatadine 0.2% drops* *Prior Authorization Required

Quantity Limits:

Date: June 2017 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: PAZEO Generic Name: olopatadine 0.7% ophthalmic drops Criteria: Diagnosis of allergic conjunctivitis AND Has inadequate response, intolerable side effect, or contraindication to ketotifen (OTC) eye drops AND olopatadine 0.1% ophthalmic drops* AND azelastine ophthalmic drops* *Prior Authorization Required

Quantity Limits: 1 bottle/rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: BLEPHAMIDE DROPS SUSP Generic Name: sulfacetamide/prednisolone acetate 10%-0.2% drops suspension Criteria: Has inadequate response, intolerable side effect, or contraindication to sulfacetamide-prednisolone drops AND Blephamide S.O.P. ointment

Quantity Limits:

Date: GTC: EYE - GENERAL DISORDERS: 1A Brand Name: ZYLET Generic Name: tobramycin/ lotepred

Criteria: Has inadequate response, intolerable side effect, or contraindication to or failure of a trial of tobramycin-dexamethasone 3%-0.1%

Quantity Limits: 1 bottle/rx

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: TOBRADEX ST Generic Name: tobramycin-dexamethasone 0.3-0.05% drops suspension Criteria: Has inadequate response, intolerable side effect, or contraindication to or failure of a trial of tobramycin-dexamethasone 3%-0.1%

Quantity Limits:

Date: May 2019 GTC: EYE - GENERAL DISORDERS: 1A Brand Name: TRIESENCE Generic Name: triamcinolone intravitreal injection Criteria: Diagnosis of macular edema AND has inadequate response, intolerable side effect, or contraindication to anti-VEGF (bevacizumab*, ranibizumab*, aflibercept*) Diagnosis of inflammatory ocular condition AND has inadequate response, intolerable side effect, or contraindication to a topical corticosteroid (such as prednisolone)

Quantity Limits:

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: BETOPTIC S Generic Name: betaxolol 0.25% suspension Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Timolol ophthalmic solution AND Betaxolol 0.5% drops

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: BETOPTIC Generic Name: betaxolol 0.5% drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Timolol ophthalmic solution

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: LUMIGAN Generic Name: bimatoprost Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Latanoprost

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: LUMIGAN Generic Name: bimatoprost 0.01% drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Latanoprost AND generic bimatoprost 0.03% drops

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: BIMATOPROST 0.03% DROPS Generic Name: bimatoprost 0.03% drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Latanoprost

Quantity Limits: 1 bottle/Rx

Date: June 2017 GTC: EYE - GLAUCOMA: 1B Brand Name: ALPHAGAN P Generic Name: brimonidine 0.1% ophthalmic drops, brimonidine 0.15% ophthalmic drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to brimonidine 0.2% ophthalmic drops

Quantity Limits: 1 bottle/rx

Date: GTC: EYE - GLAUCOMA: 1B Brand Name: COMBIGAN Generic Name: brimonidine tartrate/timolol

Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND justification provided as to why member cannot use timolol and brimonidine separately due to volume limitations, compliance and/or dexterity issues

Quantity Limits: 1 bottle/rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: AZOPT Generic Name: brinzolamide 1% Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Dorzolamide

Quantity Limits: 1 bottle/Rx

Date: June 2017 GTC: EYE - GLAUCOMA: 1B Brand Name: SIMBRINZA Generic Name: brinzolamide/brimonidine 1%-0.2% ophthalmic drops

Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to dorzolamide and brimonidine 0.2% ophthalmic drops as separate agents

Quantity Limits: 1 bottle/rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: METHAZOLAMIDE Generic Name: methazolamide tablet Criteria: Diagnosis of glaucoma and trial and inadequate response, intolerable side effect, or contraindication to acetazolamide

Quantity Limits:

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: RHOPRESSA Generic Name: netarsudil Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to 3 classes of glaucoma eye drops Examples: latanoprost, brimonidine, timolol, dorzolamide, pilocarpine

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: RHOPRESSA Generic Name: netarsudil drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND Has inadequate response, intolerant side effect, or contraindication to medications from 3 classes of glaucoma eye drops Examples: latanoprost, brimonidine, timolol, dorzolamide, pilocarpine

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: ROCKLATAN Generic Name: netarsudil-latanoprost 0.02%-0.005% drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to medications from 3 classes of glaucoma eye drops (examples: latanoprost, brimonidine, timolol, dorzolamide, pilocarpine) AND trial and failure of Rhopressa* and latanoprost as separate agents *Prior authorization required

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: ZIOPTAN Generic Name: tafluprost Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Latanoprost

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: ZIOPTAN Generic Name: tafluprost preservative-free drops Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Latanoprost OR member requires a preservative-free drop

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: TIMOPTIC-XE Generic Name: timolol (gel-forming solution) Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to timolol ophthalmic solution

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: ISTALOL Generic Name: timolol (once daily drops) Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to timolol ophthalmic solution AND timolol gel-forming solution

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: TIOPTIC OCUDOSE Generic Name: timolol 0.25% preservative-free drop Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerable side effect, or contraindication to timolol ophthalmic solution, timolol GFS*, and timolol once-daily drop* OR Diagnosis of open-angle glaucoma or ocular hypertension AND member requires a preservative-free drop AND has inadequate response, intolerable side effect, or contraindication to Zioptan* *Prior authorization required

Quantity Limits: 1 box of 60 pouches/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: TIMOPTIC-XE Generic Name: timolol gel-forming solution (gfs) Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to timolol ophthalmic solution OR Diagnosis of infantile hemangioma (for topical use)

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - GLAUCOMA: 1B Brand Name: ISTALOL Generic Name: timolol once-daily drop Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Timolol ophthalmic solution AND Timolol gel-forming solution* *Prior authorization required

Quantity Limits: 1 bottle/Rx

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: COSOPT PF Generic Name: timolol/dorzolamide preservative free Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND intolerant side effect to regular timolol/ dorzolamide

Quantity Limits:

Date: June 2018 GTC: EYE - GLAUCOMA: 1B Brand Name: TRAVATAN Z Generic Name: travoprost Criteria: Diagnosis of open-angle glaucoma or ocular hypertension AND has inadequate response, intolerant side effect, or contraindication to Latanoprost

Quantity Limits: 1 bottle/Rx

Date: May 2019 GTC: EYE - MISCELLANEOUS: 1C Brand Name: EYLEA Generic Name: aflibercept 2 mg/0.05 ml solution for intravitreal injection Criteria: Diagnosis of diabetic macular edema OR Macular edema following central or branch retinal vein occlusion OR Neovascular age-related macular degeneration AND no active intraocular inflammation or infection AND has inadequate response, intolerable side effect, or contraindication to bevacizumab injections* and Lucentis*

Quantity Limits:

Date: September 2016 GTC: EYE - MISCELLANEOUS: 1C Brand Name: EYLEA Generic Name: aflibercept 2mg/0.05ml vial for ophthalmic injection Criteria: Diagnosis of diabetic macular edema, macular edema following retinal vein occlusion, neovascular age-related macular degeneration, diabetic retinopathy in patients with DME AND has inadequate response, intolerable side effect, or contraindication to bevacizumab injections

Quantity Limits:

Date: May 2019 GTC: EYE - MISCELLANEOUS: 1C Brand Name: AVASTIN Generic Name: bevacizumab 100 mg/4 ml vial for ophthalmic injection Criteria: Diagnosis of diabetic macular edema OR Macular edema following retinal vein occlusion OR Neovascular age-related macular degeneration AND no concurrent ocular or periocular infection

Quantity Limits:

Date: June 2018 GTC: EYE - MISCELLANEOUS: 1C Brand Name: ILUVIEN Generic Name: fluocinolone implant Criteria: Diagnosis of diabetic macular edema AND has inadequate response, intolerable side effect, or contraindication to anti-VEGF (bevacizumab, ranibizumab, aflibercept) inadequate response to intravitreal triamcinolone, previously treated with a course of intravitreal corticosteroid and did not have clinically significant rise in intraocular pressure

Quantity Limits: One implant (0.19mg fluocinolone acetonide) per eye One implant per eye every 3 years

Date: June 2018 GTC: EYE - MISCELLANEOUS: 1C Brand Name: LACRISERT Generic Name: hydroxypropyl cellulose insert Criteria: Diagnosis of keratoconjunctivitis sicca, exposure keratitis, decreased corneal sensitivity, or recurrent corneal erosions AND has inadequate response, intolerable side effect, or contraindication to Restasis* AND Xiidra* for 60 days AND evaluated by ophthalmologist or optometrist *Prior Authorization Required

Quantity Limits: Box of 60 inserts/Rx

Date: May 2019 GTC: EYE - MISCELLANEOUS: 1C Brand Name: LACRISERT Generic Name: hydroxypropyl cellulose ophthalmic insert Criteria: Diagnosis of keratoconjunctivitis sicca, exposure keratitis, decreased corneal sensitivity, or recurrent corneal erosions AND has inadequate response, intolerable side effect, or contraindication to Restasis* AND Xiidra* AND Cequa* for 60 days AND evaluated by ophthalmologist or optometrist *Prior Authorization Required

Quantity Limits: Box of 60 inserts/Rx

Date: May 2019 GTC: EYE - MISCELLANEOUS: 1C Brand Name: LUCENTIS Generic Name: ranibizumab 0.3 mg/0.05 ml vial for ophthalmic injection Criteria: Diagnosis of diabetic macular edema, central retinal vein occlusion, branch retinal vein occlusion, neovascular age-related macular degeneration, cystoid macular degeneration, or retinal/macular edema AND has inadequate response, intolerable side effect, or contraindication to bevacizumab injections* *Prior authorization required

Quantity Limits:

Date: September 2016 GTC: EYE - MISCELLANEOUS: 1C Brand Name: LUCENTIS Generic Name: ranibizumab 0.3mg/0.05ml vial for ophthalmic injection

Criteria: Diagnosis of diabetic macular edema, central retinal vein occlusion, branch retinal vein occlusion, neovascular age-related macular degeneration, cystoid macular degeneration, or retinal/macular edema AND has inadequate response, intolerable side effect, or contraindication to bevacizumab injections

Quantity Limits:

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: LOTRONEX Generic Name: alosetron

Criteria: Diagnosis of Irritable Bowel Syndrome with diarrhea in women AND has inadequate response, intolerable side effect or contraindication to loperamide OR diphenoxylate-atropine AND 2 of the following medications: - Bile acid sequestrant (cholestyramine, colestipol) - Antispasmodic (dicyclomine, hyoscyamine) - Tricyclic antidepressant (amitriptyline, nortriptyline)

Quantity Limits: 2 tablets/day

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: MYTESI Generic Name: crofelemer dr 125mg oral tablet

Criteria: Diagnosis of non-infectious diarrhea in patients with HIV/AIDS on retroviral therapy AND has inadequate response, intolerable side effect or contraindication to loperamide and diphenoxylate-atropine

Quantity Limits:

Date: GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: RAVICTI Generic Name: glycerol phenylbutyrate Criteria: Diagnosis of urea cycle disorder AND prescribed by a specialist AND cannot be managed by dietary protein restriction and/or amino acid supplementation alone AND is used as adjunctive therapy with dietary protein restriction and/or amino acid supplementation

Quantity Limits: 4.5-11.2ml/m2/day 3 months

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: KRISTALOSE Generic Name: lactulose packet Criteria: Diagnosis of constipation AND medical justification why member cannot use lactulose solution AND trial and failure of 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate.

Quantity Limits: 1 packet/day 3 months

Date: GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: LINZESS Generic Name: linaclotide Criteria: Diagnosis of Irritable Bowel Syndrome with Constipation or Chronic Idiopathic Constipation AND has inadequate response, intolerable side effect or contraindication to 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate

Quantity Limits:

Date: GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: AMITIZA Generic Name: lubiprostone Criteria: Diagnosis of Irritable Bowel Syndrome with Constipation or Chronic Idiopathic Constipation or Opioid-Induced Constipation AND has inadequate response, intolerable side effect or contraindication to 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate

Quantity Limits:

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: RELISTOR Generic Name: methylnaltrexone 150mg oral tablet, 8mg/0.4ml & 12mg/0.6ml syringe, 12mg/0.6ml vial Criteria: Diagnosis of Opioid-Induced Constipation (OIC) AND has inadequate response, intolerable side effect or contraindication to 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate AND - Has inadequate response, intolerable side effect, or contraindication to 1 of the preferred alternatives; Movantik*, Amitiza*, or Symproic* *Prior Authorization Required

Quantity Limits: Oral: 450mg/day Injection (subcutaneous): 12mg/day

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: SYMPROIC Generic Name: naldemedine Criteria: Diagnosis of Opioid-Induced Constipation (OIC) AND has inadequate response, intolerable side effect or contraindication to 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: MOVANTIK Generic Name: naloxegol Criteria: Diagnosis of Opioid-Induced Constipation (OIC) AND has inadequate response, intolerable side effect or contraindication to 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate

Quantity Limits: 1 tablet/day

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: OCALIVA Generic Name: obeticholic acid Criteria: For the treatment of primary biliary cholangitis/primary biliary cirrhosis (PBC), evaluated by gastroenterology specialist AND inadequate response, intolerable side effect or contraindication to ursodiol

Quantity Limits: 1 tablet/day

Date: GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: OPIUM TINCTURE Generic Name: opium Criteria: Diagnosis of diarrhea AND has inadequate response, intolerable side effect or contraindication to maximum tolerated dosing of loperamide and diphenoxylate- atropine

Quantity Limits: 3 months

Date: December 2017 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: TRULANCE Generic Name: plecanatide Criteria: Diagnosis of Irritable Bowel Syndrome with Constipation or Chronic Idiopathic Constipation AND has inadequate response, intolerable side effect or contraindication to 3 formulary laxatives including: - 1 agent from the osmotic class (lactulose, PEG 3350) AND - 1 agent from the stimulant class (senna, bisacodyl) AND - 1 of the following: fiber, docusate, mineral oil, magnesium citrate, magnesium hydroxide or sodium phosphate

Quantity Limits:

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: MOVIPREP Generic Name: polyethylene glycol (peg) 3350/sodium sulfate/sodium chloride/potassium chloride/ascorbic acid/sodium ascorbate 7.5-2.691g powder packet

Criteria: For bowel prep for colonoscopy AND has inadequate response, intolerable side effect, or contraindication to formulary polyethylene glycol product (PEG 3350)

Quantity Limits: 1 powder pack

Date: GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: BUPHENYL Generic Name: sodium phenylbutyrate Criteria: Diagnosis of urea cycle disoders involving deficiencies of carbamylphosphate synthetase (CPS), ornithine transcarbamylase (OTC), or argininosuccinic acid synthetase (AS) AND individual has one of the following: - Neonatal-onset deficiency with complete enzymatic deficiency presenting within the first 28 days of life; OR - Late-onset disease (defined as partial enzymatic deficiency presenting after the first month of life) who have a history of hyperammonemic encephalopathy AND - Prescribed by a specialist AND - Is used as adjunctive therapy with dietary protein restriction and/or amino acid supplementation

Quantity Limits: If patient <20kg: 450-600mg/kg/day If patient >20kg: 9.9-13gm/m2/day 3 months

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: OSMOPREP Generic Name: sodium phosphate 1.5g oral tablet (1.102g sodium phosphate monobasic monohydrate, usp and 0.398g sodium phosphate dibasic anhydrous, usp) Criteria: For bowel prep for colonoscopy AND has inadequate response, intolerable side effect, or contraindication to formulary polyethylene glycol product (PEG 3350)

Quantity Limits: 32 tablets/fill

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: PREPOPIK Generic Name: sodium picosulfate/magnesium oxide/ anhydrous citric acid 10mg-3.5mg-12g powder packets for oral solution Criteria: For bowel prep for colonoscopy AND has inadequate response, intolerable side effect, or contraindication to generic polyethylene glycol product (PEG 3350)

Quantity Limits: 2 packets/fill

Date: October 2018 GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: SUPREP BOWEL PREP KIT Generic Name: sodium sulfate/potassium sulfate/ magnesium sulfate 17.5g- 3.13g/1.6g oral solution Criteria: For bowel prep for colonoscopy AND has inadequate response, intolerable side effect, or contraindication to generic polyethylene glycol product (PEG 3350)

Quantity Limits: 1 bottle (354mL)/fill

Date: GTC: GASTROINTESTINAL AGENTS: 1N Brand Name: GATTEX Generic Name: teduglutide Criteria: Diagnosis of short bowel syndrome in adults AND patient has been dependent on parenteral nutrition (PN) and/or intravenous (IV) fluids continuously for at least 12 months AND failure or clinically significant adverse effects to somatropin (human growth hormone)

Quantity Limits: 0.05mg/kg SQ QD 3 months

Date: March 2017 GTC: GOUT AND RELATED DISEASES: 1P Brand Name: ULORIC Generic Name: febuxostat oral tablet Criteria: Diagnosis of chronic management of hyperuricemia with gout AND has inadequate response, intolerable side effect, or contraindication to allopurinol

Quantity Limits:

Date: October 2018 GTC: GOUT AND RELATED DISEASES: 1P Brand Name: KRYSTEXXA Generic Name: pegloticase 8mg/ml intravenous vial

Criteria: Diagnosis of chronic gout with hyperuricemia AND at least 3 gout flares in the previous 18 months that were inadequately controlled by colchicine or nonsteroidal anti-inflammatory drugs (NSAIDS) or oral or injectable corticosteroids; OR At least 1 gout tophus or has chronic gouty arthritis AND documentation of baseline serum uric acid level greater than 8 mg/dL AND failure, contraindication or intolerance to previous therapy with maximum tolerated dose of two xanthine oxidase inhibitors (allopurinol and febuxostat) and probenecid (alone or in combination with allopurinol or febuxostat)

Quantity Limits:

Date: GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: AGRYLIN Generic Name: anagrelide Criteria: Diagnosis is the treatment of thrombocythemia secondary to a myeloproliferative disorder AND has been evaluated by an oncologist OR hematologist AND platelets ≥ 400,000/µL

Quantity Limits: Do not exceed 10mg/day

Date: March 2017 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: AGGRENOX Generic Name: aspirin/dipyridamole 25mg-200mg oral capsule Criteria: For prevention of recurrent stroke in patients who have experienced a transient ischemic attack or previous ischemic stroke AND experienced recurrent stroke while on aspirin OR failed clopidogrel

Quantity Limits:

Date: March 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: PRADAXA Generic Name: dabigatran Criteria: Diagnosis of thromboembolism, non-valvular atrial fibrillation, total hip or knee replacement, stroke/DVT prophylaxis, DVT/PE treatment AND has inadequate response, intolerable side effect, or contraindication to apixaban and rivaroxaban

Quantity Limits: 150mg 2 tabs/day 110mg 2 tabs/day 75mg 2 tabs/day

Date: GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: ARANESP Generic Name: darbepoetin alfa in polysorbate

Criteria: Diagnosis is treatment of anemia due to zidovudine therapy, cancer chemo therapy, or chronic renal failure AND documentation of ALL the following: - Hgb ≤ 10g/dL - Transferrin saturation ≥ 20% OR Ferritin ≥ 80 ng/mL OR demonstration of adequate iron stores - Trial and failure of preferred Epogen AND Procrit

Quantity Limits:

Date: March 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: SAVAYSA Generic Name: edoxaban Criteria: Diagnosis of thromboembolism, non-valvular atrial fibrillation, stroke/DVT prophylaxis, DVT/PE treatment AND has inadequate response, intolerable side effect, or contraindication to apixaban and rivaroxaban

Quantity Limits: 60mg 1 tab/day 30mg 1 tab/day

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: EPOGEN Generic Name: epoetin alfa Criteria: Diagnosis is treatment of anemia due to zidovudine therapy, cancer chemo therapy, chronic renal failure, or refusal for blood transfusions before surgery due to cultural/religious reasons AND documentation of the following: - Hgb ≤ 10g/dL AND - Transferrin saturation ≥ 20% OR Ferritin ≥ 80 ng/mL OR demonstration of adequate iron stores - Trial and failure of Retacrit* *Requires Prior Authorization

Quantity Limits:

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: PROCRIT Generic Name: epoetin alfa Criteria: Diagnosis is treatment of anemia due to zidovudine therapy, cancer chemo therapy, chronic renal failure, or refusal for blood transfusions before surgery due to cultural/religious reasons AND documentation of the following: - Hgb ≤ 10g/dL AND - Transferrin saturation ≥ 20% OR Ferritin ≥ 80 ng/mL OR demonstration of adequate iron stores - Trial and failure of preferred Retacrit* AND Epogen** *Requires Prior Authorization **Requires Prior Authorization and subject to trial and failure of Retacrit

Quantity Limits:

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: RETACRIT Generic Name: epoetin alfa-epbx

Criteria: Diagnosis is treatment of anemia due to zidovudine therapy, cancer chemo therapy, chronic renal failure, or refusal for blood transfusions before surgery due to cultural/religious reasons AND documentation of the following: Hgb ≤ 10g/dL AND Transferrin saturation ≥ 20% OR Ferritin ≥ 80 ng/mL OR Demonstration of adequate iron stores

Quantity Limits:

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: NEUPOGEN Generic Name: filgrastim* 300mcg/ml vial, 480mcg/1.6ml vial, 300mcg/0.5ml NIVESTYM syringe, 480mcg/0.8ml syringe, filgrastim-aafi 300mcg/0.5ml syringe, ZARXIO filgrastim-aafi 480mcg/0.8ml syringe, filgrastim-sndz 300mcg/0.5ml syringe, filgrastim-sndz 480mcg/0.8ml syringe

Criteria: For the treatment of neutropenia associated with chemotherapy, Hepatitis C treatment, Bone Marrow transplantation, Acute hematopoietic radiation injury syndrome, Congenital, Idiopathic or Cyclic neutropenia, Peripheral blood progenitor cell collection and therapy OR For primary prophylaxis when the anticipated incidence of neutropenic fever ≥20% with a given regimen [2015 guidelines from ASCO, NCCN guidelines, EORTC and IDSA] OR For secondary prophylaxis when a patient experienced an episode of neutropenic fever or treatment delays due to neutropenia [ASCO and EORTC guidelines] *NOTE: When filgrastim is requested, Alliance prefers Nivestym and then Zarxio in the order below. Per CCAH Biosimilars policy (403-1142). 1. Nivestym 2. Zarxio 3. Neupogen

Quantity Limits:

Date: March 2017 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: ARIXTRA Generic Name: fondaparinux Criteria: For prophylaxis and treatment of DVT or PE for patients with history of heparin induced thrombocytopenia (HIT) who requires anticoagulation.

Quantity Limits:

Date: March 2017 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: HEPARIN FLUSH Generic Name: heparin sodium Criteria: For patency maintence of indwelling intravenous device: Approve: concentrations of 2 units/mL, 10 units/mL, 50 units/mL, or 100 units/mL Route to RPh: higher concentrations of 1000 units/mL, 5000 units/mL, or 10,000 units/mL

Quantity Limits:

Date: GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: MIRCERA Generic Name: methoxy polyethylene glycol epoetin beta Criteria: Diagnosis is treatment of anemia associated with chronic kidney disease (CKD) in adult patients on dialysis, adult patients not on dialysis, and in pediatric patients 5 to 17 years of age on hemodialysis who are converting from another erythropoiesis-stimulating agent (ESA) after their hemoglobin level was stabilized with an ESA or refusal for blood transfusions before surgery due to cultural/religious reasons AND documentation of the following: - Hgb ≤ 10g/dL AND - Transferrin saturation ≥ 20% OR Ferritin ≥ 80 ng/mL OR demonstration of adequate iron stores - Medical justification for not trying or contuing preferred alternatives Retacrit* AND Epogen** *Requires Prior Authorization **Requires Prior Authorization and subject to trial and failure of Retacrit

Quantity Limits:

Date: GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: NEUMEGA Generic Name: oprelvekin Criteria: Diagnosis is treatment OR prophylaxis of thrombocytopenia following chemotherapy AND documentation of the following: - Diagnosis of non-myeloid malignancy - Platelets ≤ 20,000/µL OR documented past incidence(s) of platelets ≤ 20,000/µL

Quantity Limits: 50 mcg/kg once daily X 21 days max CrCl ≤ 30 mL/min 25mcg/kg once daily X 21 days max

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: NEULASTA Generic Name: pegfilgrastim* 6mg/0.6ml syringe NEULASTA ONPRO pegfilgrastim-jmdb 6mg/0.6ml syringe FULPHILA Criteria: For the prevention of chemotherapy induced neutropenia and acute hematopoietic radiation injury syndrome OR For primary prophylaxis when the anticipated incidence of neutropenic fever ≥20% with a given regimen [2015 guidelines from ASCO, NCCN guidelines, EORTC and IDSA] OR For secondary prophylaxis when a patient experienced an episode of neutropenic fever or treatment delays. *NOTE: When pegfilgrastim is requested for prevention of chemotherapy induced neutropenia (primary and secondary), the Alliance prefers Fulphila. Per CCAH Biosimilars policy (403-1142).

Quantity Limits:

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: MOZOBIL Generic Name: plerixafor 1mg

Criteria: Must be prescribed by a bone marrow transplant specialist, hematologist, or oncologist, patient had been diagnosed with non-Hodgkin’s lymphoma (NHL) or multiple myeloma AND require hematopoietic stem cell mobilization for collection and subsequent autologous transplantation - Must be used in combination with one of the following G-CSF: filgrastim, filgrastim-sndz, or tbo-filgrastim

Quantity Limits: Approve x 4 days maximum therapy

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: MOZOBIL Generic Name: plerixafor 24mg/1.2ml vial

Criteria: Must be prescribed by a bone marrow transplant specialist, hematologist, or oncologist, patient had been diagnosed with non-Hodgkin’s lymphoma (NHL) or multiple myeloma, AND require hematopoietic stem cell mobilization for collection and subsequent autologous transplantation - Must be used in combination with one of the following G-CSF: filgrastim, filgrastim-sndz, or tbo-filgrastim

Quantity Limits: Approve x 4 days maximum therapy

Date: October 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: NPLATE Generic Name: romiplostim 250mcg subcutaneous vial romiplostim 500mcg subcutaneous vial

Criteria: Diagnosis of chronic immune (idiopathic) thrombocytopenic purpura (ITP) who has insufficient response to corticosteroids, immunoglobulin, and splenectomy AND documentation of a treatment-limiting adverse drug reaction to corticosteroids or immunoglobulin AND documentation of why splenectomy not appropriate in patient AND current platelet count less than 50 x 10^9 /L with a clinical risk of bleeding AND prescribed by a hematologist or oncologist

Quantity Limits:

Date: June 2018 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: BRILINTA Generic Name: ticagrelor Criteria: Diagnosis of post-ACS AND has inadequate response, intolerable side effect, or contraindication to clopidogrel OR prasugrel

Quantity Limits: 90mg 2 tabs/day 60mg 2 tabs/day

Date: September 2017 GTC: HEMATOLOGICAL DISORDERS: 1T Brand Name: LYSTEDA Generic Name: tranexamic acid 650mg tablet Criteria: The member has the diagnosis of heavy menstrual bleeding AND the member tried and failed hormonal therapy, or the provider indicates clinical inappropriateness of hormonal therapy

Quantity Limits: Limit to 5 days per menstrual cycle

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: MAKENA Generic Name: 17-hydroxyprogesterone caproate Criteria: Diagnosis of history of singleton spontaneous preterm birth (defined as delivery prior to 37 completed weeks of gestation) and currently pregnant with a singleton pregnancy - initiate between 16 weeks, 0 days and 20 weeks, 6 days of gestation and continuing through 36 weeks, 6 days gestation

Quantity Limits: 1mL per 7-days; dispense in 28-day or 35-day increments. Infertility Services are not a covered benefit.

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: PREMARIN TABLET Generic Name: conjugated estrogens (oral) Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND the member has an inadequate response, intolerable side effect , or contraindication to estradiol tablets and estradiol patches

Quantity Limits:

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: DUAVEE Generic Name: conjugated estrogens/bazedoxifene Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND has inadequate response, intolerable side effect, or contraindication to a formulary combination estrogen/progestin product or an estrogen and a progestin as separate agents OR Diagnosis of postmenopausal osteoporosis and member has tried and failed bisphosphonates

Quantity Limits:

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: PREMPRO Generic Name: conjugated estrogens/medroxyprogesterone PREMPHASE Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND has inadequate response, intolerable side effect, or contraindication to a formulary combination estrogen/progestin product or an estrogen and a progestin as separate agents

Quantity Limits:

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: COVARYX Generic Name: esterified estrogens-methyltestosterone oral tablet COVARYX H.S. Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND has inadequate response, intolerable side effect, or contraindication to a formulary combination estrogen/progestin product or an estrogen and a progestin as separate agents

Quantity Limits:

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: CLIMARA Generic Name: estradiol (topical) MENOSTAR VIVELLE-DOT MINIVELLE ALORA ESTROGEL ELESTRIN DIVIGEL EVAMIST

Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND an inadequate response, intolerable side effect, or contraindication to both estradiol tablets and generic estradiol patches

Quantity Limits:

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: ESTRING Generic Name: estradiol (vaginal) and conjugated estrogens (vaginal) FEMRING PREMARIN CREAM Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND an inadequate response, intolerable side effect, or contraindication to generic estradiol vaginal cream AND estradiol vaginal insert

Quantity Limits:

Date: September 2016 GTC: HORMONAL DEFICIENCY: 1V Brand Name: ESTRACE Generic Name: estradiol tablets Criteria: Diagnosis of transgender-health issue: Approve

Quantity Limits:

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: ESTRADIOL PATCHES, ALORA, CLIMARA-PRO, ESTRADIOL, Generic Name: estradiol topical MINIVELLE, VIVELLE-DOT, GEL/RING/SPRAY, DIVIGEL, ELESTRIN, ESTRASORB, ESTRING, EVAMIST, FEMRING Criteria: Diagnosis of vasomotor symptoms secondary to menopause AND for estradiol patches, an inadequate response, intolerable side effect, or contraindication to estradiol tablets. For all other Brand estrogen products, an inadequate response, intolerable side effect, or contraindication to both estradiol tablets and generic estradiol patches.* *Prior Authorization required

Quantity Limits: 4 patches/ month 1 vaginal ring/3 months

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: CLIMARA-PRO, COMBIPATCH Generic Name: estradiol/levonorgesterel patch, estradiol/norethindrone twice weekly patch Criteria: Diagnosis of vasomotor symptoms associated with menopause AND has inadequate response, intolerable side effect, or contraindication to a formulary combination estrogen/progestin product or an estrogen and a progestin as separate agents (Combipatch* preferred over Climara-Pro*). *Prior authorization required

Quantity Limits:

Date: December 2017 GTC: HORMONAL DEFICIENCY: 1V Brand Name: MAKENA Generic Name: hydroxyprogesterone caproate (in water) Criteria: Diagnosis of advanced adenocarcinoma of the uterine corpus (Stage III or IV) OR Diagnosis of amenorrhea (primary and secondary) and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous ibroids or uterine cancer OR As requested to test for endogenous estrogen production and for the production of secretory endometrium and desquamation

Quantity Limits:

Date: December 2016 GTC: HORMONAL DEFICIENCY: 1V Brand Name: FIRST-PROGESTERONE VGS Generic Name: progesterone (vaginal) Criteria: Has contraindication or inadequate response to micronized progtesterone.

Quantity Limits: Infertility Services are not a covered benefit.

Date: December 2016 GTC: HORMONAL DEFICIENCY: 1V Brand Name: PROMETRIUM Generic Name: progesterone micronized capsule Criteria: Has contraindication or inadequate response to oral medroxyprogesterone.

Quantity Limits: Quantity limit: 200mg: 2/day 100mg: 2/day Infertility Services are not a covered benefit.

Date: GTC: HORMONAL DEFICIENCY: 1V Brand Name: XYOSTED Generic Name: testosterone enanthate auto-injector Criteria: Diagnosis of hypogonadism in male >18yo, approve if: - Lab confirming low testosterone level AND - Patient must have documented symptoms of hypogonadism AND - An inadequate response, intolerable side effect, or contraindication to generic testosterone vial

Quantity Limits: 4 pens/month

Date: September 2016 GTC: HORMONAL DEFICIENCY: 1V Brand Name: ANDRODERM, ANDROGEL, AXIRON, FORTESTA, STRIANT, Generic Name: testosterone TESTIM, VOGELXO, TESTOPEL, TESTOSTERONE-CYPIONATE, TESTOSTERONE- ENANTHATE

Criteria: Diagnosis of hypogonadism in male >18yo, approve if: - Lab confirming low testosterone AND - Patient must have documented symptoms of hypogonadism AND - For non-injectable testosterone requests: an inadequate response, intolerable side effect, or contraindication to injectable testosterone and generic topical testosterone Diagnosis of transgender-health issue AND request is for preferred injectable: Approve

Quantity Limits:

Date: October 2018 GTC: IMMUNIZATION: 1O Brand Name: IMMUNIZATION/VACCINES Generic Name: immunization/vaccines Criteria: For member under 19 years of age: - Routine vaccines to be administered by VFC provider in accordance with the Advisory Committee on Immunization Practices (ACIP). For members who are 19 years of age or older: - Routine vaccines in accordance with ACIP Prior Authorization Required for Travel vaccines and will be covered if recommended by ACIP or if medically necessary based on CDC (Centers for Disease Control and Prevention) recommendations.

Quantity Limits:

Date: October 2018 GTC: IMMUNOLOGICAL AGENTS: 2E Brand Name: SIMULECT Generic Name: basiliximab 10mg vial, 20mg vial

Criteria: For prophylaxis of organ rejection in a patient undergoing kidney transplant AND prescribed by a physician experienced in immunosuppressive therapy and management of kidney transplant patients AND used in combination with other immunosuppressants

Quantity Limits:

Date: October 2018 GTC: IMMUNOLOGICAL AGENTS: 2E Brand Name: NULOJIX Generic Name: belatacept 250ml vial

Criteria: For prophylaxis of organ rejection in a patient undergoing kidney transplant AND patient has no history of liver transplant AND patient has Epstein-Barr virus (EBV) seropositive result AND prescribed by a physician experienced in immunosuppressive therapy and management of kidney transplant patients AND patient must not be able to use tacrolimus or cyclosporine because of a drug allergy or intolerance/toxicity AND used in combination with basiliximab induction, mycophenolate mofetil, and corticosteroids

Quantity Limits:

Date: March 2018 GTC: IMMUNOLOGICAL AGENTS: 2E Brand Name: MYFORTIC Generic Name: mycophenolate sodium dr Criteria: Diagnosis of kidney transplant: - Trial and failure or intolerance to mycophenolate mofetil

Quantity Limits: 180mg 2 tabs/day 360mg 4tabs/day

Date: March 2018 GTC: IMMUNOLOGICAL AGENTS: 2E Brand Name: ASTAGRAF XL Generic Name: tacrolimus er caps Criteria: Diagnosis of kidney transplant - Trial and failure or intolerance to immediate release tacrolimus

Quantity Limits:

Date: March 2018 GTC: IMMUNOLOGICAL AGENTS: 2E Brand Name: ENVARSUS XR Generic Name: tacrolimus er tabs Criteria: Diagnosis of kidney transplant - Trial and failure or intolerance to immediate release tacrolimus

Quantity Limits:

Date: GTC: IMMUNOSUPPRESSION_MODULATION: 2E Brand Name: ALDARA Generic Name: imiquimod 5% cream Criteria: • Diagnosis of Actinic keratosis for members 18 years and older • Diagnosis of Genital and perianal warts for members 12 years and older • Diagnosis of Superficial basal cell carcinoma for member 18 years and older

Quantity Limits:

Date: June 2019 GTC: INFECTIOUS DISEASE - BACTERIAL: 0A Brand Name: CAYSTON Generic Name: aztreonam vial neb Criteria: Prescribed by or in consultation with infectious disease specialist or pulmonologist AND diagnosis of cystic fibrosis with pseudomonas or bronchiectasis with pseudomonas AND has inadequate response, intolerable side effect, or contraindication to fluconazole or other documented medical justification why tobramycin nebulized solution cannot be used

Quantity Limits: 1 vial TID

Date: June 2019 GTC: INFECTIOUS DISEASE - BACTERIAL: 0A Brand Name: TEFLARO Generic Name: ceftaroline Criteria: Diagnosis of acute bacterial skin and skin structure infection or community acquired pneumonia AND paitnet has been started and stablilized on Teflaro while in the hospital or has documented sensitivity to Teflaro AND patient has inadequate response, intolerable side effect, or contraindication to first-line antibiotics

Quantity Limits:

Date: February 2019 GTC: INFECTIOUS DISEASE - BACTERIAL: 0A Brand Name: ZYVOX Generic Name: linezolid Criteria: Approvable for members who have been started and stabilized on Zyvox (oral or IV) or IV vancomycin or daptomycin while in the hospital or ER OR Physician must submit documentation of VRE (vancomycin resistant enterococcus faccium) and MRSA (Methicillin resistant staphylococcus aureus) infection with culture and documented sensitivity to Zyvox OR Physician must submit documentation of an infection with culture and documented sensitivity to Zyvox AND the organism being treated must be resistant or not susceptible to OR member have contraindications, intolerable side effects or drug-drug interactions with the preferred first line antibiotics for that organism (Current IDSA guidelines)

Quantity Limits: 2 per day

Date: June 2019 GTC: INFECTIOUS DISEASE - FUNGAL: 0B Brand Name: CRESEMBA Generic Name: Criteria: Prescribed by or in consultation with infectious disease specialist AND diagnosis of invasive Aspergillosis AND has inadequate response, intolerable side effect, or contraindication to voriconazole or other documented medical justification why voriconazole or itraconazole cannot be used AND has inadequate response, intolerable side effect, or contraindication to or other documented medical justification why amphotericin B liposome (IV – when feasible) cannot be used OR Prescribed by or in consultation with infectious disease specialist AND diagnosis of Mucormycosis

Quantity Limits:

Date: June 2019 GTC: INFECTIOUS DISEASE - FUNGAL: 0B Brand Name: NOXAFIL Generic Name: posaconazole Criteria: Prescribed by or in consultation with infectious disease specialist AND diagnosis of non-invasive Aspergillosis, has inadequate response, intolerable side effect, or contraindication to voriconazole or other documented medical justification why voriconazole cannot be used OR Diagnosis of invasive Aspergillosis OR Diagnosis of Candidiasis or empirical treatment of invasive Candidiasis, has inadequate response, intolerable side effect, or contraindication to fluconazole or other documented medical justification why fluconazole cannot be used

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE – FUNGAL: 0B Brand Name: AMPHOTERICIN B Generic Name: amphotericin b ABELCE amphotericin b lipid complex AMBISOME amphotericin b liosome Criteria: Prescribed by or in consultation with infectious disease specialist AND diagnosis of invasive Aspergillosis, or Cryptococal systemic fungal infection OR diagnosis of Candida prophylaxis or Candidiasis, has inadequate response, intolerable side effect, or contraindication to fluconazole or other documented medical justification why fluconazole cannot be used

Quantity Limits: Amphotericin B 0.5-1mg/kg daily Lipid formulation 3-5mg/kg daily

Date: GTC: INFECTIOUS DISEASE – FUNGAL: 0B Brand Name: NOXAFIL Generic Name: posaconazole Criteria: Prescribed by or in consultation with infectious disease specialist AND diagnosis of invasive Aspergillosis - Has inadequate response, intolerable side effect, or contraindication to voriconazole or other documented medical justification why voriconazole cannot be used Diagnosis of Candidiasis or empirical treatment of invasive Candidiasis - Has inadequate response, intolerable side effect, or contraindication to fluconazole or other documented medical justification why fluconazole cannot be used

Quantity Limits: 100mg tablet: 6/day 200mg/5mL susp: 15mL/day

Date: GTC: INFECTIOUS DISEASE – FUNGAL: 0B Brand Name: VFEND Generic Name: voriconazole

Criteria: Prescribed by or in consultation with infectious disease specialist AND diagnosis of invasive Aspergillosis OR Diagnosis of Candidiasis or empirical treatment of invasive Candidiasis - Has inadequate response, intolerable side effect, or contraindication to fluconazole or other documented medical justification why fluconazole cannot be used

Quantity Limits: 200mg tablet: #2/day 50mg tablet:4/day 200mg/5mL suspension: 5 to 10mL/day

Date: June 2019 GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: SIRTURO Generic Name: bedaquiline Criteria: Documented diagnosis of PULMONARY multidrug resistant tuberculosis (MDR-TB) AND member is at least 18 years of age AND Sirturo should only be used in combination with at least three other drugs to which the patient’s MDR-TB isolate has been shown to be susceptible in vitro. If in vitro testing results are unavailable, treatment may be initiated with Sirturo in combination with at least four other drugs to which the patient’s MDR-TB isolate is likely to be susceptible

Quantity Limits:

Date: June 2019 GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: COLISTIMETHATE Generic Name: colistimethate Criteria: Prescribed by or in consultation with infectious disease specialist or pulmonologist AND diagnosis of cystic fibrosis with pseudomonas or bronchiectasis with pseudomonas

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: TOBI PODHALER Generic Name: inhaled capsule Criteria: Prescribed by or in consultation with infectious disease specialist or pulmonologist AND diagnosis of cystic fibrosis with pseudomonas or bronchiectasis with pseudomonas AND documented medical justification on why generic nebulized solution cannot be used

Quantity Limits: CI Pregnancy

Date: September 2016 GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: KALYDECO Generic Name: ivafactor Criteria: Diagnosis of cystic fibrosis AND prescribed by or in consultation with CF specialist or pulmonologist AND documentation of one of the following genetic mutations: G551D, G1244E, G1349D, G178R, G551S, R117H, S1251N, S1255P, S549N, or S549R AND age greater than 21yo (Not CCS-eligible)

Quantity Limits:

Date: September 2016 GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: PRIFTIN Generic Name: rifapentine

Criteria: Diagnosis of LTBI (latent tuberculosis infection) AND in combination with INH (isoniazid) AND in adults and children 2 years or older OR 12 years or older and who were recently in contact with infectious TB, or who had tuberculin skin test or positive blood test for TB infection conversions All potential cases for LTBI treatment (with rifapentine) will be either requested by or referred to, the TB Controller/Communicable Disease Unit of the appropriate County. That County will then prescribe and monitor DOT for 12 weeks.

Quantity Limits: Initial phase: 32 tabs/28 days x 2 months Continuation phase: 16 tabs/28 days x 4 months LTBI: 24 tabs/28 days x 3 months

Date: June 2019 GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: XIFAXAN Generic Name: rifaximin Criteria: Diagnosis of hepatic encephalopathy AND inadequate response to trial of up to 120 gram (180mL) of lactulose per day or maximally tolerated dose of lactulose OR Has contraindication or other documented medical justification why lactulose cannot be tried is provided. Diagnosis of traveler’s diarrhea AND inadequate response, contraindication, intolerable side effects, or other medical justification why ciprofloxacin and azithromycin cannot be used is provided. Diagnosis of Irritable Bowel Syndrome with diarrhea AND has inadequate response, intolerable side effect or contraindication to loperamide OR diphenoxylate- atropine AND 1 antispasmodic such as dicyclomine, hyosyamine). Diagnosis of Small intestinal bacterial overgrowth (SIBO) AND has inadequate response, intolerable side effect or contraindication to 1 of the following medications: - Amoxicillin-clauvulanate - Metronidazole - Cephalosporin - Trimethoprim-sulfamethoxazole

Quantity Limits: HE: 550mg 2 tablets/day Traveler’s diarrhea: 200mg 3 tablets/day IBS-D: 550mg 3 tablets/day (for 14 days) SIBO: 550mg 3 tablets/day (14 days)

Date: GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: MYCOBUTIN Generic Name: tobramycin ampule-nebulized

Criteria: Diagnosis of Mycobacterium avium complex (MAC), prevention of disseminated Mycobacterium avium complex (MAC), or diagnosis of tuberculosis AND contraindication, intolerable side effects, or other medical justification why rifampin cannot be used is provided OR Co-diagnosis of HIV

Quantity Limits: 2/day

Date: GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: TOBI Generic Name: tobramycin ampule-nebulized BETHKIS KITABIS PAK (GENERIC ONLY)

Criteria: Prescribed by or in consultation with infectious disease specialist or pulmonologist AND diagnosis of cystic fibrosis with pseudomonas or bronchiectasis with pseudomonas

Quantity Limits: CI Pregnancy 1 vial BID

Date: GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: TOBI Generic Name: tobramycin ampule-nebulized, inhaled capsule BETHKIS TOBI PODHALER Criteria: Diagnosis of cystic fibrosis with pseudomonas or bronchiectasis with pseudomonas

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: VANCOMYCIN (IV) Generic Name: vancomycin (iv) Criteria: Treatment of infection against aerobic gram-positive bacteria and is not being used for Clostridium difficile infections

Quantity Limits: Variable per renal function

Date: June 2018 GTC: INFECTIOUS DISEASE - MISCELLANEOUS: 0E Brand Name: VANCOCIN Generic Name: vancomycin (oral capsules) Criteria: Diagnosis of Clostridium difficile infection or Clostridium difficile –associated diarrhea AND inadequate response, intolerable side effect, contraindication, or other medical justification why Firvanq cannot be used

Quantity Limits:

Date: June 2019 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: SOLOSEC Generic Name: Criteria: Diagnosis of Bacterial Vaginosis AND has inadequate response, intolerable side effect or contraindication to 1 of the following medications: metronidazole or clindamycin

Quantity Limits: 2g x 1.

Date: June 2018 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: ALBENZA Generic Name: albendazole

Criteria: Diagnosis of pinworm or hookworm, AND has contraindication or inadequate response to pyrantel pamoate documented in claims (2 doses taken 2 weeks apart is recommended by the CDC), AND for pinworm: has contraindication or inadequate response to Emverm* OR Diagnosis of roundworm or whipworm OR Diagnosis of neurocysticercosis OR hydatid

Quantity Limits: Roundworm or Hookworm: 2 tablets per fill Pinworm: 4 tablets per fill Whipworm: 2 tablets/day x 3 days (6 tablets total)

Date: June 2017 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: MALARONE Generic Name: atovaquone/proguanil Criteria: Approvable for the treatment and prevention of chloroquine-resistant malaria OR Approvable for member with non-chloroquine-resistant malaria if member has inadequate response, intolerable side effect, or contradindication to chloroquine, and hydroxychloroquine, or other documented medical justification why these cannot be used.

Quantity Limits: 1/day

Date: June 2018 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: EMVERM Generic Name: mebendazole Criteria: Diagnosis of pinworm, hookworm, roundworm, or whipworm AND - For pinworm: has contraindication or inadequate response to pyrantel pamoate documented in claims (2 doses taken 2 weeks apart is recommended by the CDC) - For hookworm: Has contraindication or inadequate response to pyrantel pamoate documented in claims (2 doses taken 2 weeks apart is recommended by the CDC), AND has contraindication or inadequate response to Albenza* documented in claims - For roundworm or whipworm: Has contraindication or inadequate response to Albenza* documented in claims

Quantity Limits: Max: 3 days/fill

Date: June 2019 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: ALINIA Generic Name: nitazoxan Criteria: Diagnosis of Giardiasis AND has inadequate response, intolerable side effect or contraindication to tinidazole

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: ALINIA Generic Name: nitazoxanide Criteria: Treatment of diarrhea caused by Cryptosporidium parvum OR Treatment of diarrhea caused by Giarda lamblia AND has inadequate response, intolerable side effect, or contraindication to metronidazole or other documented medical justification why metronidazole cannot be used

Quantity Limits: 500mg tablet: 2/day x 3 days 100mg/5mL:20mL/day x 3 days

Date: June 2019 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: PAROMOMYCIN Generic Name: paromomycin Criteria: Diagnosis of Amebiasis AND has inadequate response, intolerable side effect or contraindication to 1 of the following medications: metronidazole or doxycycline

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: PENTAM Generic Name: pentamidine NEBUPENT Criteria: Diagnosis of pneumocystis carinii pneumonia (PCP) AND for prophylaxis, patient must be HIV-infected, with history of PCP or with a CD4 (T4) lymphocyte count ≤ 200 cells/mm3; AND nebulizer system must comply with the specifications in the prescribing information AND T/F of formulary alternatives trimethoprim- sulfamethoxazole (TMP-SMZ) and dapsone* or medical justification why they cannot be used *Prior Authorizaiton required

Quantity Limits:

Date: June 2017 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: DARAPRIM Generic Name: pyrimethamine Criteria: Approvable for the treatment of toxoplasmic encephalitis OR Approvable for the treatment of congenital toxoplasmosis OR Approvable for secondary prophylaxis of toxoplasmic encephalitis OR Approvable for primary prophylaxis of toxoplasmic encephalitis in members who are intolerant to trimethoprim- sulfamethoxazole (TMP-SMX) after a desensitization protocol or have life threatening reaction to TMP-SMX OR Approvable for treatment or prophylaxis of malaria if prescriber submits medical justification why all other antimalarial agents are not appropriate for the member.

Quantity Limits:

Date: June 2017 GTC: INFECTIOUS DISEASE – PARASITIC: 0D Brand Name: QUALAQUIN Generic Name: quinine sulfate

Criteria: Approvable for the treatment and prevention of chloroquine-resistant malaria OR Approvable for member with non-chloroquine-resistant malaria if member has inadequate response, intolerable side effect, or contraindication to chloroquine, and hydroxychloroquine, or other documented medical justification why these cannot be used

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE - VIRAL: 0C Brand Name: HEPSERA Generic Name: adefovir, entecavir

Criteria: Prescribed by or in consultation with infectious disease specialist or GI specialist AND diagnosis of chronic hepatitis B

Quantity Limits: Adefovir: 1 tablet/day

Date: GTC: INFECTIOUS DISEASE - VIRAL: 0C Brand Name: FAMVIR Generic Name: famciclovir Criteria: Diagnosis of Herpes Labialis, Genital Herpes, and Herpes Zoster AND has inadequate response, intolerable side effect, or contraindication to acyclovir

Quantity Limits:

Date: August 2019 GTC: INFECTIOUS DISEASE - VIRAL: 0C Brand Name: HCV AGENTS: Generic Name: hepatitis c virus treatment agents: MAVYRET glecaprevir/pibrentasvir ZEPATIER elbasvir/grazoprevir EPCLUSA sofosbuvir/velpatasvir HARVONI ledipasvir/sofosbuvir SOVALDI sofosbuvir OLYSIO simeprevir VICTRELIS boceprevir VIEKIRA PAK ombitasvir/paritaprevir/ritonavir/dasabuvir PEGASYS peginterferon alfa-2a ribavirin RIBASPHERE Criteria: Refer to DHCS Hepatitis C Utilization and Treatment Policy. Formulary-Preferred Hepatitis C treatment agents for treatment naïve patients (PA-Prior Authorization Required): Generic Epclusa is preferred for all genotypes.

Quantity Limits: Refer to AASLD guidelines for regimen length and dosing

Date: GTC: INFECTIOUS DISEASE - VIRAL: 0C Brand Name: SYNAGIS Generic Name: palivizumab

Criteria: Refer to current American Academy of Pediatrics (AAP) recommendations

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE - VIRAL: 0C Brand Name: VALCYTE Generic Name: valganciclovir (oral)

Criteria: Diagnosis of cytomegalovirus (CMV) prevention or treatment

Quantity Limits: For CMV prevention: 2/day For CMV treatment: 4/day

Date: June 2017 GTC: INFECTIOUS DISEASE- BACTERIAL: 0A Brand Name: SUPRAX Generic Name: cefixime oral capsules, suspension, chewable tablets Criteria: The organism being treated must be resistant or not susceptible to OR member have contraindications, intolerable side effects or drug-drug interations with formulary 3rd generation cephalosporins (cefdinir, cefpodoxime). For chewable tablets or suspension requests, trail and failure of formulary 3rd generation cephalosporins suspensions (cefdinir, cefpodoxime).

Quantity Limits:

Date: June 2017 GTC: INFECTIOUS DISEASE- BACTERIAL: 0A Brand Name: CEFTIN SUSPENSION Generic Name: cefuroxime axetil suspension (reconstituted)

Criteria: The organism being treated must be resistant or not susceptible to OR member have contraindications, intolerable side effects or drug-drug interactions with formulary 2nd generation cephalosporins (cefprozil)

Quantity Limits:

Date: GTC: INFECTIOUS DISEASE- BACTERIAL: 0A Brand Name: DIFICID Generic Name: fidaxomicin Criteria: Diagnosis of Clostridium difficile infection or Clostridium difficile –associated diarrhea AND Initial episode or first recurrence of mild to moderate Clostridium difficile infection or Clostridium difficile –associated diarrhea AND Has inadequate response, contraindication, intolerable side effect, or other documented medical justification why oral metronidazole and oral vancomycin cannot be used is provided OR Second recurrence or severe Clostridium difficile infection or Clostridium difficile –associated diarrhea AND Has inadequate response, contraindication, intolerable side effect to, or other documented medical justification why oral vancomycin cannot be used is provided

Quantity Limits: #2/day

Date: June 2017 GTC: INFECTIOUS DISEASE- BACTERIAL: 0A Brand Name: ZYVOX Generic Name: linezolid Criteria: Approvable for members who have been started and stabilized on Zyvox (oral or IV) or IV vancomycin while in the hospital or ER. OR Physician must submit documentation of VRE (vancomycin resistant enterococcus faccium) and MRSA (Methicillin resistant staphylococcus aureus) infection with culture and documented sensitivity to Zyvox OR Physician must submit documentation of an infection with culture and documented sensitivity to Zyvox AND the organism being treated must be resistant or not susceptible to OR member have contraindications, intolerable side effects or drug-drug interactions with the preferred first line antibiotics for that organism (Current IDSA guidelines)

Quantity Limits: 2/day

Date: June 2017 GTC: INFECTIOUS DISEASE- BACTERIAL: 0A Brand Name: SIVEXTRO Generic Name: tedizolid phosphate Criteria: Approvable for member who have been started and stabilized on Sivextro (oral or IV) while in the hospital or ER. OR Physician must submit documentation of acute skin and skin structure MRSA (Methicillin resistant staphylococcus aureus) infection with culture and documented sensitivity to Sivextro OR Physician must submit documentation of an infection with culture and documented sensitivity to Sivextro AND the organism being treated must be resistant or not susceptible to OR member have contraindications, intolerable side effects, or drug-drug interactions with the preferred first line antibiotics for that organism (Current IDSA guidelines).

Quantity Limits: 1/day

Date: GTC: INFECTIOUS DISEASE- BACTERIAL: 0A Brand Name: KETEK Generic Name: telithromycin Criteria: Diagnosis of community-acquired pneumonia or blood or sputum culture positive for Streptococcus pneumoniae (including multidrug-resistant isolates), Haemophilus influenzae , Moraxella catarrhalis , Chlamydophila pneumoniae , or Mycoplasma pneumonia and documented sensitivity against telithromycin AND Documented resistance to following antibiotics in culture and sensitivity report or inadequate response to trial of macrolide (azithromycin, clarithromycin, or erythromycin), doxycycline, respiratory floroquinolones (moxifloxacin, gemifloxacin, or levofloxacin), and beta-lactam (amoxicillin, amoxicillin-clavulanate, cefuroxime) plus macrolide with current infection OR Has contraindication, intolerable side effects, or other documented medical justification why susceptible antibiotic options cannot be tried

Quantity Limits: 300mg tablet, #2/day 400mg tablet, max #2/day

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ORENCIA Generic Name: abatacept Criteria: Diagnosis of rheumatoid arthritis AND : • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has severe active rheumatoid arthritis Diagnosis of juvenile idiopathic arthritis AND • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has polyarthropathy Diagnosis of psoriatic arthritis AND • Has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR • Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis)

Quantity Limits: RA/JIA/PsA: IV: Based on weight(500mg-1000mg) Wk 0: 500mg Wk 2: 500mg Wk 4: 500mg and every 4 weeks thereafter SC: 125mg/wk

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: HUMIRA Generic Name: adalimumab AMJEVITA CYLTEZO

Criteria: Diagnosis of rheumatoid arthritis AND : • Has been evaluated by a rheumatologist AND • Diagnosis of rheumatoid arthritis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has severe active rheumatoid arthritis. Diagnosis of psoriatic arthritis AND • Has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR • Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis)

Diagnosis of ankylosing spondylitis AND • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary NSAIDs or steroids

Diagnosis of juvenile idiopathic arthritis AND • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has polyarthropathy

Diagnosis of moderate to severe plaque psoriasis AND: • Psoriasis affects > 10% BSA or causes significant functional disability (Palms, soles, genitalia, severe scalp psoriasis) AND • Has inadequate response, intolerable side effect, or contraindication to phototherapy (if available) AND • Has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD.

Diagnosis of moderate to severe Crohn’s disease AND • Has been evaluated by a gastroenterologist AND • Has inadequate response, intolerable side effect, or contraindication to azathioprine, mercaptopurine or methotrexate. OR • Has severe or refractory disease OR • Perianal fistulizing disease

Quantity Limits: RA/PsA/AS/JIA: 40mg every 2 weeks +MTX Can be dosed weekly for patients not taking MTX

Psoriasis Induction Dose: Wk 0: 80mg Wk 1: 40mg Maintenance Dose: 40mg every 2 weeks

Crohn’s/UC Induction Dose: Wk 0: 160mg Wk 2: 80mg Wk 4: 40mg Crohn’s/UC maintenance dose: 40mg every 2 weeks (some may require weekly therapy)

HS Induction dose: Wk 0: 160mg WK 2: 80mg Wk 4: 40

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: OTEZLA Generic Name: apremilast Criteria: Diagnosis of moderate to severe plaque psoriasis AND: • Psoriasis affects > 10% BSA or causes significant functional disability (Palms, soles, genitalia, severe scalp psoriasis) AND • Has inadequate response, intolerable side effect, or contraindication to phototherapy (if available) AND • Has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD.

Quantity Limits: 10mg used for titration x 1 fill 30mg #2/day

Date: GTC: INFLAMMATORY DISEASE: 1F Brand Name: RIDAURA Generic Name: auranofin Criteria: Diagnosis of rheumatoid arthritis AND • Has been evaluated by a rheumatologist; AND • Has inadequate response, intolerable side effect, or contraindication to methotrexate, hydroxychloroquine, leflunomide, and sulfasalazine or medical justification why they cannot be used

Quantity Limits: 2 capsules/day

Date: October 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: OLUMIANT Generic Name: baricitnib 2mg tablet

Criteria: Diagnosis of moderate to severe rheumatoid arthritis (RA) AND • Prescribed by or in consultation with a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine )

Quantity Limits: 1/day

Date: October 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: BENLYSTA Generic Name: belimumab 120mg vial, 400mg vial, 200mg/ml prefilled syringe, 200mg/ml autoinjector syringe Criteria: Diagnosis of active systemic lupus erythematosus • Currently on and has had an inadequate response or intolerance to standard therapy for SLE (e.g., corticosteroids, azathioprine, leflunomide, methotrexate, mycophenolate, hydroxychloroquine) • Member does NOT have severe active lupus nephritis or severe active central nervous system (CNS) lupus

Quantity Limits:

Date: December 2016 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ENTOCORT Generic Name: budesonide ec 3mg capsule Criteria: Diagnosis of Crohn’s Disease AND • Has inadequate response, intolerable side effect or contraindication to oral prednisone AND • Has inadequate response, intolerable side effect, or contraindication to sulfasalazine

Quantity Limits: 3 capsules/day

Date: December 2016 GTC: INFLAMMATORY DISEASE: 1F Brand Name: UCERIS Generic Name: budesonide extended-release 9mg tablet Criteria: Diagnosis of ulcerative colitis AND • Has inadequate response, intolerable side effect or contraindication to oral prednisone AND • Has inadequate response, intolerable side effect, or contraindication to balsalazide or generic oral mesalamine DR

Quantity Limits: 1 tablet/day

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: BERINERT Generic Name: c1 esterase inhibitor, human Criteria: Member must meet ALL of the following criteria: - The medication is being used for treatment of ACUTE hereditary angioedema (HAE) attacks - Must be prescribed by, or in consultation with, a specialist (i.e. allergist, immunologist, hematologist, pulmonologist, etc) - Patient must be at least 5 years old AND Member must have at least ONE of the following clinical presentations (confirmed by testing): - HAE I (C1-Inhibitor deficiency) - HAE II (C1-Inhibitor dysfunction) - HAE with normal C1INH (also known as HAE III)

Quantity Limits:

Date: GTC: INFLAMMATORY DISEASE: 1F Brand Name: CELEBREX Generic Name: celecoxib Criteria: Diagnosis is pain, or osteoarthritis AND • T/F of at least 2 NSAIDs including meloxicam or medical justification why they cannot be used; OR • Co-morbidity with ulcer disease or history of Gastrointestinal (GI) bleeding; OR • Over 65 years old; OR • Concomitant chronic corticosteroid therapy; OR concurrent use of anticoagulants; OR • Diagnosis of rheumatoid arthritis

Quantity Limits: 100mg/200mg: 2 capsules/day 400mg: 1 capsule/day

Date: May 2019 GTC: INFLAMMATORY DISEASE: 1F Brand Name: CIMZIA Generic Name: certolizumab, pegol Criteria: Diagnosis of rheumatoid arthritis AND • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine) OR • Has severe active rheumatoid arthritis.

Diagnosis of psoriatic arthritis AND • Has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR • Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis) Diagnosis of ankylosing spondylitis AND • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary NSAIDs or steroids Diagnosis of moderate to severe Crohn’s disease AND • Has been evaluated by a gastroenterologist AND • Has inadequate response, intolerable side effect, or contraindication to azathioprine, mercaptopurine or methotrexate. OR • Has severe or refractory disease OR • Perianal fistulizing disease

Quantity Limits: RA/PsA/AS loading dose: Wk 0: 400mg Wk 2: 400mg Wk 4: 400mg Maintenance dose: 200mg every 2 wks or 400mg every 4 weeks Crohn’s Induction Dose: Wk 0: 400mg Wk 2: 400mg Wk 4: 400mg Maintenance dose: 400mg every 4 weeks

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ZIPSOR Generic Name: diclofenac potassium liquid-filled capsule Criteria: Diagnosis of pain or arthritis AND • Has inadequate response, intolerable side effect, or contraindication to 3 formulary oral NSAIDs (such as: ibuprofen, naproxen, meloxicam, diclofenac, sulindac, nabumetone, or etodolac) AND • Trial and failure of Zorvolex* *Prior authorization required

Quantity Limits: Max: 4/day

Date: December 2016 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ZORVOLEX Generic Name: diclofenac submicronized capsule Criteria: Diagnosis of pain or arthritis AND • Has inadequate response, intolerable side effect, or contraindication to 3 formulary oral NSAIDs, such as: ibuprofen, naproxen, meloxicam, diclofenac, sulindac, nabumetone, or etodolac

Quantity Limits: Max: 3/day

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ARTHROTEC-50, ARTHROTEC-75 Generic Name: diclofenac-misoprostol tablet Criteria: Trial and failure of diclofenac in combination with either a proton pump inhibitor (PPI) or an H2 blocker OR Member is age 65 or older

Quantity Limits:

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ENBREL Generic Name: etanercept ERELZI Criteria: Diagnosis of rheumatoid arthritis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has severe active rheumatoid arthritis.

Diagnosis of psoriatic arthritis AND: • Has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR • Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis) Diagnosis of ankylosing spondylitis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary NSAIDs for at least 2 months Diagnosis of juvenile idiopathic arthritis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has polyarthropathy

Quantity Limits: RA/PsA/AS/ JIA: 50mg/week Psoriasis Induction: 50mg 2x/week for 3 months Maintenance: 50mg/week

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: SIMPONI & SIMPONI ARIA Generic Name: golimumab Criteria: Diagnosis of rheumatoid arthritis AND: Has been evaluated by a rheumatologist AND Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR has severe active rheumatoid arthritis.

Diagnosis of psoriatic arthritis AND: Has been evaluated by a rheumatologist/dermatologist AND Has inadequate response, intolerable side effect, or contraindication one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis)

Diagnosis of ankylosing spondylitis AND: Has been evaluated by a rheumatologist AND Has inadequate response, intolerable side effect, or contraindication to 2 formulary NSAIDs or steroids

Diagnosis of moderate to severe ulcerative colitis AND Has been evaluated by a gastroenterologist AND Has inadequate response, intolerable side effect, or contraindication to systemic aminosalicylates (sulfasalazine, mesalamine), azathioprine or mercaptopurine OR has severe or refractory disease

Quantity Limits: RA/PsA/AS: 50mg SQ once monthly RA/PsA/AS: Simponi Aria: 2mg/kg IV at weeks 0 and 4, then every 8 weekls. UC Induction Dose: Wk 0: 200mg Wk 2: 100mg UC Maintenance Dose: 100mg every 4 weeks

Date: October 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: DUROLANE, EUFLEXXA, GEL-ONE, GELSYN-3, GENVISC 805, Generic Name: hyaluronic acid intra-articular injection (viscosupplements) SUPARTZ, SUPARTZ FX, HYALGAN, HYMOVISC, MONOVISC, ORTHOVISC, SYNVISC, SYNVISC-ONE, TRIVISC, VISCO-3 Criteria: Treatment of osteoarthritis of the knee in which each of the following are met: Member must have been evaluated by an appropriate specialist • Documentation of trial and failure, intolerance, or contraindication to at least 2 or more of the following: i. Prescription strength NSAIDs at adequate doses for 3 months of consistent usage ii. Acetaminophen iii. Tramadol • If intolerant to oral NSAIDs, must have 3 month trial of topical NSAID • Trial and failure of physical therapy • Documentation of 3 intra-articular steroid injections within the last year or documentation of complete lack of response to less than 3 injections (effects lasting less than 8 weeks) • Member does not have any other diagnosis contributing to their knee pain (i.e. meniscus tear)

Quantity Limits: If approved, no more than 2 courses of therapy per year.

Date: October 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: REMICADE, INFLECTRA, RENFLEXIS Generic Name: infliximab* 100mg intravenous vial, infliximab-dyyb 100mg intravenous vial, infliximab-abda 100mg intravenous vial

Criteria: Diagnosis of rheumatoid arthritis AND Has been evaluated by a rheumatologist AND Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate, hydroxychloroquine, leflunomide, or sulfasalazine ) • OR has severe active rheumatoid arthritis.

Diagnosis of psoriatic arthritis AND Has been evaluated by a rheumatologist/dermatologist AND Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis).

Diagnosis of ankylosing spondylitis AND Has been evaluated by a rheumatologist AND Has inadequate response, intolerable side effect, or contraindication to 2 formulary NSAIDs or steroids

Diagnosis of moderate to severe plaque psoriasis AND Psoriasis affects > 10% BSA or causes significant functional disability (Palms, soles, genitalia, severe scalp psoriasis) AND Has inadequate response, intolerable side effect, or contraindication to phototherapy (if available) AND Has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD.

Diagnosis of moderate to severe Crohn’s disease AND Has been evaluated by a gastroenterologist AND Has inadequate response, intolerable side effect, or contraindication to azathioprine, mercaptopurine or methotrexate OR has severe or refractory disease OR Perianal fistulizing disease

*NOTE: When infliximab is requested for all indications except pediatric ulcerative colitis (Remicade only), Alliance prefers Renflexis* and Inflectra* in the order mentioned below. Per CCAH Biosimilars policy (403-1142). 1. Renflexis 2. Inflectra 3. Remicade

Quantity Limits: See package insert.

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: KETOROLAC Generic Name: ketorolac tablet Criteria: Member meets all of the following: - This medication is being used for moderate-severe acute pain - It is not being used for longer than 5 days - It is being used as a continuation of parenteral (IV or IM) therapy

Quantity Limits:

Date: October 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: TAKHZYRO Generic Name: lanadelumab-flyo 300mg/2ml vial

Criteria: INITIAL: • Diagnosis of hereditary angioedema (HAE) confirmed by complement testing AND • Medication is being used for prophylaxis to prevent HAE attacks • The patient is 12 years of age or older. • Prescribed by an Allergist/Immunologist or Hematologist RENEWAL: Physician attestation of improvement (i.e., reductions in attack frequency or attack severity) compared to baseline in HAE attacks with routine prophylaxis

Quantity Limits: 4mL per 28-days

Date: GTC: INFLAMMATORY DISEASE: 1F Brand Name: MECLOFENAMATE CAPSULE Generic Name: meclofenamate capsule Criteria: T/F of at least 2 NSAIDs including meloxicam, or medical justification for why they cannot be used

Quantity Limits:

Date: September 2017 GTC: INFLAMMATORY DISEASE: 1F Brand Name: RASUVO Generic Name: methotrexate auto-injector 7.5mg/0.15, 10mg/0.2, 12.5mg/0.25, 15mg/0.3, 17.5mg/0.35, 20mg/0.4, 22.5mg/0.45, 25mg/0.5, 27.5mg/0.55, 30mg/0.6ml

Criteria: Diagnosis of psoriatic arthritis AND: • Patient has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication to generic injectable methotrexate AND oral methotrexate

Quantity Limits:

Date: September 2017 GTC: INFLAMMATORY DISEASE: 1F Brand Name: OTREXUP Generic Name: methotrexate auto-injector 7.5mg/0.4, 10mg/0.4, 15mg/0.4, 17.5mg/0.4, 20mg/0.4, 22.5mg/0.4, 25mg/0.4ml auto-injector

Quantity Limits:

Date: GTC: INFLAMMATORY DISEASE: 1F Brand Name: TIVORBEX Generic Name: micronized indomethacin capsule Criteria: Trial and failure of at least 3 NSAIDs including meloxicam and indomethacin, or medical justification why they cannot be used

Quantity Limits:

Date: GTC: INFLAMMATORY DISEASE: 1F Brand Name: VIVLODEX Generic Name: micronized meloxicam capsule Criteria: T/F of at least 3 NSAIDs including meloxicam, or medical justification for why they cannot be used

Quantity Limits:

Date: GTC: INFLAMMATORY DISEASE: 1F Brand Name: RAYOS Generic Name: prednisone delayed-release tablet Criteria: Member meets ALL of the following: - Trial and failure of prednisone tab - Trial and failure of 2 additional corticosteroid agents (such as prednisolone, methylprednisolone, or dexamethasone), or rationale why they would be inappropriate - Documentation provided for why the delayed-release agent is clinically necessary (as opposed to simply more convenient)

Quantity Limits:

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: KEVZARA Generic Name: sarilumab Criteria: Diagnosis of rheumatoid arthritis AND : • Has been evaluated by a rheumatologist AND • Diagnosis of rheumatoid arthritis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has severe active rheumatoid arthritis

Quantity Limits: Rheumatoid Arthritis: 200mg every 2 weeks

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: ACTEMRA Generic Name: tocilizumab Criteria: Diagnosis of rheumatoid arthritis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has severe active rheumatoid arthritis Diagnosis of juvenile idiopathic arthritis AND • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has polyarthropathy

Quantity Limits: IV: 4-8mg/kg every 4 weeks SC: 162mg If < 100kg, 162mg every other week If >100kg, 162mg every week

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: XELJANZ, XELJANZ XR Generic Name: tofacitinib Criteria: Diagnosis of rheumatoid arthritis AND: • Has been evaluated by a rheumatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) OR • Has severe active rheumatoid arthritis. Diagnosis of psoriatic arthritis AND: • Has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast OR • Severe active psoriatic arthritis (axial disease – sacroiliitis or spondylitis)

Quantity Limits: Xeljanz: 2 tablets/day Xeljanz XR: 1 tablet/day

Date: March 2018 GTC: INFLAMMATORY DISEASE: 1F Brand Name: STELARA Generic Name: ustekinumab Criteria: Diagnosis of psoriatic arthritis AND: • Has been evaluated by a rheumatologist/dermatologist AND • Has inadequate response, intolerable side effect, or contraindication to one DMARD (such as methotrexate , hydroxychloroquine, leflunomide, or sulfasalazine ) or apremilast AND • Has inadequate response, intolerable side effect, or contraindication to a tumor necrosis factor-alpha inhibitor (e.g., adalimumab, etanercept, infliximab) Diagnosis of moderate to severe plaque psoriasis AND • Psoriasis affects > 10% BSA or causes significant functional disability disability (Palms, soles, genitalia, severe scalp psoriasis) AND • Has inadequate response, intolerable side effect, or contraindication to phototherapy (if available) AND • Has inadequate response, intolerable side effect, or contraindication to acitretin or another DMARD. AND • Has inadequate response, intolerable side effects to a tumor necrosis factor-alpha inhibitor (e.g., adalimumab, etanercept, infliximab) Diagnosis of moderate to severe Crohn’s disease AND • Has been evaluated by a gastroenterologist AND • Has inadequate response, intolerable side effect, or contraindication to azathioprine, mercaptopurine or methotrexate. • Has inadequate response, intolerable side effect, or contraindication to a tumor necrosis factor-alpha inhibitor (e.g., adalimumab, etanercept, infliximab) OR • Has inadequate response, intolerable side effect or contraindication to Entyvio.

Quantity Limits: PsA and Psoriasis If <100kg: Wk 0: 45mg Wk 4: 45mg and 45mg every 12 weeks thereafter If >100kg: Wk 0:90mg Wk 4:90mg and 90mg every 12 weeks thereafter Crohn Disease: Induction: 55kg or less: Wk 0: 260mg 55kg to 85 kg Wk 0: 390mg More than 85kg Wk 0: 520mg Maintenance: 90mg every 8 weeks.

Date: GTC: LOCAL ANESTHESIA: 2C Brand Name: GLYDO Generic Name: lidocaine 2% gel syringes & applicators

Criteria: For urethral anesthesia only

Quantity Limits: 1 Rx/ procedure 15 ml (male) or 3—5 ml (female) of 2% lidocaine jelly or solution into the urethra

Date: October 2018 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: GIAZO Generic Name: balsalazide disodium 1.1g tablet Criteria: Diagnosis of ulcerative colitis AND • Has inadequate response, intolerable side effect, or contraindication to sulfasalazine AND • Has inadequate response, intolerable side effect, or contraindication to balsalazide or generic oral mesalamine DR

Quantity Limits: 6 tabs/day

Date: GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: UCERIS RECTAL FOAM Generic Name: budesonide 2mg rectal foam Criteria: Diagnosis of ulcerative colitis AND Has inadequate response, intolerable side effect or contraindication to hydrocortisone enema and mesalamine enema

Quantity Limits: 2 canisters/month

Date: October 2018 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: VIBERZI Generic Name: eluxadoline

Criteria: Diagnosis of Irritable Bowel Syndrome with diarrhea AND • Has inadequate response, intolerable side effect or contraindication to loperamide OR diphenoxylate-atropine AND 2 of the following medications: • Bile acid sequestrant (cholestyramine, colestipol) • Antispasmodic (dicyclomine, hyoscyamine) • Tricyclic antidepressant (amitriptyline, nortriptyline)

Quantity Limits: 2 tablets/day

Date: GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: CORTIFOAM Generic Name: hydrocortisone Criteria: Diagnosis of ulcerative colitis AND has inadequate response, intolerable side effect or contraindication to hydrocortisone enema

Quantity Limits: 15g/mth

Date: December 2016 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: CANASA Generic Name: mesalamine 1000mg rectal suppository Criteria: Diagnosis of ulcerative colitis AND has inadequate response, intolerable side effect, or contraindication to mesalamine enema and hydrocortisone enema

Quantity Limits: 1 suppository/day

Date: October 2018 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: PENTASA Generic Name: mesalamine 250mg, 500mg er oral capsule

Criteria: Diagnosis of ulcerative colitis AND • Has inadequate response, intolerable side effect, or contraindication to sulfasalazine AND • Has inadequate response, intolerable side effect, or contraindication to balsalazide or generic oral mesalamine DR

Quantity Limits: 250mg: 4 capsules/day 500mg: 8 capsules/day

Date: October 2018 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: DELZICOL Generic Name: mesalamine delayed-release 400mg capsule

Quantity Limits: 6/day

Date: October 2018 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: RECTIV Generic Name: nitroglycerin 0.4% ointment Criteria: Diagnosis of anal fissures AND has inadequate response to fiber AND stool softeners

Quantity Limits: 30gm/month

Date: December 2016 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: DIPENTUM Generic Name: olsalazine sodium Criteria: Diagnosis of ulcerative colitis AND has inadequate response, intolerable side effect, or contraindication to sulfasalazine AND has inadequate response, intolerable side effect, or contraindication to balsalazide or generic oral mesalamine DR

Quantity Limits: 4 tabs/day

Date: December 2016 GTC: LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY: 1M Brand Name: ENTYVIO Generic Name: vedolizumab Criteria: Diagnosis of moderate to severe Crohn’s disease AND • Has been evaluated by a gastroenterologist AND • Has inadequate response, intolerable side effect, or contraindication to azathioprine or mercaptopurine AND • Has inadequate response, intolerable side effects to Remicade Diagnosis of moderate to severe ulcerative colitis AND • Has been evaluated by a gastroenterologist AND • Has inadequate response, intolerable side effect, or contraindication to systemic aminosalicylate AND • Has inadequate response, intolerable side effect, or contraindication to azathioprine or mercaptopurine AND • Has inadequate response, intolerable side effect, or contraindication to Remicade

Quantity Limits: Crohn’s/UC Induction dose: Wk 0: 300mg Wk 2: 300mg Wk 6: 300mg Maintenance dose: 300mg every 8 weeks

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: LEMTRADA Generic Name: alemtuzumab

Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Has inadequate response, intolerable side effect, or contraindication to 2 of the following: Copaxone, Avonex, Rebif, Betaseron, Extavia, Plegridy, Aubagio, Tecfidera, Gilenya or Tysabri or medical justification why they can’t be used AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Plegridy, Aubagio Tecfidera, Gilenya or Tysabri)

Quantity Limits: 1st : 12mg/day x 5 days 2nd: 12mg/day x 3 days - 2nd dose given 12 mths after 1st dose

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: AMPYRA Generic Name: dalfampridine Criteria: To improve walking speed in a patient with MS AND • Has been evaluated by a neurologist AND • Patient is ambulatory AND patient has completed a baseline walking 25 ft walk test between 8-45 seconds. For continuation of therapy: • The patient has demonstrated an improvement from baseline in the timed 25 ft. walk test.

Quantity Limits: 10mg PO BID

Date: September 2017 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: NUEDEXTA Generic Name: dextromethorphan/quinidine 20/10mg capsule Criteria: Patient must be 18 years or older AND • Diagnosis of PBA (pseudobulbar affect) AND • Must be prescribed by a neurologist or psychiatrist

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: TECFIDERA Generic Name: dimethyl fumarate Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Trial and failure of Glatopa* or glatiramer acetate* AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Aubagio, Gilenya or Tysabri) *Prior Authorization required

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: GILENYA Generic Name: fingolimod Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Trial and failure of Glatopa* or glatiramer acetate* AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Aubagio, Tecfidera or Tysabri) *Prior Authorization required

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: GRALISE ER Generic Name: gabapentin extended-release tablet GRALISE 30-DAY STARTER PACK Criteria: Diagnosis of post-herpetic neuralgia AND • patient tried and failed a dose of at least 1800mg formulary gabapentin AND • Trial and failure of Lyrica* AND • Submission of medical records documenting: - Details of failure/intolerance to formulary gabapentin AND - Which attempts were taken to resolve these *Prior Authorization required

Quantity Limits:

Date: September 2017 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: HORIZANT Generic Name: gabapentin enacarbil oral tablet, extended release 300mg, 600mg Criteria: Diagnosis of moderate to severe primary restless leg syndrome AND patient is 18 year of age or older AND patient has experienced treatment failure or is intolerant to ropinirole or pramipexole Diagnosis of post-herpetic neuralgia AND patient tried and failed a dose of at least 1800 mg generic gabapentin or experienced intolerance to generic gabapentin

Quantity Limits: Diagnosis of RLS: Maximum daily dose of 600mg (600mg at bedtime) Diagnosis of post-herpetic neuralgia: Maximum daily dose of 1200mg (600mg twice daily)

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: GLATIRAMER ACETATE PRE-FILLED SYRINGE Generic Name: glatiramer acetate 20mg/ml & 40mg/ml syringe

Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Plegridy, Tecfidera, Gilenya or Tysabri)

Quantity Limits: 20mg: 1 subcutaneous injection every day 40mg: 1 subcutaneous injection 3 times per week

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: COPAXONE Generic Name: glatiramer acetate 20mg/ml & 40mg/ml syringe

Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND Has been evaluated by a neurologist AND Trial and failure of Glatopa* or glatiramer acetate* AND Not being used in combination with another MS disease-modifying therapy (Avonex, Rebif, Betaseron, Extavia, Aubagio, Tecfidera, Gilenya or Tysabri) *Prior Authorization Required

Quantity Limits: 20mg: 1 subcutaneous injection every day 40mg: 1 subcutaneous injection 3 times per week

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: GLATOPA Generic Name: glatiramer acetate 20mg/ml & 40mg/ml syringe

Quantity Limits: 20mg: 1 subcutaneous injection every day 40mg: 1 subcutaneous injection 3 times per week

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: AVONEX Generic Name: interferon beta-1a Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Trial and failure of Glatopa* or glatiramer acetate* AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Rebif, Betaseron, Extavia, Aubagio, Tecfidera, Gilenya or Tysabri) *Prior Authorization Required

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: PLEGRIDY Generic Name: interferon beta-1a Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Trial and failure of Glatopa* or glatiramer acetate* AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Aubagio, Tecfidera, Gilenya or Tysabri) *Prior Authorization Required

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: REBIF Generic Name: interferon beta-1a Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Trial and failure of Glatopa* or glatiramer acetate* AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Betaseron, Extavia, Aubagio, Tecfidera, Gilenya or Tysabri) *Prior Authorization Required

Quantity Limits:

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: BETASERON Generic Name: interferon beta-1b Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Has intolerable side effect to Extavia AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Extavia, Aubagio, Tecfidera, Gilenya or Tysabri)

Quantity Limits: 0.3mg SC QOD

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: EXTAVIA Generic Name: interferon beta-1b Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Aubagio, Tecfidera, Gilenya or Tysabri)

Quantity Limits: 0.3mg SC QOD

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: SAVELLA Generic Name: milnacipran Criteria: Diagnosis is fibromyalgia AND If patient has inadequate response, intolerable side effect, or contraindication to duloxetine, a TCA (amitriptyline, imipramine, desipramine, nortriptyline) and 1 other formulary agents from the following: gabapentin (>1200mg/day), venlafaxine, cyclobenzaprine, tramadol, or SSRIs (fluoxetine, paroxetine, sertraline, citalopram, escitalopram).

Quantity Limits: 2 capsules/day Dose Pack: 1x authorization for titration

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: NOVANTRONE Generic Name: mitoxantrone Criteria: Diagnosis of relapsing/remitting MS (RRMS) or secondary progressive relapsing MS AND • Has been evaluated by a neurologist AND • Has inadequate response, intolerable side effect, or contraindication to 2 of the following: Copaxone, Avonex, Rebif, Betaseron, Extavia, Plegridy, Aubagio, Tecfidera, Gilenya, and Tysabri or medical justification why they can’t be used

Quantity Limits: 12mg/m2 Q 3 months

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: TYSABRI Generic Name: natalizumab Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Has inadequate response, intolerable side effect, or contraindication to one of the following: Copaxone, Avonex, Rebif, Betaseron, Extavia, Plegridy, Aubagio, Tecfidera, or Gilenya or medical justification why they can’t be used AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Plegridy, Aubagio, Tecfidera, or Gilenya) • Diagnosis of moderate to severe Crohn’s disease AND • Has been evaluated by a gastroenterologist AND • Has inadequate response, intolerable side effect, or contraindication to azathioprine or mercaptopurine • Has inadequate response, intolerable side effects to Humira and Remicade.

Quantity Limits: Crohn’s/MS: 300mg IV every 4 weeks

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: OCREVUS Generic Name: ocrelizumab 300mg/10ml vial

Criteria: Diagnosis of Relapsing Forms of Multiple Sclerosis AND ≥ 18 years of age AND Trial and failure of Glatopa (glatiramer acetate) and one another MS therapy including Avonex (interferon beta-1a), Rebif (interferon beta 1-a), Betaseron/Extavia (interferon beta-1b), Plegridy (peginterferon beta1a), Copaxone (glatiramer acetate), Aubagio (teriflunomide tablets), Gilenya (fingolimod capsules), Tecfidera (dimethyl fumarate delayed-release capsules), Tysabri (Natalizumab) or Lemtrada (alemtuzumab) or medical justification why they can’t be used. AND Prescribed by a physician who specializes in the treatment of MS and/or a neurologist. Diagnosis of Primary Progressive Multiple Sclerosis AND ≥ 18 years of age AND Prescribe by a physician who specializes in the treatment of MS and/or a neurologist.

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: AUBAGIO Generic Name: teriflunomide Criteria: Diagnosis of relapsing/remitting MS (RRMS) AND • Has been evaluated by a neurologist AND • Trial and failure of Glatopa* or glatiramer acetate* AND • Not being used in combination with another MS disease-modifying therapy (Copaxone, Avonex, Rebif, Betaseron, Extavia, Tecfidera, Gilenya or Tysabri) *Prior Authorization Required

Quantity Limits:

Date: October 2018 GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I Brand Name: INGREZZA Generic Name: valbenazine 40mg & valbenazine 80mg oral capsule

Criteria: Diagnosis of moderate to severe tardive dyskinesia AND • Prescribed by or in consultation with a neurologist or psychiatrist AND • Must be 18 years of age or older AND • If tardive dyskinesia is caused by a drug, that drug must be switched to an alternative or tried at a lower dose, or provide medical justification on why this cannot be done.

Quantity Limits: 1 capsule/day

Date: GTC: NEUROLOGICAL DISEASE - MISCELLANEOUS: 2I

Brand Name: RILUTEK Generic Name: riluzole Criteria: Diagnosis of amyotrophic lateral sclerosis

Quantity Limits: 2 tablets/day

Date: GTC: NOVEL HEART FAILURE MEDICATIONS: 0L Brand Name: CORLANOR Generic Name: ivabradine Criteria: Diagnosis of heart failure AND • Has left ventricular ejection fraction ≤ 35% AND • Is in normal sinus rhythm with heart rate ≥70 beats per minute AND • Are on maximally tolerated doses of beta-blockers OR have a contraindication to beta-blocker use

Quantity Limits: 2 tablets/day

Date: December 2017 GTC: NOVEL HEART FAILURE MEDICATIONS: 0L Brand Name: RANEXA Generic Name: ranolazine oral tablet, extended release 500mg, 1000mg

Criteria: Diagnosis of Angina AND has inadequate response, intolerable side effect, or contraindication to beta blocker AND calcium channel blocker or Long acting Nitrate

Quantity Limits:

Date: December 2017 GTC: NOVEL HEART FAILURE MEDICATIONS: 0L Brand Name: ENTRESTO Generic Name: sacubitril, valsartan oral tablet 24mg-26mg, 49mg- 51mg,97mg-103mg

Criteria: Diagnosis of heart failure (NYHA Class II-IV) AND left ventricular ejection fraction ≤ 40% AND Prescribed by cardiologist AND Documentation provided regarding patient’s recent hospitalization due to CHF exacerbation or current clinical instability due to CHF Diagnosis of heart failure AND left ventricular ejection fraction ≤ 40% AND has inadequate response, intolerable side effect, or contraindication to 1 ACE inhibitor (lisinopril, benazepril, ramipril, quinapril, fosinopril, enalapril, trandolapril) OR 1 ARB (losartan, valsartan, irbesartan, telmisartan)

Quantity Limits:

Date: December 2016 GTC: ORAL/PHARYNGEAL DISORDERS: 1D Brand Name: ARESTIN Generic Name: minocycline hcl 1mg microspheres Criteria: Diagnosis of periodontitis AND has inadequate response, intolerable side effect, or contraindication to formulary antimicrobials: amoxicillin, metronidazole, azithromycin, and doxycycline

Quantity Limits:

Date: June 2018 GTC: OTHER DRUGS: 2H Brand Name: EXJADE Generic Name: deferasirox dispersible tablet (for oral suspension); 125mg, 250mg & 500mg dispersible tablet

Criteria: Diagnosis of chronic transfusional iron overload due to blood transfusions AND • Prescribed by a hematologist/oncologist AND • Serum ferritin levels are consistently > 1000mcg/L (demonstrated by at least 2 lab values in the previous 3 months) AND • Member is 2 years or older OR • Diagnosis of chronic iron overload resulting from non-tranfusion-dependent thalassemia (NTDT) AND • Liver iron iron levels > 5mg Fe/g and serum ferritin levels > 300mcg/L (demonstrated by lab values in the previous 3 months) AND • Member is 10 years or older Reauthorization: Chronic iron overload due to blood transfusion AND • Serum ferritin levels are consistently > 500mcg/L OR • NTDT AND • Liver iron iron levels > 5mg Fe/g and serum ferritin levels not less than 300mcg/L.

Quantity Limits:

Date: June 2018 GTC: OTHER DRUGS: 2H Brand Name: JADENU & JADENU SPRINKLE Generic Name: deferasirox oral tablet; 90mg, 180mg, & 360mg oral tablet, deferasirox granule packet; 90mg, 180mg, & 360mg granule packet Criteria: Diagnosis of chronic transfusional iron overload due to blood transfusions AND prescribed by a hematologist/oncologist AND serum ferritin levels are consistently > 1000mcg/L (demonstrated by at least 2 lab values in the previous 3 months) AND member is 2 years or older OR Diagnosis of chronic iron overload resulting from non-tranfusion-dependent thalassemia (NTDT) AND liver iron iron levels > 5mg Fe/g and serum ferritin levels > 300mcg/L (demonstrated by lab values in the previous 3 months) AND member is 10 years or older Renewal: Chronic iron overload due to blood transfusion AND serum ferritin levels are consistently > 500mcg/L OR NTDT AND liver iron iron levels > 5mg Fe/g and serum ferritin levels not less than 300mcg/L

Quantity Limits:

Date: June 2018 GTC: OTHER DRUGS: 2H Brand Name: FERRIPROX Generic Name: deferiprone 500mg oral tablet, deferiprone 100mg/ml oral solution

Criteria: Diagnosis of transfuional iron overload due to thalassemia syndrome AND • Has an indadequate response, intolerance or contraindication to deferoxamine (Desferal) or Exjade or Jadenu AND • Serum ferritin levels that are consistently >2500 mcg/L (demonstrated by at least 2 lab values in the previous 3 months) AND • An absolute neutrophil count (ANC) > 1.5 x 109/L AND • Prescribed by a hematologist/oncologist Reauthorization: Clinical response to treatment and continues to require therapy for serum ferritin level consistently >500mcg/L (demonstrated by at least 2 lab values in the previous 3 months) AND an absolute neutrophil count > 1.5 x 109/L

Quantity Limits:

Date: GTC: OTHER DRUGS: 2H Brand Name: ENTERAL NUTRITIONAL FORMULAS Generic Name: enteral nutritional formulas SOME EXAMPLES ARE: ENSURE, GLUCERNA, JEVITY, BOOST, PEDIASURE, PEPTAMEN

Criteria: Refer to Alliance Enteral Nutrition Products policy 403-1136 which can be found in the provider manual.

Quantity Limits:

Date: GTC: OTHER DRUGS: 2H Brand Name: HYDERGINE Generic Name: ergoloid mesylates Criteria: Diagnosis of dementia AND • Mini Mental State Examination (MMSE) score <23, or an equivalent score on another screening test; AND • Approval for 0.5mg sublingual tablets only

Quantity Limits: 6 tablets/day

Date: October 2018 GTC: OTHER DRUGS: 2H Brand Name: SOMATULINE DEPOT Generic Name: lanreotide acetate 60mg/0.2ml, 90mg/0.3ml & 120mg/0.5ml syringe

Criteria: Diagnosis of Acromegaly AND Member has a high pretreatment IGF-1 level for age and/or gender AND Member had an inadequate or partial response to surgery or radiotherapy OR there is a clinical reason why the member has not had surgery or radiotherapy. For treatment of gastroenteropancreatic neuroendocrine tumors or carcinoid syndrome.

Quantity Limits:

Date: GTC: OTHER DRUGS: 2H Brand Name: CARNITOR Generic Name: levocarnitine Criteria: Diagnosis of levocarnitine deficiency

Quantity Limits: 9 tablets/day

Date: GTC: OTHER DRUGS: 2H Brand Name: MEGACE Generic Name: megestrol acetate 20mg & 40mg tablet, 400mg/10ml oral MEGACE ES suspension & 625mg/5ml oral suspension

Criteria: Diagnosis of weight loss, cachexia, or to stimulate appetite, or for palliative treatment of advanced breast or endometrial carcinoma AND the request is for megestrol acetate 400mg/10ml suspension or tablets For Megace ES (625mg/5ml) suspension: • Patient has intolerable side effect to megestrol acetate 400mg/10ml.

Quantity Limits: Max dose: 20mL/day

Date: October 2018 GTC: OTHER DRUGS: 2H Brand Name: SANDOSTATIN LAR DEPOT Generic Name: octreotide depot form (for injectable suspension); octreotide acetate lar depot 10mg, 20mg & 30mg kit

Criteria: Diagnosis of Acromegaly AND • Member has a high pretreatment IGF-1 level for age and/or gender AND • Member had an inadequate or partial response to surgery or radiotherapy OR there is a clinical reason why the member has not had surgery or radiotherapy AND Member who have responded to and tolerated subcutaneous octreotide and have medical justification for switching to long acting depot form For treatment of gastroenteropancreatic neuroendocrine tumors or carcinoid syndrome based on NCCN guidelines

Quantity Limits:

Date: October 2018 GTC: OTHER DRUGS: 2H Brand Name: BOTOX Generic Name: onabotulinumtoxina 100-unit & 200-unit vial

Criteria: Diagnosis of migraine headaches lasting 4 hours a day or longer with frequency occurring 15 or more days per month for 3 or more months AND Has inadequate response,intolerable side effect, or contraindication to 3 preventative formulary medications x 12 weeks or complete intolerance, including: • 1 agent from beta-blockers (e.g., atenolol, propranolol, metoprolol) • 1 agent from tricyclic antidepressants (TCA) (e.g., amitriptyline) AND • 1agent from anticonvulsants (e.g., divalproex, topiramate)

Quantity Limits: Max dose: 200-units every 12 weeks (84-days)

Date: June 2019 GTC: OTHER DRUGS: 2H Brand Name: TINIDAZOLE Generic Name: tinidazole Criteria: Diagnosis of Amebiasis AND Has inadequate response, intolerable side effect or contraindication to 1 of the following medications: metronidazole or doxycycline Diagnosis of Bacterial Vaginosis AND Has inadequate response, intolerable side effect or contraindication to 1 of the following medications: metronidazole or clindamycin Diagnosis of Giardiasis Diagnosis of Trichomoniasis AND Has inadequate response, intolerable side effect or contraindication to metronidazole

Quantity Limits:

Date: October 2018 GTC: OTHER RESPIRATORY DISORDERS: 1Y Brand Name: PULMOZYME Generic Name: dornase alfa 1mg/ml ampule Criteria: Pulmozyme is being used in the management of cystic fibrosis; AND • Pulmozyme will be in conjunction with standard therapies for the management of cystic fibrosis (e.g., chest physiotherapy, bronchodilators, antibiotics, etc.); AND • Documentation must be submitted of a forced vital capacity (FVC) of > 40% of predicted. AND • For any request for twice daily Pulmozyme, documentation must be submitted of an adequate trial of once daily dosing.

Quantity Limits:

Date: June 2018 GTC: OTHER RESPIRATORY DISORDERS: 1Y Brand Name: OFEV Generic Name: nintedanib esylate Criteria: Diagnosis of Idiopathic Pulmonary fibrosis (IPF) confirmed by high resolution computed tomography (HRCT) or surgical lung biopsy AND • Has been prescribed by or in consultation with a pulmonologist AND • Patient has documented Forced Vital Capacity (FVC) greater than or equal 50% at base line within the last 60 days AND • Patient is concurrently not taking Esbriet (pirfenidone)

Quantity Limits: 2 caps per day

Date: June 2018 GTC: OTHER RESPIRATORY DISORDERS: 1Y Brand Name: SYMDEKO Generic Name: tezacaftor/ivacaftor Criteria: Diagnosis of Cystic Fibrosis (CF) AND • Submission of laboratory results documenting one of the following: • The patient is homozygous for the F508del mutation in the CFTR gene or • The patient has at least one of the following mutations in the CFTR gene that is responsive to Symdeko: A455E, A1067T, D110E, D110H, D579G, D1152H, D1270N, E56K, E193K, E831X, F1052V, F1074L, K1060T, L206W, P67L, R74W, R1070W, R117C, R347H, R352Q, 51070W, S945L, S977F, 711+3A→G, 2789+5G→A, 3272-26A→G, 3849+10kbC→T. • AND patient is greater than or equal to 12 years of age • AND prescribed by or in consultation with a specialist affiliated with a CF care center. Reauthorization: Provider must attent that the patient has achieved a clinically meaningful response while on Symdeko therapy to one or more of the following: • Decreased pulmonary exacerbations compared to pretreatment baseline • Improvement or stabilization of lung function as measured by percent predicted FEV1 compared to baseline or decrease in the rate of decline of lung function • Weight gain • Improvement in quality of life by Cystic Fibrosis Questionnaire-revised (CFQ-R) respiratory domain score

Quantity Limits: 2 tabs per day

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: DURADIN Generic Name: acetaminophen; dichloralphenazone; isometheptene Criteria: Diagnosis of migraine AND 18 years of age or older AND Inadequate response, intolerable side effect, or contraindication to - 2 formulary TRIPTANS (sumatriptan AND rizatriptan/ODT) AND - 2 formulary NSAIDS (naproxen, diclofenac, ibuprofen) AND NTE 8 tabs/ day

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: BUTRANS Generic Name: buprenorphine patch

Criteria: ***IHSS members only. Carve-out for Medi-Cal*** Diagnosis of severe chronic pain 1. Chart notes and clear treatment plan provided by MD 2. Previous treatment with short-acting opioids 3. Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) 4. Replacing current equianalgesic (or higher) dose of another opioid

Quantity Limits: 1 patch/wk 4 patches/28 days

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: STADOL Generic Name: butophhanol STADOL NS butophhanol nasal spray Criteria: Diagnosis of migraine AND • 18years of age or older • Inadequate response, intolerable side effect, or contraindication to - 2 TRIPTANS such as rizatriptan/rizatriptan ODT and sumatriptan (oral/ nasal/injectable) AND - 2 NSAIDS (naproxen, diclofenac, ibuprofen)

Quantity Limits: Quantity limit of 1 box per 30 days

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: CAMBIA Generic Name: diclofenac Criteria: Diagnosis of migraine AND • 18years of age or older • Inadequate response, intolerable side effect, or contraindication to - 2 TRIPTANS such as rizatriptan/rizatriptan ODT and sumatriptan (oral/ nasal/injectable) AND - 2 NSAIDS (naproxen, diclofenac, ibuprofen)

Quantity Limits: Quantity limit of 1 box per 30 days

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: MIGRANAL Generic Name: dihydroergotamine spray Criteria: Diagnosis of migraine AND • 18years of age or older • Inadequate response, intolerable side effect, or contraindication to - 2 TRIPTANS such as rizatriptan/rizatriptan ODT and sumatriptan (oral/ nasal/injectable) AND - 2 NSAIDS (naproxen, diclofenac, ibuprofen)

Quantity Limits: Quantity limit of 1 box per 30 days

Date: Modify GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: AIMOVIG Generic Name: erenumab-aooe 70mg/ml autoinjector syringe

Criteria: Initial Criteria 1. Prescribed by or in consultation with a neurologist. 2. The member is ≥ 18 years of age. 3. Documentation submitted that meets one of the following: a. A diagnosis of episodic migraines and all of the following must be met: i. Documentation member has at least 4 to 14 migraine days per month, but no more than 14 headache days per month. ii. Trial of at least 3 months and documented failure, contraindication, or intolerance to all of the following prophylactic therapies listed from each of the drug classes below: - Tricyclic antidepressant (TCA) (e.g., amitriptyline) - Anticonvulsants (e.g., divalproex, topiramate) - Beta‐blockers (e.g., atenolol, propranolol, metoprolol) iii. Aimovig will not be used in combination with another CGRP inhibitor (Ajovy, Emgality). iv. Aimovig with not be used in combination with Botox (onabotulinumtoxinA). b. A diagnosis of chronic migraines and all of the following must be met: i. Documentation member has been evaluated for medication overuse headache (MOH) and if MOH is diagnosed then documentation has been submitted the member has successfully tapered off the offending medication. ii. Documentation member has greater than or equal to 15 headache days per month, of which at least 8 must be migraine days for at least 3 months. iii. Trial of at least 3 months and documented failure, contraindication, or intolerance to all of the following prophylactic therapies listed from each of the drug classes below: - Tricyclic antidepressant (TCA) (e.g., amitriptyline) - Anticonvulsants (e.g., divalproex, topiramate) - Beta‐blockers (e.g., atenolol, propranolol, metoprolol). iv. Aimovig will not be used in combination with another CGRP inhibitor (Ajovy, Emgality). v. Aimovig with not be used in combination with Botox (onabotulinumtoxinA).

Continuation Criteria: 1. Documentation submitted member has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity compared to baseline. 2. The number of migraine days per month must be documented and submitted. Per prescription claims history the use of acute migraine medications (e.g., NSAIDs, triptans, opiates and other migraine medications) has decreased while on therapy. 3. Per prescription claims history member has demonstrated complete adherence to monthly fills of Aimovig. If nonadherence present then documentation must be submitted, by chart notes, that the provider has addressed the nonadherence and a treatment plan is in place to prevent future non‐adherence. 4. Documentation that member continues to be monitored for Medication Overuse Headache (MOH) and offending medications, if applicable.

Quantity Limits: The use of two 70 mg (140 mg) injections per month will require documentation of failure of 70 mg once a month after a 90 day trial with complete adherence per prescription claims. Failure is defined as not meeting the continuation criteria of a positive response to therapy demonstrated by a reduction in headache frequency and/or intensity compared to baseline.

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ERGOMAR Generic Name: ergotamine sublingual tablets Criteria: Diagnosis of migraine AND • 18 years of age or older AND • Inadequate response, intolerable side effect, or contraindication to - 2 formulary TRIPTANS (sumatriptan AND rizatriptan/ODT) AND - 2 formulary NSAIDS (naproxen, diclofenac, ibuprofen)

Quantity Limits: Quantity limit 10 tablets per 30 days

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: CAFERGOT Generic Name: ergotamine/caffeine Criteria: Diagnosis of migraine AND • 18 years of age or older AND • Inadequate response, intolerable side effect, or contraindication to - 2 formulary TRIPTANS (sumatriptan AND rizatriptan/ODT) AND - 2 formulary NSAIDS (naproxen, diclofenac, ibuprofen)

Quantity Limits: Quantity limit 24 tablets per 30 days

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ACTIQ Generic Name: fentanyl oral lozenge, tablet, spray, film, etc. FENTORA ONSOLIS ABSTRAL SUBSYS LAZANDA

Criteria: For management of severe breakthrough cancer pain 1. Clear treatment plan provided by MD 2. Previous treatment with short-acting opioids 3. Must be on maintenance (around-the-clock) opioid concurrently

Quantity Limits:

Date: Split criteria GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: DURAGESIC Generic Name: fentanyl patch Criteria: Diagnosis of severe chronic pain AND 1. Chart notes and clear treatment plan provided by MD 2. Previous treatment with short-acting opioids AND 3. Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or Buprenorphine 4. Replacing current equianalgesic (or higher) dose of another opioid which patient was on for at least 1 week

Quantity Limits:

Date: September 2016 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: FORUMULARY OPIOID MEDICATIONS LIMITED BY QUANTITY Generic Name: forumulary opioid medications limited by quantity supply: SUPPLY: hydrocodone/apap HYDROCODONE/APAP hydromorphone ir tablets HYDROMORPHONE IR TABLETS oxycodone/apap OXYCODONE/APAP oxycodone ir OXYCODONE IR morphine sulfate ir MORPHINE SULFATE IR morphine sulfate er tablets MORPHINE SULFATE ER TABLETS etc. ETC.

Criteria: Diagnosis of cancer, palliative, or hospice pain Approve as requested under HICL, with 999 fills, and DOS end date: 12/31/2999 (leave end date open in MedAccess)

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: AJOVY Generic Name: fremanezumab-vfrm 225mg/1.5ml prefilled syringe

Criteria: Initial Criteria 1. Prescribed by or in consultation with a neurologist. 2. The member is ≥ 18 years of age. 3. Documentation submitted that meets one of the following: a. A diagnosis of episodic migraines and all of the following must be met: i. Documentation member has at least 4 to 14 migraine days per month, but no more than 14 headache days per month. ii. Trial of at least 3 months and documented failure, contraindication, or intolerance to all of the following prophylactic therapies listed from each of the drug classes below: - Tricyclic antidepressant (TCA) (e.g., amitriptyline) - Anticonvulsants (e.g., divalproex, topiramate) - Beta‐blockers (e.g., atenolol, propranolol, metoprolol) iii. Ajovy will not be used in combination with another CGRP inhibitor (Aimovig, Emgality). iv. Ajovy with not be used in combination with Botox (onabotulinumtoxinA). b. A diagnosis of chronic migraines and all of the following must be met: i. Documentation member has been evaluated for medication overuse headache (MOH) and if MOH is diagnosed then documentation has been submitted the member has successfully tapered off the offending medication. ii. Documentation member has greater than or equal to 15 headache days per month, of which at least 8 must be migraine days for at least 3 months. iii. Trial of at least 3 months and documented failure, contraindication, or intolerance to all of the following prophylactic therapies listed from each of the drug classes below: - Tricyclic antidepressant (TCA) (e.g., amitriptyline) - Anticonvulsants (e.g., divalproex, topiramate) - Beta‐blockers (e.g., atenolol, propranolol, metoprolol). iv. Ajovy will not be used in combination with another CGRP inhibitor (Aimovig, Emgality). v. Ajovy with not be used in combination with Botox (onabotulinumtoxinA).

Continuation Criteria: 1. Documentation submitted member has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity compared to baseline. 2. The number of migraine days per month must be documented and submitted. Per prescription claims history the use of acute migraine medications (e.g., NSAIDs, triptans, opiates and other migraine medications) has decreased while on therapy. 3. Per prescription claims history member has demonstrated complete adherence to monthly fills of Ajovy. If nonadherence present then documentation must be submitted, by chart notes, that the provider has addressed the nonadherence and a treatment plan is in place to prevent future non‐adherence. 4. Documentation that member continues to be monitored for Medication Overuse Headache (MOH) and offending medications, if applicable.

Quantity Limits: 225mg subcutaneous once monthly or 675mg subcutaneous every 3 months. (The 675mg quarterly dosage is administered as three consecutive injections of 225mg each).

Date: October 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: EMGALITY Generic Name: galcanezumab-gnlm 120mg/ml prefilled pen Criteria: Initial Criteria 1. Prescribed by or in consultation with a neurologist. 2. The member is ≥ 18 years of age. 3. Documentation submitted that meets one of the following: a. A diagnosis of episodic migraines and all of the following must be met: i. Documentation member has at least 4 to 14 migraine days per month, but no more than 14 headache days per month. ii. Trial of at least 3 months and documented failure, contraindication, or intolerance to all of the following prophylactic therapies listed from each of the drug classes below: - Tricyclic antidepressant (TCA) (e.g., amitriptyline) - Anticonvulsants (e.g., divalproex, topiramate) - Beta‐blockers (e.g., atenolol, propranolol, metoprolol) iii. Emgality will not be used in combination with another CGRP inhibitor (Aimovig, Ajovy). iv. Emgality with not be used in combination with Botox (onabotulinumtoxinA). b. A diagnosis of chronic migraines and all of the following must be met: i. Documentation member has been evaluated for medication overuse headache (MOH) and if MOH is diagnosed then documentation has been submitted the member has successfully tapered off the offending medication. ii. Documentation member has greater than or equal to 15 headache days per month, of which at least 8 must be migraine days for at least 3 months. iii. Trial of at least 3 months and documented failure, contraindication, or intolerance to all of the following prophylactic therapies listed from each of the drug classes below: - Tricyclic antidepressant (TCA) (e.g., amitriptyline) - Anticonvulsants (e.g., divalproex, topiramate) - Beta‐blockers (e.g., atenolol, propranolol, metoprolol). iv. Emgality will not be used in combination with another CGRP inhibitor (Aimovig, Ajovy). v. Emgality with not be used in combination with Botox (onabotulinumtoxinA).

Continuation Criteria: 1. Documentation submitted member has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity compared to baseline. 2. The number of migraine days per month must be documented and submitted. Per prescription claims history the use of acute migraine medications (e.g., NSAIDs, triptans, opiates and other migraine medications) has decreased while on therapy. 3. Per prescription claims history member has demonstrated complete adherence to monthly fills of Emgality. If nonadherence present then documentation must be submitted, by chart notes, that the provider has addressed the nonadherence and a treatment plan is in place to prevent future non‐adherence. 4. Documentation that member continues to be monitored for Medication Overuse Headache (MOH) and offending medications, if applicable.

Quantity Limits: 240mg subcutaneous loading dose followed by monthly doses of 120mg. (Administered as two consecutive injections of 120mg each).

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: EXALGO Generic Name: hydromorphone er formulations /combinations Criteria: Diagnosis is moderate to severe chronic pain AND • Chart notes and clear treatment plan provided by MD • Previous treatment with formulary short-acting opioids • Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or buprenorphine • Replacing current, equianalgesic (or higher) opioid dose

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: PRODRIN Generic Name: isometheptene/ caffeine/ acetaminophen Criteria: Diagnosis of migraine AND 18 years of age or older AND Inadequate response, intolerable side effect, or contraindication to - 2 formulary TRIPTANS (sumatriptan AND rizatriptan/ODT) AND - 2 formulary NSAIDS (naproxen, diclofenac, ibuprofen)

Quantity Limits: 8 tablets/ day 64 tablets/ month

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: DOLOPHINE Generic Name: methadone Criteria: Approve if current diagnosis of: • Cancer, palliative or hospice pain Diagnosis of severe chronic pain 1. Chart notes and clear treatment plan provided by MD 2. Previous treatment with short-acting opioids 3. Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or buprenorphine 4. Member is not concurrently taking any benzodiazepine or carisoprodol 5. Replacing current equianalgesic (or higher) dose of another opioid

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: EMBEDA Generic Name: morphine/ naltrexone er

Criteria: Diagnosis of severe chronic pain AND 1. Chart notes documenting history of tampering with opioid tabs/caps 2. Medical justification why formulary MSER cannot be used 3. Medical justification why buprenorphine and methadone* cannot be used 4. Clear treatment plan provided by MD 5. Member is not concurrently taking any benzodiazepine or carisoprodol 6. Replacing current equianalgesic (or higher) dose of another opioid *Requires prior authorization

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ZOHYDRO ER Generic Name: non formulary hydrocodone er formulations/combinations HYSINGLA ER Criteria: Diagnosis is moderate to severe chronic pain AND • Chart notes and clear treatment plan provided by MD • Previous treatment with short-acting opioids AND • Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or buprenorphine. • Replacing current, equianalgesic (or higher) opioid dose

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: AVINZA Generic Name: non formulary morphine er formulations/combinations KADIAN ARYMO ER MORPHABOND ER

Criteria: Diagnosis is moderate to severe chronic pain AND • Chart notes and clear treatment plan provided by MD • Previous treatment with short-acting opioids AND • Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or buprenorphine. • Replacing current, equianalgesic (or higher) opioid dose

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: OXYCONTIN Generic Name: non formulary oxycodone er formulations/combinations XTAMPZA Criteria: Diagnosis is moderate to severe chronic pain AND • Chart notes and clear treatment plan provided by MD • Previous treatment with short-acting opioids AND • Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or buprenorphine. • Replacing current, equianalgesic (or higher) opioid dose

Quantity Limits:

Date: September 2016 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: NON-FORMULARY OPIOID MEDICATIONS: Generic Name: non-formulary opioid medications: FENTANYL PATCHES fentanyl patches HYDROMORPHONE ER TABLETS hydromorphone er tablets OXYCODONE ER TABLETS oxycodone er tablets OXYMORPHONE ER TABLETS oxymorphone er tablets MORPHINE SULFATE ER CAPSULES morphine sulfate er capsules ETC. etc.

Criteria: Diagnosis of cancer, palliative, or hospice pain AND •Has previously approved by a pharmacist •Approve as requested for re-authorization and/or dose titration

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: AXERT Generic Name: non-formulary triptan formulations pa criteria: RELPAX almotriptan FROVA eletriptan AMERGE frovatriptan ZOMIG zolmitriptan ZOMIG ODT zolmitriptan odt

Criteria: Diagnosis of migraine AND •18 years of age and older •Inadequate response, intolerable side effect, or contraindication to 2 triptans such as rizatriptan/rizatriptan ODT, sumatriptan (oral/nasal/injectable) AND

Quantity Limits: Quantity limit of 9 tablets per 30 day supply

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ALLZITAL, BUPAP, MARTEN, CAPACET, ESGIC, FIORICET, Generic Name: non-formulary PHRENILIN FORTE, ZEBUTAL, VANATOL, BAC, REPAN, FIORINAL butalbital formulations/ combinations Criteria: Diagnosis of migraine headaches AND Has inadequate response, intolerable side effect, or contraindication to 1 formulary formulation such as: - Butalbital/APAP 50/325 mg tablet - Butalbital/APAP/caffeine 50/325/40 mg tablet NTE 6 tablets per 24 hours

Quantity Limits: 6 tablets/ day 48 tablets/ month Initial approval: 6 fills

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: OXYCODONE 20MG/ML SOLUITON Generic Name: oxycodone 20mg/ml soluiton Criteria: Approve for diagnosis of cancer, palliative or hospice pain

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ROXYBOND Generic Name: oxycodone 5, 15, 30mg

Criteria: Diagnosis of severe pain AND 1. Chart notes documenting IV drug abuse 2. Medical justification why formulary MSIR and oxy IR tabs cannot be used 3. Medical justification why buprenorphine cannot be used (if concerned about drug abuse) 4. Clear treatment plan provided by MD 5. Member is not concurrently taking any benzodiazepine or carisoprodol 6. Replacing current equianalgesic (or higher) dose of another opioid

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: PERCODAN Generic Name: oxycodone/ aspirin 4.8335/325mg ENDODAN

Criteria: Use separate agents

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: COMBUNOX Generic Name: oxycodone/ ibuprofen 5/400mg

Criteria: Use separate agents

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: NALOCET Generic Name: oxycodone/apap 2.5/300mg

Criteria: Use preferred morphine, or oxy/APAP 2.5/325mg or oxycodone 5mg (half tablet) + APAP

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: PRIMLEV Generic Name: oxycodone/apap 5, 7.5, 10/300mg

Criteria: Use formulary strengths: 5, 7.5, 10/325mg APAP

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: OPANA Generic Name: oxymorphone OPANA ER Criteria: Diagnosis is moderate to severe chronic pain AND - Chart notes and clear treatment plan provided by MD - Previous treatment with formulary short-acting opioids Oxymorphone ER: All of the above AND - Inadequate response, intolerable side effect, or contraindication to formulary long-acting opioid morphine sulfate ER tablets (MS Contin) or buprenorphine AND - Replacing current, equianalgesic (or higher) opioid dose

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: TALWIN NX Generic Name: pentazocine/ naloxone

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ZEMBRACE SYMTOUCH Generic Name: sumatriptan 3mg/0.5ml autoinjector

Criteria: Diagnosis of migraine headaches AND •Has inadequate response, intolerable side effect, or contraindication to formulary oral triptans: sumatriptan, rizatriptan AND •Formulary injectable sumatriptan (cartridge or syringe formulation)

Quantity Limits: 4 units/ month

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ALSUMA Generic Name: sumatriptan inj. SUMAVEL DOSEPRO Criteria: Diagnosis of migraine headaches AND •Has inadequate response, intolerable side effect, or contraindication to formulary oral triptans: sumatriptan, rizatriptan AND •Formulary injectable sumatriptan (cartridge or syringe formulation).

Quantity Limits: 2 doses/day Max: 6 mg/dose up to 12 mg/24h

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ZECUITY Generic Name: sumatriptan patch Criteria: Diagnosis of migraine headaches AND •Has inadequate response, intolerable side effect, or contraindication to formulary oral triptans: sumatriptan, rizatriptan AND •Formulary injectable sumatriptan (cartridge or syringe formulation).

Quantity Limits: 3 patches/day

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: NUCYNTA ER Generic Name: tapentadol

Criteria: Diagnosis is moderate to severe chronic pain AND •Chart notes and clear treatment plan provided by MD AND •Has inadequate response, intolerable side effect, or contraindication to: - NSAID and - tramadol or tramadol/APAP and •T/F of immediate-release tapentadol AND •Replacing current, equianalgesic (or higher) dose of Nucynta IR

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: NUCYNTA Generic Name: tapentadol

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ULTRAM ER Generic Name: tramadol er Criteria: Diagnosis of chronic pain AND •T/F of tramadol or tramadol APAP AND •Replacing current, equianalgesic dose of tramadol IR

Quantity Limits:

Date: GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: CONZIP Generic Name: tramadol er (extended biphasic-release) capsules

Criteria: Diagnosis of chronic pain AND 1. Previous treatment with tramadol or tramadol/APAP AND 2. Replacing current, equianalgesic dose of tramadol IR 3. Medical justification why regular tramadol ER* tablets cannot be used or continued *Requires prior authorization

Quantity Limits:

Date: March 2018 GTC: PAIN MANAGEMENT - ANALGESICS: 0M Brand Name: ZOMIG NASAL SPRAY Generic Name: zolmitriptan

Criteria: Diagnosis of migraine headaches AND •12 years of age or older •Inadequate response, intolerable side effect, or contraindication to 1 oral triptan such as sumatriptan, rizatriptan / ODT AND to Sumatriptan nasal spray* * No requirement of trial of nasal sumatriptan if < 18 years old

Quantity Limits:

Date: September 2017 GTC: PARKINOSON’S DISEASE: 0P Brand Name: RYTARY Generic Name: carbidopa, levodopa oral capsule, extended release 23.75mg- 95mg, 36.25mg-145mg, 48.75mg-195mg, 61.25mg-245mg

Criteria: Diagnosis of Parkinson’s disease • Age ≥ 18 years • Documented intolerance or contraindication to carbidopa/levodopa ER tablets (Sinemet CR)

Quantity Limits: The maximum recommended daily dose is 612.5 mg/2,450 mg

Date: September 2017 GTC: PARKINOSON’S DISEASE: 0P Brand Name: MIRAPEX ER Generic Name: pramipexole dihydrochloride oral tablet, extended release 0.375mg, 0.75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg

Criteria: Member had an adequate trial and failure OR Inadequate response (duration of at least 4 weeks) OR Intolerance to pramipexole IR

Quantity Limits: 1 tablet /day

Date: September 2017 GTC: PARKINOSON’S DISEASE: 0P Brand Name: AZILECT Generic Name: rasagiline oral tablet 0.5mg, 1mg

Criteria: Diagnosis of Parkinson disease AND Failure of ≥ 30 days of selegiline unless contraindicated

Quantity Limits: 1 tablet /day

Date: September 2017 GTC: PARKINOSON’S DISEASE: 0P Brand Name: REQUIP XL Generic Name: ropinirole extended-release tablet 2mg, 4mg, 6mg, 8mg, 12mg

Criteria: Member had an adequate trial and failure OR Inadequate response (duration of at least 4 weeks) OR Intolerance to ropinirole IR

Quantity Limits: 1 tablet /day

Date: September 2017 GTC: SEIZURE DISORDER: 0O Brand Name: BRIVIACT Generic Name: brivaracetam 10mg, 25mg, 50mg, 75mg, 100mg Criteria: Prescribed by Neurologist or a psychiatrist AND • Diagnosed with seizures AND • Patient is 16 years of age or older AND • Patient has tried and failed at least TWO formulary anti-epileptic drugs such as: lamotrigine, levetiracetam, oxcarbazepine, topiramate, carbamazepine.

Quantity Limits: 2 tablets / day

Date: January 2019 GTC: SEIZURE DISORDER: 0O Brand Name: EPIDIOLEX Generic Name: cannabidiol Criteria: Diagnosis of Dravet syndrome AND • Patient is 2 years of age or older AND • Prescribed by a neurologist AND • Member has had adequete trial of two of the following: clobazam, valproid acid derivative product, topiramate Diagnosis of Lennox-Gastaut Syndrome (LGS) AND • Patient is 2 years of age or older AND • Prescribed by a neurologist AND • Member has had a trial of or contraindication to topiramate or lamotrigine AND clobazam.

Quantity Limits:

Date: September 2016 GTC: SEIZURE DISORDER: 0O Brand Name: ONFI Generic Name: clobazam oral tablets, oral suspension Criteria: Diagnosis of Lennox-Gastaut Syndrome AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, ethosuximide, and tiagabine. • Onfi oral suspension requires T/F of Onfi tablets or medical justification why tablets cannot be used.

Quantity Limits: 2 tablets/day

Date: September 2017 GTC: SEIZURE DISORDER: 0O Brand Name: KLONOPIN WAFER Generic Name: clonazepam oral disintegrating tablet 0.125mg, 0.25mg, 0.5mg, 1mg, 2mg

Criteria: Patient has a documented inability to swallow tablets OR • Inadequate response to clonazepam tablets

Quantity Limits:

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: APTIOM Generic Name: eslicarbazepine Criteria: Diagnosis of partial seizures AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, or ethosuximide

Quantity Limits: 200mg, 1/day 400mg, 1/day 800mg, 1/day 600mg, 2/day Age ≥ 4 years

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: FELBAMATE Generic Name: felbamate

Criteria: Diagnosis of partial seizures or lennox-gastaut syndrome AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, or ethosuximide • Felbamate oral suspension requires t/f of felbamate tablets or medical justification why tablets cannot be used

Quantity Limits:

Date: September 2016 GTC: SEIZURE DISORDER: 0O Brand Name: VIMPAT Generic Name: lacosamide oral tablets and oral suspension 50mg, 100mg, 150mg, 200mg, 10mg/ml solution

Criteria: Diagnosis of partial seizures AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital • Vimpat oral suspension requires T/F of Vimpat tablets or medical justification why tablets cannot be used

Quantity Limits: 2 tablets/day

Date: September 2016 GTC: SEIZURE DISORDER: 0O Brand Name: LAMICTAL XR Generic Name: lamotrigine oral tablet, extended release 25mg, 50mg, 100mg, 200mg, 250mg, 300mg

Criteria: Had an adequate trial and failure OR Inadequate response (duration of at least 4 weeks) OR Intolerance to lamotrigine IR tablets

Quantity Limits: 1 tablet/ day

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: LAMICTAL ODT Generic Name: lamotrigine orally disintegrating tablet 25mg, 50mg, 100mg, 200mg

Criteria: Patient has a documented inability to swallow tablets OR Inadequate response to lamotrigine IR tablets AND unable to use chew tab

Quantity Limits: 1 tablet /day

Date: September 2016 GTC: SEIZURE DISORDER: 0O Brand Name: KEPPRA XR Generic Name: levetiracetam oral tablet, extended release 500mg, 750mg

Criteria: Patient had an adequate trial and failure OR inadequate response (duration of at least 4 weeks) OR Intolerance to levetiracetam IR tablets

Quantity Limits: 3000mg/day

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: FYCOMPA Generic Name: perampanel oral tablets, oral suspension Criteria: Diagnosis of partial or tonic-clonic (Grand mal) seizures AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, or ethosuximide.

Quantity Limits: Age ≥ 12 years

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: LYRICA Generic Name: pregabalin oral capsule 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 225mg, 300mg Criteria: Approve when either one of the following is met: • Opioid taper • Diagnosis of pain and related (Chronic pain, Fibromyalgia, Neuropathy) AND patient has inadequate response, intolerable side effect, or contraindication to gabapentin (>1200mg/day) • Diagnosis of seizures AND has an inadequate response, intolerable side effects, or contraindications to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, or ethosuximide.

Quantity Limits: 3 capsules/day can be authorized if the daily dose cannot be achieved using BID dosing.

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: BANZEL Generic Name: rufinamide oral tablets, oral suspension Criteria: Diagnosis of Lennox-Gastaut syndrome AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, ethosuximide

Quantity Limits: Age ≥ 1 years

Date: September 2016 GTC: SEIZURE DISORDER: 0O Brand Name: GABITRIL Generic Name: tiagabine oral tablets Criteria: Diagnosis of partial seizures AND • Has inadequate response, intolerable side effect, or contraindication to 2 formulary anti-seizure medications including: gabapentin, carbamazepine, oxcarbamazepine, divalproex sodium, topiramate, lamotrigine, levetiracetam, phenytoin, phenobabrbital, and ethosuximide or medical justification why they cannot be used

Quantity Limits: Max: 56mg/day

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: QUDEXY XR Generic Name: topiramate oral capsule extended release sprinkles 24 hour 25mg, 50mg, 100mg, 150mg, 200mg

Criteria: Prescribed by Neurologist or a psychiatrist AND diagnosis of seizures AND patient has had a two-months trial of immediate-release topiramate

Quantity Limits: 1 capsule/ day

Date: July 2018 GTC: SEIZURE DISORDER: 0O Brand Name: TROKENDI XR Generic Name: topiramate oral capsule, extended release 25mg, 50mg, 100mg, 200mg Criteria: Prescribed by a Neurologist or a psychiatrist AND Patient is 6 years of age or older and diagnosis of seizures OR Patient is 12 years of age or older and diagnosis of migraine AND patient has had a two-month trial of immediate-release topiramate AND Topiramate Oral capsule extended release sprinkles 24 hour* *Prior Authorization Required

Quantity Limits: 1 capsule/day

Date: September 2017 GTC: SEIZURE DISORDER: 0O Brand Name: SABRIL Generic Name: vigabatrin oral tablet 500mg Criteria: Diagnosis of refractory complex partial seizures AND • Prescribed by neurologist • Age ≥ 10 years • Inadequate response to ≥ 2 alternative anticonvulsant drugs • Vision assessment at baseline and at least every 3 months during therapy • Prescribed daily dose* does not exceed: • Pediatric members age 10 to 16 years: 1,000 mg twice daily (if weight is > 60 kg, dosing should follow adult recommendations) • Adults age ≥ 17 years: 1,500 mg twice daily

Quantity Limits: 3000mg per day

Date: October 2018 GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: LIORESAL INTRATHECAL (IT) Generic Name: baclofen intrathecal ampule 0.05mg/ml (50mcg/ml) ampule, 10mg/20ml (500mcg/ml), 10 mg/5ml (2000mcg/ml) & 40mg/20ml (2000mcg/ml) ampule kit

Criteria: Must have severe spasticity of spinal or cerebral origin (multiple sclerosis, cerebral palsy, spinal cord injury, or traumatic brain) AND • Age > 4 years AND • Documentation of unacceptable side effects from or intolerance to oral baclofen at an effective dose. OR documentation of unresponsiveness or ineffectiveness to maximal dosing of oral baclofen AND • Must have a positive response to a screening trial. AND • Must be prescribed by a neurologist

Quantity Limits:

Date: December 2016 GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: SOMA Generic Name: carisoprodol Criteria: Diagnosis of ACUTE muscle spasm or pain AND • 16 years of age or older AND =<65 years old • Chart notes and clear treatment plan provided by MD, including anticipated treatment duration • Trial and failure of methocarbamol AND cyclobenzaprine AND • Member is not concurrently taking any benzodiazepine (clonazepam, lorazepam, alprazolam, etc.) • Member is not currently taking any opiate medications (such as hydrocodone/APAP, Tylenol w/Codeine, oxycodone/APAP, morphine sulfate ER, etc.) AND • If all above met, may authorize total duration of therapy up to 3 weeks (NTE 4 tablets per day)

Quantity Limits:

Date: GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: LORZONE Generic Name: chlorzoxazone Criteria: Diagnosis of ACUTE muscle spasm or pain AND • 18 years of age and older • Chart notes and clear treatment plan provided by MD, including anticipated treatment duration • Trial and failure of formulary methocarbamol AND cyclobenzaprine

Quantity Limits:

Date: October 2018 GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: XIAFLEX Generic Name: collagenase, clostridium histolyticum 0.9mg vial

Criteria: For the treatment of adult patients with Dupuytren’s contracture with a palpable cord.

Quantity Limits:

Date: June 2018 GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: AMRIX Generic Name: cyclobenzaprine er Criteria: 1. Diagnosis of ACUTE muscle spasm or pain AND 2. Patient is 15 years of age or older and <65 years old AND 3. Chart notes and clear treatment plan provided by MD, including anticipated treatment duration AND 4. Trial and failure of methocarbamol AND cyclobenzaprine AND 5. If all above met, may authorize total duration of therapy up to 3 weeks (NTE 2 tabs per day)

Quantity Limits:

Date: GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: DANTRIUM Generic Name: dantrolene Criteria: Diagnosis of clinical spasticity resulting from motor neuron disorders (e.g. spinal cord injury, stroke, cerebral palsy or multiple sclerosis) AND • Failure or clinically significant adverse effects to ONE of the formulary alternatives: baclofen or tizanidine AND • Baseline Liver function test provided • Dose NTE 400mg/day

Quantity Limits:

Date: GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: SKELAXIN Generic Name: metaxalone Criteria: Diagnosis of ACUTE muscle spasm or pain AND • 18 years of age and older • Chart notes and clear treatment plan provided by MD, including anticipated treatment duration • Trial and failure of formulary methocarbamol AND cyclobenzaprine

Quantity Limits: 4/day

Date: GTC: SKELETAL MUSCLE DISORDER: 1Q Brand Name: NORFLEX Generic Name: orphanadrine, orphenadine er NORFLEX ER Criteria: Diagnosis of ACUTE muscle spasm or pain AND • 18 years of age and older • Chart notes and clear treatment plan provided by MD, including anticipated treatment duration • Trial and failure of formulary methocarbamol AND cyclobenzaprine

Quantity Limits: 2/day

Date: December 2017 (Updated) GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: PYLERA Generic Name: bismuth subcitrate/metronidazole/tetracycline

Criteria: Diagnosis of H. Pylori treatment AND inability to use the individual agents concurrently (Bismuth salicylate salt, metronidazole, tetracycline)

Quantity Limits: 120

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: DEXILANT DR CAPSULE Generic Name: dexlansoprazole dr capsule

Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND has inadequate response or intolerable side effect to maximum tolerated dosing of 4 of the preferred alternatives: omeprazole, lansoprazole, pantoprazole, esomeprazole*, or rabeprazole* *Prior Authorization Required

Quantity Limits: 1 capsule/day

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: NEXIUM DR CAPSULE Generic Name: esomeprazole dr capsule Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD),GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND • Has inadequate response or intolerable side effect to maximum tolerated dosing of omeprazole, lansoprazole, and pantoprazole

Quantity Limits: 20mg: 1 capsule/day 40mg: 2 capsules/day

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: NEXIUM DR POWDER FOR SUSPENSION Generic Name: esomeprazole dr powder for oral suspension packet

Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer OR Zollinger-Ellison Syndrome AND has inadequate response OR intolerable side effect to maximum tolerated dosing of 4 of the following preferred alternatives: omeprazole, lansoprazole, pantoprazole, esomeprazole* DR capsule, OR rabeprazole* IF unable to swallow the above preferred alternatives: • Unable to use omeprazole OR lansoprazole capsules opened AND sprinkled in applesauce AND • Has inadequate response OR intolerable side effect to First–Omeprazole** AND First-Lansoprazole** suspension. *Prior Authorization Required **Prior Authorization Required if older than 5yo

Quantity Limits: 1 packet/day

Date: December 2016 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: PEPCID Generic Name: famotidine oral suspension Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer, or Zollinger-Ellison AND • Has inadequate response, intolerable side effect, or unable to use ranitidine syrup and famotidine tablets

Quantity Limits:

Date: May 2019 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: CUVPOSA Generic Name: glycopyrrolate oral solution Criteria: Diagnosis of chronic drooling AND patient is between ages 3-16 AND patient has inadequate response, intolerable side effect, or contraindication to glycopyrrolate tablets

Quantity Limits:

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: PREVACID SOLUTABS Generic Name: lansoprazole oral disintegrating tablet (odt) Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND • Has inadequate response or intolerable side effect to maximum tolerated dosing of 4 of the preferred alternatives: omeprazole, lansoprazole capsule, pantoprazole, esomeprazole*, or rabeprazole* If unable to swallow above preferred alternatives: • Unable to use omeprazole or lansoprazole capsules opened and sprinkled in applesauce AND • Has inadequate response or intolerable side effect to First–Omeprazole** AND First-Lansoprazole** suspension *Prior Authorization Required *Prior Authorization Required if older than 5yo

Quantity Limits: 15mg: 1 tablet/day 30mg: 2 tablets/day

Date: GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: PREVPAC Generic Name: lansoprazole/amoxicillin/clarithromycin

Criteria: Diagnosis of H.Pylori treatment AND inability to use the individual agents concurrently

Quantity Limits: 112 pills

Date: December 2016 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: FIRST-OMEPRAZOLE Generic Name: omeprazole 2mg/ml oral suspension & lansoprazole 3mg/ml FIRST-LANSOPRAZOLE oral suspension Criteria: First-omeprazole and First-lansoprazole are formulary for patients younger than or equal to 5 years of age. For patients older than 5 years of age: • Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer, or Zollinger-Ellison AND • Unable to use omeprazole or lansoprazole capsules opened and sprinkled in applesauce

Quantity Limits:

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: PRILOSEC DR GRANULES FOR SUSPENSION Generic Name: omeprazole granules for oral suspension packet

Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND • Has inadequate response or intolerable side effect to maximum tolerated dosing of 4 of the preferred alternatives: omeprazole, lansoprazole capsule, pantoprazole, esomeprazole*, or rabeprazole* If unable to swallow above preferred alternatives: • Unable to use omeprazole or lansoprazole capsules opened and sprinkled in applesauce AND • Has inadequate response or intolerable side effect to First–Omeprazole** AND First-Lansoprazole** suspension *Prior Authorization Required *Prior Authorization Required if older than 5yo

Quantity Limits: 1 packet/day

Date: GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: OMECLAMOX-PAK Generic Name: omeprazole/amoxicillin/clarithromycin

Criteria: Diagnosis of H.Pylori treatment AND inability to use the individual agents concurrently

Quantity Limits: 80 pills

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: ZEGERID CAPSULE Generic Name: omeprazole/sodium bicarbonate oral capsule

Quantity Limits: 1 capsule/day

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: ZEGERID POWDER FOR SUSPENSION Generic Name: omeprazole/sodium bicarbonate powder packet for oral suspension Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND • Has inadequate response or intolerable side effect to maximum tolerated dosing of 4 of the preferred alternatives: omeprazole, lansoprazole, pantoprazole, esomeprazole*, or rabeprazole* If unable to swallow above preferred alternatives: • Unable to use omeprazole or lansoprazole capsules opened and sprinkled in applesauce AND • Has inadequate response or intolerable side effect to First–Omeprazole** AND First-Lansoprazole** suspension *Prior Authorization Required **Prior Authorization Required if older than 5yo

Quantity Limits: 1 packet/day

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: PROTONIX DR GRANULES FOR SUSPENSION Generic Name: pantoprazole granules for oral suspension & packet

Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND • Has inadequate response or intolerable side effect to maximum tolerated dosing of 4 of the preferred alternatives: omeprazole, lansoprazole, pantoprazole, esomeprazole*, or rabeprazole* If unable to swallow above preferred alternatives: • Unable to use omeprazole or lansoprazole capsules opened and sprinkled in applesauce AND • Has inadequate response or intolerable side effect to First–Omeprazole** AND First-Lansoprazole** suspension *Prior Authorization Required **Prior Authorization Required if older than 5yo

Quantity Limits: 1 packet/day

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J Brand Name: ACIPHEX DR SPRINKLE CAPSULE Generic Name: rabeprazole dr sprinkle capsule

Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD), GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND • Has inadequate response or intolerable side effect to maximum tolerated dosing of 4 of the preferred alternatives: omeprazole, lansoprazole, pantoprazole, esomeprazole*, or rabeprazole* If unable to swallow above preferred alternatives: • Unable to use omeprazole or lansoprazole capsules opened and sprinkled in applesauce AND • Has inadequate response or intolerable side effect to First–Omeprazole** AND First-Lansoprazole** suspension *Prior Authorization Required **Prior Authorization Required if older than 5yo

Quantity Limits: 1 capsule/day

Date: October 2018 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J

Brand Name: ACIPHEX DR TABLET Generic Name: rabeprazole dr tablet Criteria: Diagnosis of Gastroesophageal Reflux Disease (GERD),GI distress, heartburn, stomach ulcer or Zollinger-Ellison Syndrome AND has inadequate response or intolerable side effect to maximum tolerated dosing of omeprazole, lansoprazole, and pantoprazole

Quantity Limits: 2 tablets/day

Date: December 2016 GTC: UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE: 1J

Brand Name: ZANTAC Generic Name: ranitidine oral capsules Criteria: Use ranitidine tablets.

Quantity Limits:

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: ENABLEX Generic Name: darifenacin Criteria: Diagnosis of overactive bladder or urinary incontinence or urgency AND has inadequate response or intolerable side effect to maximum tolerated dosing to 2 of the following: oxybutynin ER, tolterodine ER or trospium.

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: AVODART Generic Name: dutasteride Criteria: Diagnosis of Benign Prostatic Hyperplasia AND has inadequate response or intolerable side effect to maximum tolerated dosing of finasteride

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: JALYN Generic Name: dutasteride/tamsulosin Criteria: Diagnosis of Benign Prostatic Hyperplasia AND has inadequate response or intolerable side effect to finasteride and tamsulosin as 2 separate drugs taken concurrently

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: TOVIAZ Generic Name: fesoterodine er

Criteria: Diagnosis of overactive bladder or urinary incontinence or urgency AND has inadequate response or intolerable side effect to maximum tolerated dosing to 2 of the following: oxybutynin ER, tolterodine ER or trospium.

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: MYRBETRIQ Generic Name: mirabegron er Criteria: Diagnosis of overactive bladder or urinary incontinence or urgency AND has inadequate response or intolerable side effect to maximum tolerated dosing to 2 of the following: oxybutynin ER, tolterodine ER or trospium.

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: GELNIQUE 3% PUMP OR 10% SACHET Generic Name: oxybutynin Criteria: Diagnosis of overactive bladder or urinary incontinence or urgency AND • Has inadequate response or intolerable side effect to maximum tolerated dosing to 2 of the following: oxybutynin ER, tolterodine ER or trospium AND • Inadequate response or intolerable side effect to Oxytrol patch (OTC formulation)

Quantity Limits: 1 sachet/day or 92gm/30 day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: OXYTROL 3.9MG/24HR PATCH Generic Name: oxybutynin Criteria: Diagnosis of overactive bladder or urinary incontinence or urgency AND • Has inadequate response or intolerable side effect to maximum tolerated dosing to 2 of the following: oxybutynin ER, tolterodine ER or trospium AND • Only required if female: inadequate response or intolerable side effect to Oxytrol For Women patch (OTC formulation)

Quantity Limits: 8 patches/28 days

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: ELMIRON Generic Name: pentosan polysulfate sodium Criteria: Diagnosis of chronic interstitial cystitis or painful bladder syndrome

Quantity Limits: 3 capsules/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: RAPAFLO Generic Name: silodosin Criteria: Diagnosis of Benign Prostatic Hyperplasia AND • Has inadequate response or intolerable side effect to maximum tolerated dosing to 2 of the 4 formulary alternatives: tamsulosin, alfuzosin, terazosin, or doxazosin.

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: VESICARE Generic Name: solifenacin

Criteria: Diagnosis of overactive bladder OR urinary incontinence OR urgency AND has inadequate response OR intolerable side effect to maximum tolerated dosing to 2 of the following: oxybutynin ER, tolterodine ER OR trospium.

Quantity Limits: 1 tab/day

Date: GTC: URINARY TRACT - FUNCTIONAL DISORDERS: 2B Brand Name: TROSPIUM ER CAPSULE Generic Name: trospium er capsule Criteria: Trial and failure of tolterodine ER capsule or oxybutynin ER tablet, or medical justification for why they cannot be used

Quantity Limits:

Date: September 2017 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R

Brand Name: INJECTAFER Generic Name: ferric carboxymaltose 750mg/15ml vial Criteria: Diagnosis of iron-deficiency anemia AND • Laboratory evidence of iron deficiency anemia AND • Has inadequate response, intolerable side effect or contraindication to oral iron therapy AND • Has inadequate response, intolerable side effect or contraindication to 1 of the 3 formulary alternatives: iron sucrose, sodium ferric gluconate or iron dextran.

Quantity Limits: 750mg IV infusion for 2 doses per course of therapy

Date: September 2017 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: FERAHEME Generic Name: ferumoxytol 510mg/17ml vial Criteria: Diagnosis of iron-deficiency anemia AND • Laboratory evidence of iron deficiency anemia AND • Has inadequate response, intolerable side effect or contraindication to oral iron therapy AND • Has inadequate response, intolerable side effect or contraindication to 1 of the 3 formulary alternatives: iron sucrose, sodium ferric gluconate or iron dextran.

Quantity Limits: 510mg IV infusion for 2 doses per course of therapy

Date: September 2017 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: INFED Generic Name: iron dextran 100mg/2ml vial Criteria: Diagnosis of iron-deficiency anemia AND • Laboratory evidence of iron deficiency anemia AND • Has inadequate response, intolerable side effect or contraindication to oral iron therapy

Quantity Limits:

Date: September 2017 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: VENOFER Generic Name: iron sucrose 100mg/5ml vial Criteria: Diagnosis of iron-deficiency anemia AND • Laboratory evidence of iron deficiency anemia AND • Has inadequate response, intolerable side effect or contraindication to oral iron therapy

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PRENATAL 19 Generic Name: pnv #119/iron fumarate/folic acid/dss 29-1-25mg oral tablet

Criteria: Formulary OTC-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PNV #133/FERROUS FUMARATE/FOLIC ACID 28-0.8MG ORAL Generic Name: pnv #133/ferrous fumarate/folic acid 28-0.8mg oral tablet TABLET

Criteria: Formulary OTC-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PNV #95/IRON FUMARATE/FOLIC ACID 28-0.8MG ORAL TABLET Generic Name: pnv #15/iron carbonyl/dss/folic acid 90-50-1mg oral caplet

Criteria: Formulary RX-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PNV #96/FERROUS FUMARATE/FOLIC ACID 27-0.8MG ORAL Generic Name: pnv #15/iron carbonyl/folic acid/dss 90-1-50mg oral tablet TABLET

Criteria: Formulary RX-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PNV #36/CALCIUM/IRON/FOLIC ACID 13.5-0.4MG ORAL CAPSULE Generic Name: pnv #36/calcium/iron/folic acid 13.5-0.4mg oral capsule

Criteria: Formulary OTC-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: ONE-A-DAY WOMEN’S PRENATAL DHA, ONE DAILY PRENATAL Generic Name: pnv #75/iron fumarate/fa/om3/dha/epa 28-800-440mg oral combo pack (tabs/caps)

Criteria: Formulary OTC-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PNV #95/IRON FUMARATE/FOLIC ACID 28-0.8MG ORAL TABLET Generic Name: pnv #95/iron fumarate/folic acid 28-0.8mg oral tablet

Criteria: Formulary OTC-PNV

Quantity Limits:

Date: September 2016 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PNV #96/FERROUS FUMARATE/FOLIC ACID 27-0.8MG ORAL Generic Name: pnv #96/ferrous fumarate/folic acid 27-0.8mg oral tablet TABLET

Criteria: Formulary OTC-PNV

Quantity Limits:

Date: July 2018 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: PRENATAL Generic Name: prenatal vitamin Criteria: • Limited to use during pregnancy or lactation • Women of childbearing age • Generic only • Not used as an alternative to regular multivitamin supplementation

Quantity Limits: 1 tablet/day

Date: September 2017 GTC: VITAMINS AND MINERALS DEFICIENCY: 1R Brand Name: FERRLECIT Generic Name: sodium ferric gluconate 62.5 mg/5ml vial Criteria: • Diagnosis of iron-deficiency anemia AND • Laboratory evidence of iron deficiency anemia AND • Has inadequate response, intolerable side effect or contraindication to oral iron therapy.

Quantity Limits:

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: EVEKEO Generic Name: amphetamine

Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5% weight lost.

Diagnosis is Attention Deficit Hyperactivity Disorder(ADHD) or Attention Deficit Disorder (ADD) AND • Has inadequate response, intolerable side effect or contraindication to formulary ADHD stimulant medications (1 product from the methylphenidate class and 1 from the amphetamine class) Diagnosis of Narcolepsy • Has inadequate response, intolerable side effect or contraindication to formulary stimulant medications (1 product from the methylphenidate class and 1 from the amphetamine class)

Quantity Limits: 3 tablets/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: DIDREX Generic Name: benzphetamine REGIMEX

Quantity Limits: 3 tablets/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: TENUATE Generic Name: diethylproprion Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost.

Quantity Limits: IR: 4tabs/day ER: 1 tab/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: SAXENDA Generic Name: liraglutide Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost.

Quantity Limits:

Date: February 2019 GTC: WEIGHT REDUCTION – 2K Brand Name: BELVIQ Generic Name: lorcaserin Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost.

Quantity Limits: 2 tabs/day

Date: February 2019 GTC: WEIGHT REDUCTION – 2K Brand Name: BELVIQ XR Generic Name: lorcaserin Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost.

Quantity Limits: 1 tabs/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: CONTRAVE Generic Name: naltrexone/ buproprion er Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost.

Quantity Limits: 4 tabs/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: XENICAL/ALLI Generic Name: orlistat Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • If request is for Xenical, redirect to the preferred alternative Alli Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost

Quantity Limits: Xenical: 3 tabs/day Alli: 6 tabs/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: BONTRIL Generic Name: phendimetrazine Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications

Reauthorization after 12 weeks: • Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: • Requires at least a 5% weight lost from baseline weight or maintenance of 5 % weight lost

Quantity Limits: IR: 3 tabs/day ER: 1 tab/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: ADIPEX Generic Name: phentermine SUPRENZA ODT Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications

Quantity Limits: 2 tablets/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: ADIPEX Generic Name: phentermine SUPRENZA ODT

Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications. Reauthorization after 12 weeks: Requires at least a 2.5% weight lost from baseline weight Reauthorization after 24 weeks: Requires at least a 5% weight lost from baseline weight or maintenance of 5% weight lost.

Quantity Limits: Approve for 12 weeks. 2 tablets/day

Date: GTC: WEIGHT REDUCTION – 2K Brand Name: QSYMIA Generic Name: phentermine/topiramate er Criteria: Diagnosis of BMI ≥ 30 with no risk factors or ≥ 27 with at least 1 risk factor: • Metabolic Conditions • Hypertension • Dyslipidemia • Prediabetes • Type 2 Diabetes • Metabolic Syndrome • NAFLD/NASH • Sleep Apnea • PCOS • Osteoarthritis • Stress Incontinence • GERD • Disability/Immobility • Psychological Disorder/Stigmatization AND • Patient has failed diet and lifestyle modifications AND • Has inadequate response, intolerable side effect, or contraindication to the preferred alternative phentermine or Alli

Quantity Limits: