Prior Authorization Detail Updated on 9/1/2021

Selected Formulary: 2021 Medicare Assured℠ | CMS Formulary ID: 00021431 | CMS Version: 21

Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration ABEMACICLIB (VERZENIO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ABIRATERONE ACETATE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (YONSA) Indications. oncologist or hematologist

ABIRATERONE ACETATE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (ZYTIGA) Indications. oncologist or hematologist

ABOBOTULINUMTOXINA 1 - All FDA-approved Diagnosis. 12 months For reauthorization: documentation from prescriber indicating (DYSPORT) Indications. stabilization or improvement in condition. ACALABRUTINIB (CALQUENCE) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ACITRETIN (SORIATANE) 1 - All FDA-approved Diagnosis. Must have severe disease covering at least 10% to 20% of the body surface area (not required if Coverage is provided for By or in consultation with a 12 months Indications. on palms, soles, head/neck, genitalia). Must have adequate trial of methotrexate or cyclosporine with members 18 years of age dermatologist inadequate response or significant side effect/toxicity or have a contraindication to these therapies. For and older. female members of reproductive potential, documentation of 2 negative urine or serum pregnancy tests before receiving the initial acitretin prescription.

ADALIMUMAB (HUMIRA) 1 - All FDA-approved Coverage is not provided for Diagnosis. For rheumatoid arthritis (RA): history of trial and failure, contraindication, or intolerance to a 3 Member must be 2 years By or in consultation with a 12 months For hidradenitis suppurativa (HS): moderate to severe disease with 3 Indications. use of once weekly doses of month trial with methotrexate or another DMARD. For juvenile idiopathic arthritis (JIA): history of trial of age or older. rheumatologist, active abscesses, inflammatory nodules, or lesions with adequate trial of Humira in combination with and failure, contraindication, or intolerance to a 3 month trial with methotrexate, leflunomide, or gastroenterologist, an oral antibiotic with inadequate response or side effects/toxicities methotrexate. Coverage is not sulfasalazine. For psoriatic arthritis (PsA): history of trial and failure, contraindication, or intolerance to a 4 ophthalmologist, or unless contraindicated. For uveitis: adequate trial of a corticosteroid or provided for use of Humira in week trial of 2 NSAIDs, and for moderate to severe psoriatic arthritis indicated by the presence of at least dermatologist. immunomodulator with inadequate response or side effects/toxicities combination with other ONE of the following: erosive disease, elevated markers of inflammation attributable to psoriatic arthritis, unless contraindicated. For reauth: must have documentation from biologic DMARDS (e.g., long-term damage that interferes with function (i.e., joint deformities), highly active disease that causes a prescriber indicating stabilization or improvement in condition. anakinra and abatacept) or major impairment in quality of life, active PsA at many sites including dactylitis, enthesitis, function-limiting other TNF blockers. Evidence PsA at a few sites, and/or rapidly progressive disease. For ankylosing spondylitis (AS): history of trial and of infection. failure, contraindication, or intolerance to a 4 week trial each of at least 2 NSAIDs. For plaque psoriasis: minimum BSA involvement of at least 5% (not required if on palms, soles, head/neck, genitalia), a history of trial and failure, contraindication, or intolerance to a three-month trial of systemic treatment (methotrexate, cyclosporine, oral retinoids, etc.). For Crohns (CD): history of trial and failure, contraindication, or intolerance to 2 of the following therapy options: aminosalicylates, corticosteroids, or immunomodulators with inadequate response or side effects/toxicity unless contraindicated. For Ulcerative Colitis (UC): history of trial and failure, contraindication, or intolerance to 2 of the following therapy options: aminosalicylates, corticosteroids, antibiotics, or immunomodulators with inadequate response or side effects/toxicity unless contraindicated.

AFATINIB DIMALEATE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (GILOTRIF) Indications. oncologist or hematologist

AGALSIDASE BETA 1 - All FDA-approved Diagnosis. For males: must have diagnosis of Fabry disease based upon clinical symptoms and less than 12 months (FABRAZYME) Indications. 35% alpha-Gal A leukocyte activity or by genetic testing. For females: must have presumed symptoms of Fabry disease (heterozygous carriers) based on genetic testing.

ALECTINIB (ALECENSA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ALIROCUMAB (PRALUENT) 1 - All FDA-approved Diagnosis. Must have confirmed diagnosis of heterozygous familial hypercholesterolemia (see Other By or in consultation with a 12 months For ASCVD: must have chart documentation confirming history of at least Indications. Criteria), clinical atherosclerotic cardiovascular disease (ASCVD, see Other Criteria), or primary cardiologist, endocrinologist, one of the following: myocardial infarction or other acute coronary hyperlipidemia. Must have baseline LDL-cholesterol levels greater than or equal to 100 mg/dL (w/o ASCVD), or lipid specialist. syndromes (including ST-elevation myocardial infarction, non-ST elevation 70mg/dL (w/ ASCVD), or 55mg/dl if has extreme risk designation (see Other Criteria). Must have failed to myocardial infarction, and unstable angina), coronary or other achieve goal LDL-C reduction after an adequate trial consisting of 8 consecutive weeks of 1 high intensity revascularization procedure, ischemic stroke or transient ischemic attack, statin (atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily) OR LDL-C level is above target despite a atherosclerotic peripheral arterial disease. For HeFH: must have chart trial of 8 consecutive weeks of 2 moderate-intensity statins (atorvastatin or rosuvastatin) at the member's documentation of one of the following: A score of greater than 8 using maximally tolerated dose OR documentation the member is determined to be intolerant to statin therapy, the Dutch Lipid Clinic Network criteria, Simon-Broome criteria leading to a provider attestation of intolerance to statin therapy consisting of statin related rhabdomyolysis or skeletal- definite diagnosis, or genetic testing confirming a point mutation in LDLR, muscle related symptoms while receiving at least 2 separate trials of different statin therapy which APOB, PCSK9, or LDLRAP1 genes. Extreme risk: must have one of the resolved upon discontinuation of statin therapy OR statin treatment is contraindicated (defined as following: progressive ASCVD, including unstable angina, that persists documented active liver disease, which may include unexplained persistent elevations in hepatic after achieving an LDL-C less than 70 mg/dL, or established clinical transaminase levels or muscle symptoms with statin treatment with CK elevations greater than 10 times cardiovascular disease in individuals with diabetes, stage 3 or 4 chronic upper limit of normal) and has documentation of a labeled contraindication to all statins. If able to tolerate kidney disease (CKD), or heterozygous familial hypercholesterolemia ( statin, must continue treatment with statin at maximally tolerated dose. HeFH), or a history of premature ASCVD (less than 55 years of age for males, less than 65 for females) . For reauthorization documentation of improvement in LDL from baseline and continued treatment with maximally tolerated statin dose (if applicable). Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration ALOSETRON (LOTRONEX) 1 - All FDA-approved Constipation. Concomitant use Diagnosis. Documentation of chronic IBS symptoms diarrhea lasting at least 6 months. Gastrointestinal Coverage is provided for By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. of fluvoxamine. Male gender. tract abnormalities have been ruled out. Must have trial of loperamide and dicyclomine used in the members 18 years of age Gastroenterologist stabilization or improvement in condition. History of chronic or severe treatment of IBS-D with inadequate response or significant side effects/toxicity unless contraindicated and older. constipation or sequelae from constipation, intestinal obstruction, stricture, toxic megacolon, gastrointestinal perforation and/or adhesions, ischemic colitis, impaired intestinal circulation, thrombophlebitis, or hypercoagulable state, Crohn's disease, ulcerative colitis, diverticulitis, or severe hepatic impairment.

ALPELISIB (PIQRAY) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ALPHA-1 PROTEINASE 1 - All FDA-approved Diagnosis. Must have Pi*ZZ, Pi*Z(null), Pi*(null)(null), or Pi*SZ protein phenotypes (homozygous) OR other Coverage is provided for By or in consultation with a Initial: 6 months For reauthorization: documentation from prescriber indicating INHIBITOR (PROLASTIN) Indications. rare AAT deficiency disease-causing alleles associated with serum AAT level less than 11 micromoles per members 18 years of age pulmonologist Reauthorization improvement in condition. liter. Must have a serum AAT level less than 11 micromoles per liter (80 milligrams per deciliter if and older. : 12 months measured by radial immunodiffusion or 50 milligrams per deciliter if measure by nephelometry). Must have a predicted FEV1 value between 30 and 65% OR FEV1 from greater than 65% to less than 80% of predicted, post-bronchodilator, and a rapid decline in lung function showing a change in FEV1 greater than 100 mL/year except for members with concomitant necrotizing panniculitis.

ALPHA-1 PROTEINASE 1 - All FDA-approved Diagnosis. Must have Pi*ZZ, Pi*Z(null), Pi*(null)(null), or Pi*SZ protein phenotypes (homozygous) OR other Coverage is provided for By or in consultation with a Initial: 6 For reauthorization: documentation from prescriber indicating INHIBITOR (ZEMAIRA) Indications. rare AAT deficiency disease-causing alleles associated with serum AAT level less than 11 micromoles per members 18 years of age pulmonologist months, improvement in condition. liter. Must have a serum AAT level less than 11 micromoles per liter (80 milligrams per deciliter if and older. Reauthorization measured by radial immunodiffusion or 50 milligrams per deciliter if measure by nephelometry). Must : 12 months have a predicted FEV1 value between 30 and 65% OR FEV1 from greater than 65% to less than 80% of predicted, post-bronchodilator, and a rapid decline in lung function showing a change in FEV1 greater than 100 mL/year except for members with concomitant necrotizing panniculitis.

AMBRISENTAN (LETAIRIS) 1 - All FDA-approved Pregnancy Diagnosis. Pulmonary arterial hypertension (PAH) WHO Group I confirmed by chart documentation of right- Prescribed by or in Initial For reauth: documentation from prescriber that demonstrates member is Indications. heart catheterization (RHC) indicating a mean pulmonary arterial pressure greater than or equal to 20 consultation with cardiologist authorization: 3 tolerating and receiving clinical benefit from treatment mmHg, pulmonary vascular resistance greater than 3 wood units, and mean pulmonary capillary wedge or pulmonologist. months pressure less than 15 mmHg. If provider indicates RHC is not recommended, must have documentation of Reauthorization an echocardiography. : 12 months

AMITRIPTYLINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, Viibryd, trazodone or mirtazapine for applies to enrollees aged depression. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

AMOXAPINE (ASENDIN) 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 of Prior authorization only 12 months Indications. the following for depression: a SSRI (except paroxetine), SNRI, mirtazapine, or bupropion applies to enrollees aged 65 or older. All enrollees less than age 65 are not subject to prior authorization.

APALUTAMIDE (ERLEADA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

APREPITANT (EMEND) 1 - All FDA-approved Diagnosis. If being prescribed to prevent postoperative nausea and vomiting must be for capsule and dosed 6 months For reauthorization: must have documentation from prescriber indicating Indications. within 3 hours of anesthesia induction with a prior failure of ondansetron. stabilization or improvement in condition.

ARIPIPRAZOLE INJECTION 1 - All FDA-approved Diagnosis. Documentation of prior trial and failure of oral aripiprazole (Abilify) therapy. 12 months (ABILIFY MAINTENA) Indications. ARIPIPRAZOLE TABLET WITH 1 - All FDA-approved Dementia-related psychosis Diagnosis. Documentation the member had at least a one-month trial of oral aripiprazole (Abilify) therapy. Coverage is provided for 12 months SENSOR (ABILIFY MYCITE) Indications. members 18 years of age and older. ASENAPINE (SAPHRIS) 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic atypical antipsychotics. 12 months Indications. ASENAPINE TRANSDERMAL 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic atypical antipsychotics. 12 months SYSTEM (SECUADO) Indications.

ASPARAGINASE ERWINIA 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months CHRYSANTHEMI Indications. oncologist or hematologist (RECOMBINANT)-RYWN (RYLAZE) ATROPINE/DIPHENOXYLATE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of Prior authorization only 12 months (LOMOTIL) Indications. loperamide. applies to enrollees aged 65 or older. All enrollees less than age 65 are not subject to prior authorization. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration AVAPRITINIB (AYVAKIT) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

AVATROMBOPAG (DOPTELET) 1 - All FDA-approved Diagnosis. For ITP, documentation of inadequate response to corticosteroids or immunoglobulins or By or in consultation with a Chronic ITP: 6 For reauth of chronic ITP: documentation of improvement in platelet Indications. splenectomy and documentation of a platelet count less than or equal to 30,000/microliter. For hematologist, oncologist, or months. count from baseline. thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure, hepatologist Thrombocytope documentation of a platelet count less than 50,000/microliter. nia in patients with chronic liver disease: 1 month

AXITINIB (INLYTA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

AZACITIDINE (ONUREG) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

AZTREONAM LYSINE 1 - All FDA-approved Diagnosis. Must have a diagnosis of cystic fibrosis AND a positive sputum cultures for Pseudomonas Coverage is provided for 12 months For reauthorization: must have documentation from prescriber indicating (CAYSTON) Indications. aeruginosa. Documentation of a FEV1 greater than 25% or less than 75% predicted. members 7 years of age stabilization or improvement in condition. and older. BEDAQUILINE (SIRTURO) 1 - All FDA-approved Diagnosis. Must have either inadequate response to a first-line tuberculosis regimen containing isoniazid Member must be 5 years By or in consultation with a 6 months Indications. and rifampin OR chart documentation of resistance to isoniazid or rifampin per susceptibility testing. Must of age or older. pulmonologist or infectious weigh at least 15 kg. disease specialist.

BELIMUMAB (BENLYSTA) (IV 1 - All FDA-approved Severe active central nervous Diagnosis of active, autoantibody-positive, systemic lupus erythematosus (SLE) or lupus nephritis. Must Coverage is provided for By or in consultation with a 12 months For reauth: documentation from the prescriber indicating stabilization or FORMULATION) Indications. system lupus. Combination have ANA of at least 1:80 or anti-dsDNA of at least 30 IU/ml to support being autoantibody positive. Must members 5 years of age rheumatologist, hematologist, improvement in condition. therapy with other biologics or be currently taking or has tried and failed or had an intolerance or contraindication to at least one standard and older for SLE or 18 or nephrologist IV cyclophosphamide. therapy for systemic lupus erythematosus (e.g. corticosteroids, antimalarials, NSAIDS, or years or older for lupus immunosuppressives) or lupus nephritis (e.g. corticosteroids, mycophenolate, cyclophosphamide, nephritis azathioprine). Diagnosis of active lupus nephritis. Documentation of a biopsy-proved lupus nephritis Class III, IV or V.

BELIMUMAB (BENLYSTA) (SQ) 1 - All FDA-approved Severe active central nervous Diagnosis of active, autoantibody-positive, systemic lupus erythematosus (SLE) or lupus nephritis. Must Coverage is provided for By or in consultation with a 12 months For reauth: documentation from the prescriber indicating stabilization or Indications. system lupus. Combination have ANA of at least 1:80 or anti-dsDNA of at least 30 IU/ml to support being autoantibody positive. Must members 18 years of age rheumatologist, hematologist, improvement in condition. therapy with other biologics or be currently taking or has tried and failed or had an intolerance or contraindication to at least one standard and older. or nephrologist IV cyclophosphamide. therapy for systemic lupus erythematosus (e.g. corticosteroids, antimalarials, NSAIDS, or immunosuppressives) or lupus nephritis (e.g. corticosteroids, mycophenolate, cyclophosphamide, azathioprine). Diagnosis of active lupus nephritis. Documentation of a biopsy-proved lupus nephritis Class III, IV or V.

BEXAROTENE GEL 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (TARGRETIN) Indications. oncologist or hematologist

BINIMETINIB (MEKTOVI) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

BOSENTAN (TRACLEER) 1 - All FDA-approved Pregnancy Diagnosis. Pulmonary arterial hypertension (PAH) WHO Group I confirmed by chart documentation of right- Prescribed by or in Initial For reauth: documentation from prescriber that demonstrates member is Indications. heart catheterization (RHC) indicating a mean pulmonary arterial pressure greater than or equal to 20 consultation with cardiologist authorization: 3 tolerating and receiving clinical benefit from treatment mmHg, pulmonary vascular resistance greater than 3 wood units, and mean pulmonary capillary wedge or pulmonologist. months pressure less than 15 mmHg. If provider indicates RHC is not recommended, must have documentation of Reauthorization an echocardiography. : 12 months

BOSUTINIB (BOSULIF) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

BRIGATINIB (ALUNBRIG) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

BRIVARACETAM (BRIVIACT) 1 - All FDA-approved Diagnosis. Must have tried and failed or intolerant to levetiracetam and at least one other generic Coverage is provided for By or in consultation with a 12 months Indications. anticonvulsant indicated for partial-onset seizures (e.g. lamotrigine, topiramate, etc.). members 4 years of age neurologist and older BUDESONIDE EXTENDED 1 - All FDA-approved Diagnosis. Must have a trial and failure, a contraindication, or an intolerance to two (2) of the following Member must be 18 years By or in consultation with a 8 weeks For reauth: must have documentation from prescriber indicating RELEASE TABLETS (UCERIS) Indications. therapy options: aminosalicylates, corticosteroids, antibiotics, or immunomodulators with inadequate of age or older. rheumatologist or stabilization or improvement in condition. response or side effects/toxicity unless contraindicated. gastroenterologist.

BUROSUMAB-TWZA 1 - All FDA-approved Use with oral phosphate or Diagnosis. For X-linked hypophosphatemia: confirmation of the diagnosis by at least one of the following: A By or in consultation with a 12 months Reauthorization: Documentation current (within the past 12 months) (CRYSVITA) Indications. active vitamin D analogs genetic test showing a PHEX gene mutation (phosphate regulating gene with homology to endopeptidase physician who is experienced serum phosphorus level is not above the upper limit of the laboratory on the X chromosome) or Serum fibroblast growth factor 23 (FGF23) level greater than 30 pg/mL. in the management of normal reference range and documentation the member has had a Documentation of a baseline fasting serum phosphorus concentration that is below the reference range for patients with metabolic bone positive clinical response or stabilization in their disease. the members age (reference range must be provided). For FGF23-related hypophosphatemia in tumor- disease. induced osteomalacia (TIO): documentation the member has a phosphaturic mesenchymal tumor that cannot be resected or localized. Documentation of a baseline fasting serum phosphorus concentration that is below the reference range for the members age (reference range must be provided).

BUT/APAP/CAF TAB 1 - All FDA-approved Diagnosis. This Prior Authorization requirement only applies to members when a non-FDA approved Coverage is provided for 12 months Indications. diagnosis is submitted. FDA-approved diagnosis codes submitted will pay without prior authorization members 12 years of age requirement. or older. BUTAL/APAP TAB 50-325MG 1 - All FDA-approved Diagnosis. This Prior Authorization requirement only applies to members when a non-FDA approved Coverage is provided for 12 months Indications. diagnosis is submitted. FDA-approved diagnosis codes submitted will pay without prior authorization members 12 years of age requirement. or older. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration C1 ESTERASE INHIBITOR 1 - All FDA-approved Diagnosis of HAE is confirmed by laboratory values obtained on two separate instances (laboratory reports Coverage is provided for Prescribed by or in Initial: 3 months For reauth: must have documentation from prescriber indicating (CINRYZE) Indications. must contain reference ranges). For Type I: Low C4 level and low C1-INH antigenic level. For Type II: Low C4 members 6 years of age consultation with an Reauthorization improvement in condition. level and normal or elevated C1-INH antigenic level and low C1-INH functional level. Must have or older. allergist/immunologist, : 12 months documentation of a previous HAE attack in the absence of hives or a medication known to cause hematologist, dermatologist angioedema to demonstrate member is candidate for prophylactic therapy. Member must not be taking any medications that may exacerbate HAE, including angiotensin-converting enzyme (ACE) inhibitors, Tamoxifen, and estrogen-containing medications. Must be using Cinryze as prophylactic therapy for the prevention of HAE attacks.

CABOZANTINIB (CABOMETYX) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

CABOZANTINIB (COMETRIQ) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

CANNABIDIOL (EPIDIOLEX) 1 - All FDA-approved Diagnosis. Documentation member's seizures are uncontrolled while stable on antiepileptic drug therapy. Member must be 1 year By or in consultation with a 12 months Indications. of age or older neurologist CAPMATINIB (TABRECTA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months Indications. oncologist or hematologist

CARGLUMIC ACID (CARBAGLU) 1 - All FDA-approved Diagnosis. By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating Indications. physician who specializes in stabilization or improvement in condition. the treatment of inherited metabolic disorders.

CARIPRAZINE (VRAYLAR) 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic atypical antipsychotics. 12 months Indications. CEFTAROLINE (TEFLARO) 1 - All FDA-approved Diagnosis of community-acquired bacterial pneumonia OR Diagnosis of Acute bacterial skin and skin 14 days Indications. structure infection (ABSSSI) with history of treatment failure with or contraindication to vancomycin therapy for ABSSSI. CENOBAMATE (XCOPRI) 1 - All FDA-approved Familial QT syndrome Diagnosis. Coverage is provided for By or in consultation with a 12 months Indications. members 18 years of age neurologist. or older CERITINIB (ZYKADIA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

CLOMIPRAMINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 of Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. the following: fluoxetine, fluvoxamine, and sertraline. applies to enrollees aged stabilization or improvement in condition. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

COBIMETINIB FUMARATE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (COTELLIC) Indications. oncologist or hematologist

CRIZOTINIB (XALKORI) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

CYPROHEPTADINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document contraindication to, intolerance to or Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. clinical failure of cetirizine and levocetirizine for use as an antihistamine. applies to enrollees aged stabilization or improvement in condition. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

CYSTEAMINE (CYSTAGON) 1 - All FDA-approved Diagnosis. Must have documentation of CTNS gene mutation, elevated white blood cell cystine levels By or in consultation with a Initial: 3 months For reauth: must have documentation from prescriber indicating Indications. greater than 2nmol per half-cystine per mg of protein, or cystine corneal crystals by slit lamp examination. nephrologist or physician who Reauthorization improvement in condition and a reduction in WBC cystine levels since specializes in the treatment of : 12 months starting treatment with oral cysteamine inherited metabolic disorders

DABRAFENIB (TAFINLAR) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

DACOMITINIB (VIZIMPRO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

DALFAMPRIDINE (AMPYRA) 1 - All FDA-approved History of seizure disorder, Diagnosis of multiple sclerosis. Chart documentation of baseline motor disability or dysfunction. Coverage is provided for Neurologist Initial: 3 months For reauthorization: must have documentation from prescriber indicating Indications. moderate to severe renal members 18 years of age Reauthorization stabilization or improvement in condition. impairment (CrCl less than or or older. : 12 months equal to 50 mL/min).

DARATUMUMAB- 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months HYALURONIDASE (DARZALEX) Indications. oncologist or hematologist

DARBEPOETIN ALFA 1 - All FDA-approved Uncontrolled hypertension Diagnosis. Must have Hgb level less than 10 g/dL. 6 months For reauth for CKD on dialysis: must have a Hgb less than or equal to (ARANESP) Indications. 11g/dl. For reauth for CKD not on dialysis: must have Hgb less than or equal to 10 g/dl. For pediatric members with CKD: must have a Hgb less than or equal to 12 g/dl. Reauth for all other dx must meet initial criteria.

DAROLUTAMIDE (NUBEQA) 3 - All Medically-accepted Diagnosis. Coverage is provided for By or in consultation with an 6 months Indications. members 18 years of age oncologist or hematologist and older. DASATINIB (SPRYCEL) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration DECITABINE-CEDAZURIDINE 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months (INQOVI) Indications. oncologist or hematologist

DEFERIPRONE (FERRIPROX) 1 - All FDA-approved Diagnosis. Must have transfusional iron overload due to thalassemia syndromes. Must have Prescribed by or in 12 months For reauth: documentation from prescriber indicating stabilization or Indications. documentation of a trial and failure of Exjade (this requires a PA) unless contraindicated . consultation with a improvement in condition. hematologist DEGARELIX ACETATE 3 - All Medically-accepted Diagnosis. Coverage is provided for By or in consultation with an 6 months (FIRMAGON) Indications. members 18 years of age oncologist or hematologist and older. DENOSUMAB (PROLIA) 1 - All FDA-approved Diagnosis. Member must have a history of trial and failure, contraindication, or intolerance to the Coverage is provided for 12 months For reauthorization must have attestation from prescriber indicating Indications. following: At least one oral bisphosphonate therapy (e.g. alendronate or risedronate). For postmenopausal members 18 years of age stabilization or improvement in condition. osteoporosis in females or to increase bone mass in males with osteoporosis at moderate to high risk of and older fracture must have at least one of the following: 1. a bone mineral density T-score of less than or equal to - 2.5 at conventional skeletal sites including the total hip, femoral neck, lumbar spine, or 33% radius. 2. a T- score between -1.0 and -2.5 at the lumbar spine, total hip, femoral neck, or 33% radius and either a 10-year probability for major osteoporotic fracture of greater than or equal to 20% or the 10-year probability of hip fracture greater than or equal to 3% based on the U.S. adapted World Health Organization (WHO) algorithm (also known as FRAX). 3. have a history of hip, spine, or wrist fracture as an adult. For females with breast cancer: must be receiving aromatase inhibitor therapy. For males with non-metastatic prostate cancer: must be receiving androgen deprivation therapy. For glucocorticoid-induced osteoporosis: must be on at least 7.5 mg per day oral prednisone (or equivalent) for at least 3 months and planning to continue treatment for at least 6 months and have one of the following: 1. a bone mineral density Z score less than - 3 at the hip or spine. 2. a greater than or equal to 10% per year bone loss at hip or spine. 3. bone mineral density T score less than or equal to -2.5 at the hip or spine. 4. history of fracture as an adult at hip, spine, or wrist. 5. FRAX (GC adjusted) 10-year risk for major osteoporotic fracture greater than or equal to 10%. 6. FRAX (GC-adjusted) 10-year risk for hip fracture greater than or equal to 1%.

DENOSUMAB (XGEVA) 1 - All FDA-approved Pre-existing hypocalcemia, Diagnosis of prevention of skeletal-related events in members with multiple myeloma or bone metastases Prevention of skeletal- Prescribed by or in 6 months Indications. concurrent use of Prolia from solid tumors. For diagnosis of giant cell tumor: must have disease that is unresectable or where related events in consultation with a surgical resection is likely to result in severe morbidity and member must be skeletally mature if less than members with multiple hematologist or oncologist 18 years of age (defined by at least 1 mature long bone and a body weight of greater than or equal to 45 myeloma and in members kg). For diagnosis of hypercalcemia of malignancy: must have a trial and failure of one IV bisphosphonate with bone metastases therapy (i.e. etidronate disodium, zoledronic acid, or pamidronate disodium) with failure defined as an from solid tumors or albumin-corrected calcium greater than 12.5mg/dL (3.1 mmol/L) despite recent treatment with an IV hypercalcemia of bisphosphonate. malignancy: age 18 years or older.

DESFERASIROX (EXJADE) 1 - All FDA-approved Glomerular Filtration Rate less Diagnosis. For chronic iron overload due to blood transfusions: pretreatment serum ferritin level is greater Prescribed by or in 12 months For reauth: documentation from prescriber indicating stabilization or Indications. than 40mL/min/1.73 m2. than 1000 mcg/L. For chronic iron overload due to non-transfusion-dependent thalassemia (NTDT) consultation with a improvement in condition. Concomitant advanced syndromes: pretreatment serum ferritin level is greater than 300 mcg/L and a liver iron concentration of at hematologist malignancy or high risk least 5mg iron per gram dry weight. myelodysplastic syndrome. Platelet count less than 50000000000/L

DESIPRAMINE (NORPRAMIN) 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, viibryd, trazodone or mirtazapine for applies to enrollees aged stabilization or improvement in condition. depression. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

DEUTETRABENAZINE 1 - All FDA-approved Uncontrolled depression, Diagnosis. For chorea: must have confirmed Huntington's disease either by Huntington Disease Mutation Coverage is provided for By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating (AUSTEDO) Indications. actively suicidal, hepatic analysis (with laboratory result indicating expanded CAG repeat of greater than or equal to 36 in the members 18 years of age neurologist or psychiatrist stabilization or improvement in condition. impairment, concurrent use Huntington gene) or a positive family history of Huntington's Disease with autosomal dominant inheritance or older with MAOI's, reserpine, pattern, must have clinical signs of Huntington's Disease including chart documentation of a clinical work- tetrabenazine, or valbenazine. up showing one or more of the following signs: motor (e.g. finger tapping, rigidity), oculomotor, bulbar (e.g. dysarthria, dysphagia), affective (e.g. depression), cognitive. For tardive dyskinesia (TD): must have moderate to severe TD according to the DSM V criteria including involuntary athetoid or choreiform movements and has a history of treatment with neuroleptic agent (i.e. antipsychotic). Adjustments to possible offending medication such as dose reduction or discontinuation were attempted but ineffective in resolving TD symptoms or member is not a candidate for dose reduction or discontinuation of the offending medication. If the member is using the offending medication for a behavioral health indication, the use of a second generation atypical antipsychotic has been attempted unless contraindicated. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration DEXTROMETHORPHAN- 1 - All FDA-approved Members on quinidine, Diagnosis. Pseudobulbar affect (PBA): documentation supporting the following: involuntary outbursts of Coverage is provided for By or in consultation with Initial: 3 months For reauthorization: Documentation indicating a decrease in the number QUINIDINE (NUEDEXTA) Indications. quinine, mefloquine, MAOIs in laughing and/or crying that are incongruent or disproportionate to the member's emotional state AND members 18 years of age neurologist Reauthorization of laughing and/or crying episodes since starting the medication. the last 14 days, drugs that other possible conditions that could result in emotional lability (e.g. depression, bipolar disorder, and older. : 12 months prolong the QT interval and schizophrenia, epilepsy) have been ruled out. Must have underlying neurological disorder such as are metabolized by CYP2D6. amyotrophic lateral sclerosis, multiple sclerosis, Alzheimer's and related diseases, Stroke, Traumatic Brain Diagnosis of prolonged QT Injury, or Parkinsonian Syndrome. interval, congenital long QT syndrome or a history suggestive of torsade's de pointes, heart failure, complete AV (atrioventricular) block without an implanted pacemaker, or high risk of complete AV block, History of quinine-, mefloquine-, dextromethorphan/quinidine-, or quinidine-induced thrombocytopenia, hepatitis, bone marrow depression, or lupus-like syndrome. History of hypersensitivity to dextromethorphan.

DICLOFENAC TOPICAL GEL 1 - All FDA-approved Diagnosis. 90 days For reauthorization: documentation from prescriber indicating (SOLARAZE) Indications. stabilization or improvement in condition. DICYCLOMINE (BENTYL) 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure to Prior authorization only 12 months Indications. loperamide. applies to enrollees aged 65 or older. All enrollees less than age 65 are not subject to prior authorization.

DIHYDROERGOTAMINE NASAL 1 - All FDA-approved Members with hemiplegic or Diagnosis. Documentation of trial and failure of 1 medication from each of the following classes: a NSAID Coverage is provided for 12 months For reauth: documentation from prescriber indicating stabilization or SPRAY (MIGRANAL) Indications. basilar migraine, ischemic and a triptan unless contraindicated. members 18 years of age improvement in condition. heart disease (angina pectoris, and older. history of MI, or documented silent ischemia) or who have clinical symptoms or findings consistent with coronary artery vasospasm (including Prinzmetal's variant angina or uncontrolled hypertension).

DIMETHYL FUMARATE 1 - All FDA-approved Combination therapy with Diagnosis. Coverage is provided for By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating (TECFIDERA) Indications. Tecfidera and non- members 18 years of age neurologist stabilization or improvement in condition. corticosteroid and older. immunosuppressive therapy, antineoplastic therapy, and other disease modifying MS agents (e.g., Avonex, Copaxone, Rebif, Gilenya, Aubagio, etc.) is not covered.

DORNASE ALFA (PULMOZYME) 1 - All FDA-approved Diagnosis. By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. pulmonologist or cystic stabilization or improvement in condition. fibrosis specialist DOXEPIN (SINEQUAN) 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, Viibryd, trazodone or mirtazapine for applies to enrollees aged depression. For all other FDA approved indications, no prior drug trials are required. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

DRONABINOL 1 - All FDA-approved Diagnosis. Nausea and vomiting associated with cancer chemotherapy: must have trial of two conventional 12 months For reauth: must have documentation from prescriber indicating Indications. antiemetic treatments (e.g., ondansetron, aprepitant, metoclopramide, dexamethasone, prochlorperazine) stabilization or improvement in condition. with inadequate response or significant side effects/toxicity unless contraindicated.

DROXIDOPA (NORTHERA) 1 - All FDA-approved Diagnosis. Documentation of a clinical diagnosis of symptomatic neurogenic orthostatic hypotension Coverage is provided for 2 weeks For reauth: rationale from the provider for continuing therapy beyond 2 Indications. caused by one of the following: Primary autonomic failure (Parkinson's disease, multiple system atrophy, or members 18 years of age weeks pure autonomic failure), dopamine beta-hydroxylase deficiency or non-diabetic autonomic neuropathy. and older. Must have a trial of midodrine with inadequate response or significant side effects/toxicity unless contraindicated.

DUVELISIB (COPIKTRA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration ELBASVIR- GRAZOPREVIR 1 - All FDA-approved Members with moderate or Criteria will be applied consistent with current AASLD/IDSA guidance and/or FDA approved labeling Coverage is provided for By or in consultation with a Criteria will be (ZEPATIER) Indications. severe hepatic impairment members who are age- gastroenterologist, applied (Child-Pugh B or C) or those appropriate according to hepatologist, infectious consistent with with any history of hepatic AASLD/IDSA guidance disease or transplant current decompensation due to the and/or FDA-approved specialist. AASLD/IDSA risk of hepatic labeling. guidance and/or decompensation. FDA approved Coadministration with labeling inhibitors of organic anion transporting polypeptides 1B1/3 (OATP1B1/3) that are known or expected to significantly increase grazoprevir plasma concentrations, strong inducers of cytochrome P450 3A (CYP3A), and efavirenz.

ELEXACAFTOR/TEZACAFTOR/I 1 - All FDA-approved Diagnosis. Documentation of genetic test confirming the member has at least one F508del mutation in the Coverage is provided for By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating VACAFTOR (TRIKAFTA) Indications. CFTR gene or a mutation in the CFTR gene that is responsive based on in vitro data. members 6 years of age cystic fibrosis specialist or stabilization or improvement in condition. Repeat AST/ALT are less than 5 and older pulmonologist times the upper normal limit and must not have repeat lab results with both AST/ALT greater than 3 times the upper normal limit AND bilirubin greater than 2 times the upper normal limit.

ELTROMBOPAG (PROMACTA) 1 - All FDA-approved Diagnosis. For ITP, documentation of inadequate response to corticosteroids or immunoglobulins or By or in consultation with a 6 months For reauth: for all dx documentation of improvement in platelet count Indications. splenectomy and documentation of a platelet count less than or equal to 30,000/microliter. For chronic hematologist, oncologist, from baseline. For hepatitis C: documentation the member is still on hepatitis C, documentation that thrombocytopenia prevents the initiation of interferon-based therapy or gastroenterologist, or antiviral therapy. limits the ability to maintain interferon-based therapy, and documentation of a platelet count less than hepatologist 75,000/microliter. For severe aplastic anemia, documentation of a platelet count less than 30,000/microliter and one of the following: the member has had an insufficient response to immunosuppressive therapy or the members will be using the medication in combination with immunosuppressive therapy .

ENASIDENIB (IDHIFA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ENCORAFENIB (BRAFTOVI) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ENTECAVIR (BARACLUDE) 1 - All FDA-approved Diagnosis. For HBeAG-positive chronic HBV members, serum HBV DNA greater than 20,000 IU/mL AND By or in consultation with an 12 months For reauth: documentation from prescriber that demonstrates member is Indications. evidence of persistent elevations in serum aminotransferase (ALT or AST) at least 2 times the upper limit of infectious disease physician, tolerating and receiving clinical benefit from treatment normal or histologically active disease (i.e. moderate to severe inflammation or significant fibrosis on gastroenterologist, biopsy). For HBeAG-negative chronic HBV members, serum HBV DNA greater than 2,000 IU/mL AND hepatologist, or transplant evidence of persistent elevations in serum aminotransferase (ALT or AST) at least 2 times the upper limit of physician normal or histologically active disease (i.e. moderate to severe inflammation or significant fibrosis on biopsy). If member has HIV co-infection, member is receiving anti-retroviral therapy.

ENTRECTINIB (ROZLYTREK) 3 - All Medically-accepted Diagnosis. For NTRK gene fusion- By or in consultation with an 6 months Indications. positive solid tumors: 12 oncologist or hematologist years and older, For ROS1- positive NSCLC: 18 years of age and older

ENZALUTAMIDE (XTANDI) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

EPOETIN ALFA-EPBX 1 - All FDA-approved Uncontrolled hypertension Diagnosis. For Reduction of Allogeneic Red Blood Cell Transfusions in Members Undergoing Elective, 6 months For reauth for CKD on dialysis: must have a Hgb less than or equal to (RETACRIT) Indications. Noncardiac, Nonvascular Surgery: must have hemoglobin (Hgb) greater than 10 and less than or equal to 13 11g/dl. For reauth for CKD not on dialysis: must have Hgb less than or g/dL, be at high risk for perioperative blood loss from surgery, and documentation that erythropoietin equal to 10 g/dl. For reauth for zidovudine treated members and pediatric therapy will be used to decrease the need for transfusions associated with surgery in members unwilling or members with CKD: must have a Hgb less than or equal to 12 g/dl. Reauth unable to undergo autologous blood donation prior to surgery. All other dx must have Hgb level less than for all other dx must meet initial criteria. 10 g/dL.

ERDAFITINIB (BALVERSA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ERENUMAB-AOOE (AIMOVIG) 1 - All FDA-approved Diagnosis. For episodic migraine: Documentation the member has 4 to 14 headache days per month. For Coverage is provided for By or in consultation with a Initial: 6 months A migraine is defined as a headache that has at least two of the following Indications. chronic migraine: Documentation the member has at least 15 headache days per month for 3 or more members 18 years of age neurologist, headache Reauthorization characteristics: unilateral location, pulsating/throbbing quality, moderate months with at least 8 migraine days per month. For both: Must have an adequate trial and failure of one and older specialist, or pain specialist : 12 months or severe intensity (inhibits or prohibits daily activities), is aggravated by beta-blocker and one anticonvulsant unless contraindicated or intolerant. routine activity, nausea and/or vomiting, photophobia and phonophobia. For reauthorization: must have documentation from prescriber indicating stabilization or improvement in condition.

ERLOTINIB (TARCEVA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration ETANERCEPT (ENBREL) 1 - All FDA-approved Diagnosis. For rheumatoid arthritis (RA): history of trial and failure, contraindication, or intolerance to a Member must be 2 years By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. three-month trial with methotrexate or another DMARD. For juvenile idiopathic arthritis (JIA): history of of age or older. rheumatologist or stabilization or improvement in condition. trial and failure, contraindication, or intolerance to a three-month trial with methotrexate, leflunomide, or dermatologist. sulfasalazine. For psoriatic arthritis (PsA): history of trial and failure, contraindication, or intolerance to a four-week trial of 2 NSAIDs, and must have moderate to severe PsA indicated by the presence of at least ONE of the following: erosive disease, elevated markers of inflammation attributable to psoriatic arthritis, long-term damage that interferes with function (i.e., joint deformities), highly active disease that causes a major impairment in quality of life, active PsA at many sites including dacylitis, enthesitis, function-limiting PsA at a few sites, and/or rapidly progressive disease. For ankylosing spondylitis (AS): history of trial and failure, contraindication, or intolerance to a four-week trial each of at least 2 NSAIDs. For plaque psoriasis: minimum BSA involvement of at least 5% (not required if on palms, soles, head/neck, genitalia), a history of trial and failure, contraindication, or intolerance to a three-month trial of systemic treatment (methotrexate, cyclosporine, oral retinoids, etc.).

EVEROLIMUS (AFINITOR AND 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months AFINITOR DISPERZ) Indications. oncologist or hematologist, or neurologist

EVEROLIMUS (ZORTRESS) 1 - All FDA-approved Diagnosis. 12 months Indications. FEDRATINIB (INREBIC) 1 - All FDA-approved Diagnosis of intermediate-2 or high-risk myelofibrosis (includes primary myelofibrosis, post-polycythemia Coverage is provided for By or in consultation with an 6 months For reauth: must have documentation from prescriber indicating Indications. vera myelofibrosis, and post-essential thrombocythemia myelofibrosis). members 18 years of age oncologist or hematologist stabilization or improvement in condition. or older. FENFLURAMINE (FINTEPLA) 1 - All FDA-approved Use of monoamine oxidase Diagnosis. Must have had an inadequate response or intolerance to two generic antiepileptic drugs (e.g. Member must be 2 years By or in consultation with a 12 months Indications. inhibitors within 14 days lamotrigine, topiramate, felbamate) of age or older neurologist

FENTANYL CITRATE 1 - All FDA-approved Acute or postoperative pain Diagnosis. Documentation the member has active cancer and is experiencing breakthrough pain despite By or in consultation with an 6 months Opioid tolerant is defined as being on around-the-clock medicine Indications. including headache/migraines being on around the clock opioid therapy. Must be opioid tolerant. Must currently be using a long-acting oncologist, pain specialist, or consisting of at least 60 mg of oral morphine per day, at least 25 mcg of and dental pain. opioid. hospice/palliative care transdermal fentanyl per hour, at least 30 mg of oral oxycodone per day, specialist at least 8 mg of oral hydromorphone per day, at least 25 mg oral oxymorphone per day, at least 60 mg oral hydrocodone per day, or an equianalgesic dose of another opioid daily for a week or longer. For reauthorization: Documentation the member still has active cancer and the member continues to have a medical need for the medication.

FERRIC CITRATE (AURYXIA) 1 - All FDA-approved Members with Iron overload Diagnosis of hyperphosphatemia in adult patients with CKD on dialysis. Must have an intolerance, Coverage provided for By or in consultation with a 12 months For reauth: documentation from prescriber indicating stabilization or Indications. syndromes (e.g. contraindication, or trial and failure of calcium acetate and sevelamer carbonate. members 18 years of age hematologist or nephrologist improvement in condition. hemochromatosis) are and older excluded from coverage. Use for iron deficiency anemia is excluded. FILGRASTIM-AAFI (NIVESTYM) 1 - All FDA-approved Diagnosis. 6 months For reauthorization: must have documentation from prescriber indicating Indications. stabilization or improvement in condition.

FILGRASTIM-SNDZ (ZARXIO) 1 - All FDA-approved Diagnosis. 6 months For reauthorization: must have documentation from prescriber indicating Indications. stabilization or improvement in condition.

FINGOLIMOD (GILENYA) 1 - All FDA-approved Combination therapy with Diagnosis. Coverage is provided for By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. Gilenya and non- members 10 years of age neurologist stabilization or improvement in condition. corticosteroid and older. immunosuppressive therapy, antineoplastic therapy, and other disease modifying MS agents (e.g., Avonex, Copaxone, Rebif, Tecfidera, Aubagio, etc.) is not covered. Recent (within last 6 months) myocardial infarction, unstable angina, stroke, transient ischemic attack, decompensated heart failure with hospitalization, or Class III/IV heart failure, history of Mobitz Type II 2nd degree or 3rd degree AV block or sick sinus syndrome, unless member has a pacemaker, baseline QTc interval greater than or equal to 500 msec, treatment with Class Ia or Class III anti-arrhythmic drugs

FLUCYTOSINE (ANCOBON) 1 - All FDA-approved Diagnosis. Treatment of systemic fungal infection: culture positive for Candidiasis or Cryptococcosis. 12 months Indications. FREMANEZUMAB-VFRM 1 - All FDA-approved Diagnosis. For episodic migraine: Documentation the member has 4 to 14 headache days per month. For Coverage is provided for By or in consultation with a Initial: 6 months A migraine is defined as a headache that has at least two of the following (AJOVY) Indications. chronic migraine: Documentation the member has at least 15 headache days per month for 3 or more members 18 years of age neurologist, headache Reauthorization characteristics: unilateral location, pulsating/throbbing quality, moderate months with at least 8 migraine days per month. For both: Must have an adequate trial and failure of one and older specialist, or pain specialist : 12 months or severe intensity (inhibits or prohibits daily activities), is aggravated by beta-blocker and one anticonvulsant unless contraindicated or intolerant. routine activity, nausea and/or vomiting, photophobia and phonophobia. For reauthorization: must have documentation from prescriber indicating stabilization or improvement in condition. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration GALSULFASE (NAGLAZYME) 1 - All FDA-approved Diagnosis. Documentation of deficiency in glycosaminoglycan-specific enzyme indicated for members with By or in consultation with 12 months For reauth: must have documentation from prescriber indicating Indications. Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome) physician who specializes in stabilization or improvement in condition. the treatment of inherited metabolic disorders

GEFITINIB (IRESSA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

GILTERITINIB (XOSPATA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

GIVOSIRAN (GIVLAARI) 1 - All FDA-approved Diagnosis. Coverage is provided for 12 months Reauthorization criteria: documentation the member had a positive Indications. members 18 years of age clinical response or stabilization in disease. or older GLASDEGIB (DAURISMO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

GLECAPREVIR-PIBRENTASVIR 1 - All FDA-approved Members with moderate or Criteria will be applied consistent with current AASLD/IDSA guidance and/or FDA approved labeling Coverage is provided for By or in consultation with a Criteria will be (MAVYRET) Indications. severe hepatic impairment members who are age- gastroenterologist, applied (Child-Pugh C). appropriate according to hepatologist, infectious consistent with Coadministration with AASLD/IDSA guidance disease or transplant current atazanavir and rifampin. and/or FDA-approved specialist. AASLD/IDSA labeling. guidance and/or FDA approved labeling

GLYCEROL PHENYLBUTYRATE 1 - All FDA-approved Diagnosis. Documentation member has urea cycle disorders (UCDs). Must have a trial of sodium By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating (RAVICTI) Indications. phenylbutyrate with inadequate response or significant side effects/toxicity unless contraindicated. physician who specializes in stabilization or improvement in condition. the treatment of inherited metabolic disorders.

GUANFACINE IR 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. alternatives such as nifedipine long-acting, amlodipine, felodipine. applies to enrollees aged stabilization or improvement in condition. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

HIGH RISK MEDICATION 1 - All FDA-approved Diagnosis. This Prior Authorization requirement only applies to members 65 years of age or older. Prior authorization only 12 months For reauthorization: Prescriber must acknowledge that medication Indications. Prescriber must acknowledge that medication benefits outweigh potential risks in the member 65 years of applies to enrollees aged benefits outweigh potential risks in the member 65 years of age or older. age or older. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

HUMAN CHORIONIC 1 - All FDA-approved Diagnosis. 12 months For reauthorization: documentation from prescriber indicating GONADOTROPIN (HCG) Indications. stabilization or improvement in condition. HYDROXYZINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. alternatives such as buspirone, citalopram, escitalopram, sertraline for anxiety OR cetirizine, levocetirizine applies to enrollees aged stabilization or improvement in condition. for pruritus. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

IBRUTINIB (IMBRUVICA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

ICATIBANT ACETATE (FIRAZYR) 1 - All FDA-approved Diagnosis of HAE is confirmed by laboratory values obtained on two separate instances (laboratory reports Coverage is provided for By or in consultation with an 12 months For reauthorization: documentation from prescriber indicating Indications. must contain reference ranges). For Type I HAE: Low C4 level and low C1-INH antigenic level. For Type II members 18 years of age allergist, immunologist, stabilization or improvement in condition. HAE: Low C4 level and Normal or elevated C1-INH antigenic level and low C1-INH functional level. There is a or older. hematologist, or documented history of at least one symptom of a moderate to severe HAE attack (i.e. moderate to severe dermatologist abdominal pain, facial swelling, airway swelling) in the absence of hives or a medication known to cause angioedema. Member must not be taking any medications that may exacerbate HAE, including angiotensin- converting enzyme (ACE) inhibitors, tamoxifen, or estrogen-containing medications.

IDELALISIB (ZYDELIG) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

IDURSULFASE (ELAPRASE) 1 - All FDA-approved Diagnosis. Documentation of deficiency in glycosaminoglycan-specific enzyme indicated for members with Coverage is provided for By or in consultation with 12 months For reauthorization: documentation from prescriber indicating Indications. Hunter syndrome (Mucopolysaccharidosis II). members 16 months of physician who specializes in stabilization or improvement in condition. age and older. the treatment of inherited metabolic disorders

ILOPERIDONE (FANAPT) 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic atypical antipsychotics. Coverage is provided for 12 months Indications. members 18 years of age or older. ILOPROST (VENTAVIS) 1 - All FDA-approved Diagnosis. Pulmonary arterial hypertension (PAH) WHO Group I confirmed by chart documentation of right- Coverage is provided for Prescribed by or in 12 months For reauthorization: documentation from prescriber that demonstrates Indications. heart catheterization (RHC) indicating a mean pulmonary arterial pressure greater than or equal to 20 members 18 years of age consultation with a member is tolerating and receiving clinical benefit from treatment mmHg, pulmonary vascular resistance greater than 3 wood units, and mean pulmonary capillary wedge or older. pulmonologist or cardiologist pressure less than 15 mmHg. If provider indicates RHC is not recommended, must have documentation of an echocardiography. Must have WHO Functional Class III-IV symptoms.

IMATINIB (GLEEVEC) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration IMIPRAMINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, trazodone or mirtazapine for depression. applies to enrollees aged stabilization or improvement in condition. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

INCOBOTULINUMTOXINA 1 - All FDA-approved Diagnosis. 12 months For reauthorization: documentation from prescriber indicating (XEOMIN) Indications. stabilization or improvement in condition. INFIGRATINIB (TRUSELTIQ) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

INFLIXIMAB-ABDA 1 - All FDA-approved Doses greater than 5mg/kg in Diagnosis. For rheumatoid arthritis (RA): history of trial and failure, contraindication, or intolerance to a For RA, PsA, AS, Plaque By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating (RENFLEXIS) Indications. moderate to severe heart three-month trial with methotrexate and another DMARD. For psoriatic arthritis (PsA): history of trial and Psoriasis: coverage is rheumatologist, stabilization or improvement in condition. failure. failure, contraindication, or intolerance to a four-week trial of 2 NSAIDs, and for moderate to severe provided for members 18 gastroenterologist, or psoriatic arthritis indicated by the presence of at least ONE of the following: erosive disease, elevated years of age or older. For dermatologist. markers of inflammation attributable to psoriatic arthritis, long-term damage that interferes with function CD, UC: coverage is (i.e., joint deformities), highly active disease that causes a major impairment in quality of life, active PsA at provided for members 6 many sites including dactylitis, enthesitis, function-limiting PsA at a few sites, and/or rapidly progressive years of age or older. disease. For ankylosing spondylitis (AS): history of trial and failure, contraindication, or intolerance to a four-week trial each of at least 2 NSAIDs. For plaque psoriasis: minimum BSA involvement of at least 5% (not required if on palms, soles, head/neck, genitalia), a history of trial and failure, contraindication, or intolerance to a three-month trial of systemic treatment (methotrexate, cyclosporine, oral retinoids, etc.). For Crohns (CD): history of trial and failure, contraindication, or intolerance to 2 of the following therapy options: aminosalicylates, corticosteroids, or immunomodulators with inadequate response or side effects/toxicity unless contraindicated. For Ulcerative Colitis (UC): history of trial and failure, contraindication, or intolerance to 2 of the following therapy options: aminosalicylates, corticosteroids, antibiotics, or immunomodulators with inadequate response or side effects/toxicity unless contraindicated.

INFLIXIMAB-DYYB (INFLECTRA) 1 - All FDA-approved Diagnosis. For RA (rheumatoid arthritis): History of trial and failure, contraindication, or intolerance to a For RA, PsA, AS, Plaque By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. three-month trial with methotrexate or another DMARD. For psoriatic arthritis (PsA): History of trial and Psoriasis: Coverage is rheumatologist, stabilization or improvement in condition. failure, contraindication, or intolerance to a four-week trial of 2 NSAIDs, and moderate to severely psoriatic provided for members 18 gastroenterologist, or arthritis indicated by the presence of at least ONE of the following: Erosive Disease, elevated markers of years of age or older. For dermatologist. inflammation attributable to psoriatic arthritis, long-term damage that interferes with function (i.e., joint CD, UC: Coverage is deformities), highly active disease that causes a major impairment in quality of life, active PsA at many sites provided for members 6 including dactylitis, enthesitis, function-limiting PsA at a few sites, and/or rapidly progressive disease. For years of age or older. ankylosing spondylitis (AS): History of trial and failure, contraindication, or intolerance to a four-week trial each of at least 2 NSAIDs. For plaque psoriasis: minimum BSA involvement of at least 5% (not required if on palms, soles, head/neck, genitalia), a history of trial and failure, contraindication, or intolerance to a three- month trial of systemic treatment (methotrexate, cyclosporine, oral retinoids, etc.) For Crohns (CD): History of trial and failure, contraindication, or intolerance to 2 of the following therapy options: aminosalicylates, corticosteroids, or immunomodulators with inadequate response or side effects/toxicity unless contraindicated. For Ulcerative Colitis (UC): History of trial and failure, contraindication, or intolerance to 2 of the following therapy options: aminosalicylates, corticosteroids, antibiotics, or immunomodulators with inadequate response or side effects/toxicity unless contraindicated.

IVABRADINE (CORLANOR) 1 - All FDA-approved Acute decompensated heart Diagnosis. For Adult Chronic Heart Failure (CHF): Must have left ventricular ejection fraction (LVEF) less CHF: coverage is provided By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating Indications. failure, blood pressure less than or equal to 35%, member is in sinus rhythm and has a resting heart rate of greater than or equal to 70 for members 18 years of cardiologist stabilization or improvement in condition. than 90/50 mmHG, sick sinus beats per minute, must currently be taking a beta-blocker (e.g., bisoprolol, carvedilol, metoprolol succinate) age or older. DCM: syndrome, sinoatrial block, or at the maximally tolerated dose or has a contraindication to beta-blocker use. For Pediatric Dilated coverage is provided for 3rd degree AV block-unless a Cardiomyopathy (DCM): Must have stable symptomatic heart failure with left ventricular ejection fraction members 6 months of age functioning demand less than or equal to 45%, must be in sinus rhythm, must have an elevated heart rate (greater than or or older. pacemaker is present, resting equal to 105 beats per minute (BPM) for 6-12 months of age, greater than or equal to 95 for 1-3 years of heart rate less than 60 bpm age, greater than or equal to 75 for 3-5 years of age, greater than or equal to 70 for 5-18 years of age). prior to treatment, severe hepatic impairment, pacemaker dependence (heart rate maintained exclusively by the pacemaker), concomitant use of strong CYP3A4 inhibitors.

IVACAFTOR (KALYDECO) 1 - All FDA-approved Diagnosis. Documentation of genetic test confirming the member has at least one mutation in the CFTR Coverage is provided for By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating Indications. gene that is responsive to ivacaftor based on clinical and/or in vitro assay data. members 6 months of age pulmonologist or cystic stabilization or improvement in condition. or older. fibrosis specialist

IVOSIDENIB (TALZENNA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

IVOSIDENIB (TIBSOVO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

IXAZOMIB CITRATE (NINLARO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration IXEKIZUMAB (TALTZ) 1 - All FDA-approved Diagnosis. For psoriatic arthritis (PsA) and ankylosing spondylitis (AS): Must have a trial and failure, For plaque psoriasis: By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. contraindication, or intolerance to a four-week trial of an NSAID and a trial and failure, contraindication, or member must be 6 years rheumatologist or stabilization or improvement in condition. intolerance to a TNF inhibitor (ie. etanercept (Enbrel), adalimumab (Humira), infliximab-abda (Renflexis)). of age or older. All other dermatologist. For plaque psoriasis: must have a trial and failure, contraindication, or intolerance to a three-month trial of diagnoses: member must systemic treatment (ie. methotrexate, cyclosporine, oral retinoids) and a trial and failure, contraindication, be 18 years of age or or intolerance to a TNF inhibitor (ie. etanercept (Enbrel), adalimumab (Humira), infliximab-abda older. (Renflexis)). For non-radiographic axial spondyloarthritis (nr-axSpA): must have a trial and failure, contraindication, or intolerance to a four-week trial with 2 different NSAIDs.

LANREOTIDE (SOMATULINE 1 - All FDA-approved Diagnosis. For acromegaly: must have inadequate response to surgery or radiotherapy or documentation Coverage is provided for By or in consultation with an For oncology For reauth: documentation of improvement or stabilization. DEPOT) Indications. that these therapies are inappropriate, must have the following baseline labs: elevated serum IGF-1 level members 18 years of age endocrinologist or oncologist indications: 6 for gender/age range (including lab reference range) and elevated growth hormone level defined as GH at and older. months. All least 1ng/mL during oral glucose tolerance test. other indications: 12 months LAPATINIB (TYKERB) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

LARONIDASE (ALDURAZYME) 1 - All FDA-approved Diagnosis. Member must have Hurler or Hurler-Scheie forms of Mucopolysaccharidosis I (MPS I). Members By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating Indications. with the Scheie form must have moderate to severe symptoms. Documentation of deficiency in physician who specializes in stabilization or improvement in condition. glycosaminoglycan-specific enzyme. the treatment of inherited metabolic disorders

LAROTRECTINIB (VITRAKVI) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

LEDISPASVIR-SOFOSBUVIR 1 - All FDA-approved Criteria will be applied consistent with current AASLD/IDSA guidance and/or FDA approved labeling Coverage is provided for By or in consultation with a Criteria will be (HARVONI) Indications. members who are age- gastroenterologist, applied appropriate according to hepatologist, infectious consistent with AASLD/IDSA guidance disease or transplant current and/or FDA-approved specialist. AASLD/IDSA labeling. guidance and/or FDA-approved labeling.

LENALIDOMIDE (REVLIMID) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

LENVATINIB (LENVIMA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

LETROZOLE/RIBOCICLIB 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (KISQALI FEMARA CO-PACK) Indications. oncologist or hematologist

LEUPROLIDE ACETATE 1 - All FDA-approved Diagnosis. For endometriosis: Documentation the member has tried and failed or has a contraindication to Prostate cancer For reauth: documentation indicating stabilization or improvement in Indications. 2 conventional treatments such as oral contraceptives, non steroidal anti-inflammatory agents, progestins, and condition. For endometriosis, a single retreatment course of not more or danazol. For CPP: Documentation that the age of onset of secondary sexual characteristics occurred at endometriosis: than six months may be administered after the initial course of treatment less than 8 years of age in a female child or less than 9 years of age in a male child 6 months. CPP if symptoms recur or Fibroids: 3 months

LEUPROLIDE- 1 - All FDA-approved Diagnosis. Documentation the drug will be used for initial management of the painful symptoms of 6 months For reauth: documentation indicating stabilization or improvement in NORETHINDRONE Indications. endometriosis or for the management of recurrence of symptoms of endometriosis. condition. A single retreatment course of not more than six months may (LUPANETA) be administered after the initial course of treatment if symptoms recur.

LEVETIRACETAM (SPRITAM) 1 - All FDA-approved Diagnosis. Must have had an inadequate response or intolerance to generic levetiracetam and one other Coverage is provided for By or in consultation with a 12 months Indications. generic antiepileptic drug (such as carbamazepine, oxcarbazepine, or phenytoin). members 4 years of age neurologist. and older weighing more than 20kg.

LIDOCAINE PATCH 1 - All FDA-approved Diagnosis. 12 months For reauthorization: Documentation the member still has an appropriate (LIDODERM) Indications. diagnosis and the member continues to have a medical need for the medication. LOMUSTINE (GLEOSTINE) 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months Indications. oncologist or hematologist

LORLATINIB (LORBRENA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

LUMACAFTOR/IVACAFTOR 1 - All FDA-approved Diagnosis. Documentation of a genetic test confirming that the member has two copies of the F508del Coverage is provided for By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating (ORKAMBI) Indications. mutation in the CFTR gene. members 2 years of age pulmonologist or cystic stabilization or improvement in condition, repeat AST/ALT are less than 5 or older. fibrosis specialist times the upper normal limit and must not have repeat lab results with both AST/ALT greater than 3 times the upper normal limit AND bilirubin greater than 2 times the upper normal limit.

LUMATEPERONE (CAPLYTA) 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic atypical antipsychotics. Coverage is provided for 12 months Indications. members 18 years of age and older. MACITENTAN (OPSUMIT) 1 - All FDA-approved Pregnancy Diagnosis. Pulmonary arterial hypertension (PAH) WHO Group I confirmed by chart documentation of right- Prescribed by or in Initial: 3 months For reauth: documentation from prescriber that demonstrates member is Indications. heart catheterization (RHC) indicating a mean pulmonary arterial pressure greater than or equal to 20 consultation with cardiologist Reauth: 12 tolerating and receiving clinical benefit from treatment mmHg, pulmonary vascular resistance greater than 3 wood units, and mean pulmonary capillary wedge or pulmonologist. months pressure less than 15 mmHg. If provider indicates RHC is not recommended, must have documentation of echocardiography. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration MECASERMIN (INCRELEX) 1 - All FDA-approved Coverage is not provided for Diagnosis. Growth chart and documentation that epiphyses are open. For growth hormone deletion: must Coverage is provided for By or in consultation with an 12 months For reauth, must include a recent progress note from prescriber indicating Indications. members with active or have growth hormone (GH) gene deletion in gene GH1 and developed neutralizing antibodies to GH members 2 years of age Endocrinologist growth and maturation as a result of treatment and that epiphyses have suspected neoplasia, known therapy. For growth failure due to severe IGF-1 deficiency: must have dx of severe IGF-1 deficiency (defined or older. not closed. hypersensitivity to as having all of the following: height below or equal to 3.0 standard deviation (SD) of the mean for age and mecasermin, closed sex, basal IGF-1 SD of less than or equal to 3.0 based on lab reference range, normal or elevated GH defined epiphyses, secondary forms of as stimulated serum GH level of greater than 10ng/mL or basal serum GH level greater than 5ng/mL). IGF-1 deficiency such as GH deficiency, malnutrition, hypothyroidism, or chronic treatment with pharmacologic doses of anti-inflammatory steroids.

MECHLORETHAMINE HCL 3 - All Medically-accepted Diagnosis. By or in consultation with a 6 months (VALCHLOR) Indications. Dermatologist, Oncologist, or Hematologist

MEPERIDINE (DEMEROL) 1 - All FDA-approved Diagnosis. Failure or clinically significant adverse effects to two of the following: tramadol, morphine, 12 months For reauthorization: documentation from prescriber indicating Indications. oxycodone immediate release with acetaminophen, or hydrocodone. stabilization or improvement in condition.

MEPOLIZUMAB (NUCALA) 1 - All FDA-approved Diagnosis. For severe eosinophilic asthma: eosinophil blood count greater than or equal to Asthma: Coverage is Severe eosinophillic asthma: 12 months Severe eosinophilic asthma 1st reauth: evidence of improvement by Indications. 150cells/microliter within last six weeks or greater than or equal to 300cells/microliter within the last 12 provided for members 6 Prescribed by or in meeting 1 of the following: (1) reduction in asthma symptoms, (2) months. Documentation of inadequate response, intolerance, or contraindication to a high-dose ICS in years of age and older. consultation with an allergist, reduction in dose and frequency on inhaled steroids compared to combination with a LABA. Meets one of the following within the past year: one or more acute asthma- EGPA: Coverage is immunologist, or baseline (but not discontinued), or (3) reduction in acute asthma related ED visit(s), one or more acute inpatient visits where asthma was the principal diagnosis, or two or provided for members 18 pulmonologist. EGPA: exacerbations requiring oral systemic steroids. Subsequent reauths: more acute asthma exacerbations requiring oral systemic steroids. For relapsing or refractory eosinophilic years of age and older. Prescribed by or in Evidence of reduction or stability in any of the three areas outlined in 1st granulomatosis with polyangiitis (EGPA): patient has relapsing or refractory disease despite treatment with HES: Coverage is provided consultation with an reauth. EGPA reauth: documentation from prescriber indicating oral corticosteroid and/or immunosuppressive therapy (e.g. azathioprine, methotrexate, mycophenolic for members 12 years of immunologist, pulmonologist, stabilization or improvement in condition. HES reauth: documentation acid). For hypereosinophilic syndrome (HES): Must not be FIP1L1-PDGFRA kinase-positive or have non- age and older. or rheumatologist. HES: from prescriber indicating stabilization or improvement in condition. hematologic secondary HES (e.g., drug hypersensitivity, parasitic helminth infection, HIV infection, non- Prescribed by or in hematologic malignancy). Must provide documentation of at least 2 HES flares (worsening of clinical signs consultation with an and symptoms of HES or increasing eosinophils on at least 2 occasions) within the past 12 months and a immunologist or blood eosinophil count of 1,000 cells/mcL or higher during screening. Must provide documentation of trial rheumatologist and failure, contraindication, or intolerance to hydroxyurea or interferon alpha.

METHOTREXATE ORAL 3 - All Medically-accepted Diagnosis. Medical rationale why patient cannot take methotrexate tablet formulation. 6 months For reauthorization: documentation from prescriber indicating SOLUTION (XATMEP) Indications. stabilization or improvement in condition. METHSCOPOLAMINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months For reauthorization: documentation from prescriber indicating (PAMINE, PAMINE FORTE) Indications. alternative antiulcer agents (such as omeprazole, sucralfate, famotidine). applies to enrollees aged stabilization or improvement in condition. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

METHYLNALTREXONE 1 - All FDA-approved Diagnosis. For opioid-induced constipation and advanced life-limiting illness: must have documentation of Coverage is provided for 12 months For reauth: Documentation from the prescriber indicating an (RELISTOR) Indications. previous trial of lactulose. For opioid-induced constipation with chronic non-cancer pain: must have members 18 years of age improvement in condition (both diagnoses) and must continue to be on documentation of current and ongoing opioid therapy and must have adequate trials with inadequate and older. opioid therapy (non-cancer pain). . responses or significant side effects/toxicity or have a contraindication to naloxegol (Movantik) and lactulose . MIDOSTAURIN (RYDAPT) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

MIFEPRISTONE (KORLYM) 1 - All FDA-approved Diagnosis. Documentation of an adequate trial and failure of conventional anti-hyperglycemic medication. Coverage is provided for By or in consultation with an 12 months Indications. Female members of reproductive potential: must have baseline (within previous month, must include date members 18 years of age endocrinologist of test) negative pregnancy test prior to starting mifepristone and must be using nonhormonal medically and older. acceptable method of contraception (unless surgically sterilized) during treatment and for 1 month after mifepristone therapy.

MIGLUSTAT (ZAVESCA) 1 - All FDA-approved Miglustat is being used in Diagnosis. Documentation the member has at least one of the following: 1) anemia not due to iron Coverage is provided for By or in consultation with an 12 months Reauthorization: Documentation from the prescriber indicating Indications. combination with another deficiency with a low hemoglobin for age and sex, 2) thrombocytopenia 3) evidence of bone disease, 4) members 18 years of age appropriate specialist (i.e. improvement or stabilization in member's condition. therapy for Gaucher's disease presence of hepatomegaly or splenomegaly. Enzyme replacement therapy must not be a therapeutic and older. hematologist, geneticist, option for the member (i.e. due to allergy, hypersensitivity, or poor venous access). radiologist, orthopedist, endocrinologist, rheumatologist)

MODAFINIL (PROVIGIL) 1 - All FDA-approved Diagnosis. For narcolepsy: Sleep Study (e.g. Polysomnogram, Multiple Sleep Latency Test) confirming Coverage is provided for Sleep Specialist, ENT (ear, SWSD: 6 For reauthorization: must have documentation from prescriber indicating Indications. diagnosis and documentation of trial and failure of at least 2 stimulants (or documented clinical rationale as members 17 years of age nose, and throat specialist), months stabilization or improvement in condition. to why stimulants may not be used). For obstructive sleep apnea: Sleep study (e.g. polysomnogram) and older. neurologist, pulmonologist Narcolepsy, confirming diagnosis. For shift work sleep disorder (SWSD): must meet International Classification of Sleep OSA: 12 months Disorders criteria for SWSD (either primary complaint of excessive sleepiness or insomnia temporarily associated with work period that occurs during habitual sleep phase OR polysomnography and Multiple Sleep Latency Test demonstrate loss of normal sleep wake pattern, no other medical or mental disorders account for symptoms, and symptoms do not meet criteria for any other sleep disorder producing insomnia or excessive sleepiness such as time zone change syndrome) and must provide documentation of shift work schedule showing 5 or more night shifts per month (defined as at least 4 hours of shift occurring between 10pm and 8am).

MULTIPLE SCLEROSIS 1 - All FDA-approved Diagnosis. Documentation that functional status is preserved and patient is either still able to walk at least By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating THERAPIES Indications. a few steps or alternatively must have some functional arm/hand use consistent with performing activities neurologist stabilization or improvement in condition. of daily living. NERATINIB (NERLYNX) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration NETARSUDIL (RHOPRESSA) 1 - All FDA-approved Diagnosis. Member must have a baseline intraocular pressure of less than 30 mmHg. Documentation of Coverage is provided for 12 months For reauthorization: must have documentation from prescriber indicating Indications. trial and failure, contraindication, or intolerance to timolol and latanoprost. members 18 years of age stabilization or improvement in condition. and older. NILOTINIB (TASIGNA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

NINTEDANIB (OFEV) 1 - All FDA-approved Diagnosis. Must submit documentation of baseline liver function testing, including alanine Coverage provided for By or in consultation with a Initial: 3 For reauth: must have documentation from prescriber indicating that Indications. aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin. For a diagnosis of Idiopathic members age 18 years pulmonologist months, member still is a candidate for treatment and showing that liver function Pulmonary Fibrosis (IPF): Must have diagnosis confirmed by either high-resolution computed tomography and older. Reauth: 6 tests (including ALT, AST, and bilirubin) are being monitored regularly. (HRCT) or surgical lung biopsy and must have all other diagnoses ruled out (e.g., domestic and occupational months environmental exposures, connective tissue disease, and drug toxicity). For a diagnosis of Systemic Sclerosis-Associated Interstitial Lung Disease (SSc-ILD): Must have onset of disease (first non-Raynaud symptom) within the past 7 years and at least 10% fibrosis on a chest high-resolution computed tomography (HRCT) scan within the past 12 months.

NIRAPARIB (ZEJULA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

NITISINONE (ORFADIN) 1 - All FDA-approved Diagnosis of hereditary tyrosinemia type 1 (HT-1) confirmed by DNA testing or biochemical testing (ie. urine 12 months For reauth: Documentation from the prescriber indicating improvement or Indications. succinylacetone (SA) level). stabilization in the member's condition NITROGLYCERIN 0.4% 1 - All FDA-approved Severe anemia (defined as Diagnosis. Must provide documentation that chronic anal fissure symptoms have persisted for at least 6 Initial: 2 months For reauth: must have documentation of improvement in condition. OINTMENT (RECTIV) Indications. hemoglobin less than 8g/dL). weeks. Reauthorization Increased intracranial : 12 months pressure. Concomitant use of a phosphodiesterase type 5 (PDE5) inhibitor such as sildenafil (Revatio, Viagra), tadalafil (Adcirca, Cialis), or vardenafil (Levitra, Staxyn).

NORTRIPTYLINE (PAMELOR) 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months For reauthorization: documentation from prescriber indicating Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, trazodone or mirtazapine for applies to enrollees aged stabilization or improvement in condition. depression. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

OLANZAPINE (ZYPREXA 1 - All FDA-approved Diagnosis. Documentation of prior oral Zyprexa therapy. Coverage is provided for 12 months For reauthorization: documentation from prescriber indicating RELPREVV) Indications. members 18 years of age stabilization or improvement in condition. or older OLAPARIB (LYNPARZA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

OMACETAXINE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months MEPESUCCINATE (SYNRIBO) Indications. oncologist or hematologist

OMALIZUMAB (XOLAIR) 1 - All FDA-approved Diagnosis. For moderate to severe allergic asthma: recent total serum IgE level of greater than 30IU/ml and Allergic Asthma: Member Urticaria: by or in consultation 12 months For reauthorization: documentation from prescriber indicating Indications. the pre-treatment IgE levels do not exceed manufacturers dosing recommendations. Documentation of is 6 years of age or older. with an allergist, stabilization or improvement in condition. recent use and failure to respond to optimal tolerated inhaled steroid dose in combo with long acting beta CIU: Member is 12 years dermatologist, immunologist. agonist. Documentation of a positive skin or in vitro reactivity to perennial aeroallergen. Must have asthma of age or older. Nasal Asthma: by or in consultation symptoms that are inadequately controlled while on treatment (uncontrolled defined as having an asthma Polyps: Member is 18 with a pulmonologist or exacerbations requiring hospitalization in the past year or having 2 or more asthma exacerbations requiring years of age or older allergist. Nasal Polyps: by or in oral systemic steroids). Must follow recommended dosing guidelines based upon weight and IgE level. For consultation with an allergist, chronic idiopathic urticaria: must have chart documentation showing history of urticaria w/ presence of ear/nose/throat specialist, or hives, must have adequate trial of one 2nd generation H1 antihistamine (e.g. levocetirizine) and one immunologist leukotriene antagonist (e.g. montelukast) with inadequate responses or significant side effects/toxicity unless contraindicated. For nasal polyps: Must be used as add-on maintenance therapy. Must have symptoms that are inadequately controlled while on intranasal corticosteroid treatment (uncontrolled defined as having at least two of the following symptoms: nasal blockade/obstruction/congestion/discharge, facial pain or pressure, and reduction or loss of smell). Must follow recommended dosing guidelines based upon weight and IgE level.

OMNIPOD POD 1 - All FDA-approved Must have documentation of previous insulin use. 12 months Indications. ONABOTULINUMTOXINA 1 - All FDA-approved Diagnosis. For migraine prophylaxis: must have adequate trial of two migraine prophylactic agents each Hyperhidrosis: Dermatologist. 12 months For reauth: documentation from prescriber indicating stabilization or (BOTOX) Indications. from a separate class (e.g. anticonvulsants, beta-blockers, tricyclic antidepressants) with inadequate Migraine prophylaxis: improvement in condition. response. For urinary incontinence or OAB with urge urinary incontinence, urgency, frequency: must have Neurologist. OAB: Urologist adequate trial (at least 4 weeks) at recommended dose of 2 anticholinergic meds (e.g., oxybutynin ER, oxybutynin, Toviaz) with inadequate response or intolerance unless contraindicated.

OSIMERTINIB MESYLATE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (TAGRISSO) Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration OXANDROLONE 1 - All FDA-approved Coverage is not provided for Diagnosis. Documentation the medication will be used as adjunctive therapy to promote weight gain after 12 months For reauth: Documentation from the prescriber indicating an Indications. members with the following: weight loss following extensive surgery, chronic infections, or severe trauma, and in some patients who improvement or stabilization in the member's condition carcinoma of breast or without definite pathophysiologic reasons fail to gain or to maintain normal weight, to offset the protein prostate in male members, catabolism associated with prolonged administration of corticosteroids, and for the relief of the bone pain carcinoma of breast in female frequently accompanying osteoporosis. members with hypercalcemia, pregnancy, nephrosis (nephrotic phase of nephritis), hypercalcemia or severe hepatic dysfunction.

PALBOCICLIB (IBRANCE) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PALIFERMIN (KEPIVANCE) 1 - All FDA-approved Diagnosis. Documentation of severe oral mucositis in patients with hematologic malignancies receiving By or in consultation with an Up to 12 Indications. myelotoxic therapy in a regimen that includes hematopoietic stem cell support. oncologist or hematologist months

PALIPERIDONE PALMITATE ER 1 - All FDA-approved Diagnosis. Patients must have been adequately treated with Invega Sustenna for at least four months. Coverage is provided for 12 months INJECTION (INVEGA TRINZA) Indications. members 18 years of age and older. PALIPERIDONE PALMITATE 1 - All FDA-approved Diagnosis. Documentation of prior oral paliperidone therapy. Coverage is provided for 12 months INJECTION (INVEGA Indications. members 18 years of age SUSTENNA) and older. PALIVIZUMAB (SYNAGIS) 1 - All FDA-approved Diagnosis. If under age 12 mo. at start of RSV season w/ no other medical diagnosis: must have gestational Less than 12 months or Minimum Indications. age (GA) less than 29 wks. If under age 24 mo. at start of RSV season during 1st year of life w/ Chronic Lung less than 24 months of duration 1 Disease (CLD) of prematurity: must have GA less than 32 weeks 0 days AND required greater than 21% age at start of RSV season month. oxygen (O2) for at least first 28 days of life. If under age 24 mo. at start of RSV season during 2nd year of depending on criteria. Maximum of 5 life w/ CLD of prematurity: must have GA less than 32 weeks 0 days AND required greater than 21% O2 for doses per RSV at least first 28 days of life AND have continued to require medical support (chronic corticosteroid therapy, season diuretic therapy, supplemental O2) during 6 months before start of 2nd RSV season. If under age 12 mo. at start of RSV season w/ heart disease: must have hemodynamically significant Congenital Heart Disease (CHD) (and be on drugs to control heart failure) OR have acyanotic heart disease (and be on drugs to control heart failure and require cardiac surgery) OR have moderate to severe pulm HTN OR have cardiac lesions adequately corrected by surgery (and continue to be on drugs for heart failure). If under age 12 mo. at start of RSV season w/ neuromuscular disease or congenital anomaly: must demonstrate that disease/anomaly impairs ability to clear secretions from upper airway b/c of ineffective cough. If under age 24 mo. at start of RSV season and profoundly immunocompromised: must have doc of reason (e.g. severe combined immunodeficiency, severe T-cell deficiency, severe AIDS, AML, acute lymphoblastic leukemia, receiving chemotx, received hematopoietic SCT). If under age 24 mo. w/ cystic fibrosis (CF): during 1st year of life must have clinical evidence of CLD and/or nutritional compromise OR during 2nd year of life must have manifestation of severe lung disease (prior hospitalization for pulmonary exacerbation in 1st year of life, abnormalities on chest radiography/CT that persist when stable, weight for length is less than 10th %.

PAMIDRONATE (AREDIA) 1 - All FDA-approved Diagnosis. For hypercalcemia of malignancy: must be used in conjunction with adequate hydration in Coverage is provided for 12 months For reauth: documentation from prescriber indicating stabilization or Indications. members with moderate or severe hypercalcemia associated with malignancy, with or without bone members 18 years of age improvement in condition. metastases. For Paget's disease: must have moderate to severe Paget's disease of bone. For osteolytic or older. bone metastases of breast cancer and osteolytic lesions of multiple myeloma: must be used in conjunction with standard antineoplastic therapy .

PANOBINOSTAT (FARYDAK) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PASIREOTIDE (SIGNIFOR) 1 - All FDA-approved Diagnosis of Cushing's disease for whom pituitary surgery is not an option or has not been curative. Coverage is provided for By or in consultation with an 12 months For reauth: documentation of improvement or stabilization. Indications. Documentation of trial and failure with ketoconazole to reduce cortisol secretion. members 18 years of age Endocrinologist or older. PAZOPANIB (VOTRIENT) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PEGFILGRASTIM-BMEZ 1 - All FDA-approved Diagnosis. 6 months For reauth: documentation from prescriber that demonstrates member is (ZIEXTENZO) Indications. tolerating and receiving clinical benefit from treatment

PEGFILGRASTIM-CBQV 1 - All FDA-approved Diagnosis. 6 months For reauth: documentation from prescriber that demonstrates member is (UDENYCA) Indications. tolerating and receiving clinical benefit from treatment

PEGFILGRASTIM-JMDB 1 - All FDA-approved Diagnosis. 6 months For reauth: documentation from prescriber that demonstrates member is (FULPHILA) Indications. tolerating and receiving clinical benefit from treatment

PEGINTERFERON ALFA-2A 1 - All FDA-approved Coverage is not provided for Diagnosis. For adults with chronic hepatitis B, must have documentation of HBeAg-positive and HBeAg- Coverage is provided for 12 months (PEGASYS) Indications. patient's with autoimmune negative chronic hepatitis B (CHB) infection with compensated liver disease and evidence of viral members 3 years of age hepatitis, hepatic replication and liver inflammation. Pediatric patients with CHB must have documentation of HBeAg- and older. decompensation with positive CHB and evidence of viral replication and elevations in serum alanine aminotransferase (ALT). cirrhosis, use in neonates/infants or for patient's who would be receiving more than one interferon product concomitantly. PEGINTERFERON ALFA-2B 3 - All Medically-accepted Diagnosis. Coverage is provided for 12 months (SYLATRON) Indications. members 18 years of age or older. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration PEGVISOMANT (SOMAVERT) 1 - All FDA-approved Diagnosis of acromegaly. Must have inadequate response to surgery or radiation therapy or documentation Coverage is provided for By or in consultation with an 12 months For reauth: documentation of improvement or stabilization. Indications. that these therapies are inappropriate. Must have a trial and failure or inadequate response to one members 18 years of age Endocrinologist medical therapy (e.g. octreotide, octreotide LAR, lanreotide) or documentation that these therapies are or older. inappropriate. Must have the following baseline labs: elevated serum IGF-1 level for gender/age range (including lab reference range) and elevated growth hormone level defined as GH at least 1ng/mL during oral glucose tolerance test.

PEMIGATINIB (PEMAZYRE) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PERAMPANEL (FYCOMPA) 1 - All FDA-approved Diagnosis. Must have had an inadequate response or intolerance to two generic antiepileptic drugs. Coverage is provided for By or in consultation with a 12 months Indications. members 4 years of age neurologist. or older. PERTUZUMAB-TRASTUZUMAB- 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months HYALURONIDASE (PHESGO) Indications. oncologist or hematologist

PEXIDARTINIB (TURALIO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PHENOBARBITAL 1 - All FDA-approved Diagnosis. This Prior Authorization requirement only applies to members 65 years of age or older. Prior authorization only By or in consultation with a 12 months For Reauth: documentation from prescriber indicating stabilization or Indications. Prescriber must acknowledge that medication benefits outweigh potential risks in the member 65 years of applies to enrollees aged neurologist improvement in condition. age or older. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

PIMAVANSERIN (NUPLAZID) 1 - All FDA-approved Diagnosis. Submission of a Mini-Mental State Examination (MMSE) score greater than or equal to 21 and Coverage is provided for By or in consultation with a 12 months Indications. documentation the member is able to self-report symptoms. members 18 years of age neurologist or psychiatrist or older. PIRFENIDONE (ESBRIET) 1 - All FDA-approved Diagnosis. Must have diagnosis of idiopathic pulmonary fibrosis (IPF) confirmed by either high-resolution Coverage provided for Pulmonologist Initial: 3 For reauth: must have documentation from prescriber indicating that Indications. computed tomography (HRCT) or surgical lung biopsy. Must have all other diagnoses ruled out (e.g., members age 18 years months, member still is a candidate for treatment and showing that liver function domestic and occupational environmental exposures, connective tissue disease, and drug toxicity). Must and older. Reauth: 6 tests (including ALT, AST, and bilirubin) are being monitored regularly. submit documentation of baseline liver function testing, including alanine aminotransferase (ALT), months aspartate aminotransferase (AST), and bilirubin.

PLERIXAFOR (MOZOBIL) 3 - All Medically-accepted Diagnosis. By or in consultation with a 1 month Indications. bone marrow transplant specialist, hematologist, or oncologist

POMALIDOMIDE (POMALYST) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PONATINIB HCL (ICLUSIG) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

POSACONAZOLE (NOXAFIL) 1 - All FDA-approved Coadministration with Diagnosis. For oropharyngeal candidiasis, must have at least a 2 week trial of fluconazole with an Suspension and delayed 12 months Indications. sirolimus, ergot alkaloids (e.g., insufficient response, intolerable side effect, or have a contraindication. released tablets: age 13 ergotamine, years or older. dihydroergotamine), HMG- CoA reductase inhibitors that are primarily metabolized through CYP3A4 (e.g., atorvastatin, lovastatin, simvastatin), or CYP3A4 substrates that prolong the QT interval (e.g., pimozide, quinidine), hypersensitivity to posaconazole, other azole antifungal agents, or any component of the formulation.

PRALSETINIB (GAVRETO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

PRAMLINTIDE (SYMLIN) 1 - All FDA-approved Diagnosis of Type 1 or Type 2 Diabetes Mellitus for member who has mealtime insulin and has failed to 12 months For reauth: if the patient has been receiving Symlin for at least 3 months, Indications. achieve desired glycemic control despite optimal insulin therapy. Initial A1C greater than or equal to 6.5. patient demonstrated a reduction in HbA1c since starting therapy with Symlin. PREGABALIN (LYRICA) 1 - All FDA-approved Diagnosis. For fibromyalgia: must have chart documentation of diagnosis with history of widespread pain For partial onset seizures, 12 months Indications. involving extremities for 3 months and localized area of tenderness, must have trial and failure or coverage is provided for contraindication to gabapentin at a dose of at least 1200mg/day or maximally tolerated dose in intolerant members 18 years of age patients AND either duloxetine or muscle relaxant unless contraindicated. For PHN: must have trial and or less. For fibromyalgia, failure, intolerance, or contraindication to gabapentin. For DPN: must have documented pharmacy claim PHN, DPN, and history or prior therapy with a diabetic medication OR a medical/lab claim or physician chart note of neuropathic pain diabetes diagnosis and must have trial and failure, intolerance, or contraindication to gabapentin. For assoicated with spinal partial-onset seizures: must have an inadequate response, intolerance, or contraindication to 2 generic cord injury, coverage is antiepileptic drugs (e.g., lamotrigine, topiramate, felbamate). Additionally for pregabalin oral solution: must provided for members 18 have chart documentation of the clinical rationale for why pregabalin capsule cannot be used. years of age or older Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration PROTRIPTYLINE (VIVACTIL) 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, Viibryd, trazodone or mirtazapine for applies to enrollees aged depression. 65 or older. All enrollees less than age 65 are not subject to prior authorization.

RANOLAZINE (RANEXA) 1 - All FDA-approved Coverage is not provided for Diagnosis. Patient remains symptomatic despite treatment with at least 2 combined anti-anginal therapies By or in consultation with a 12 months For Reauth: documentation from prescriber indicating stabilization or Indications. those with a pre-existing QT such as: nitrates, beta-blockers, and calcium channel blockers or has an intolerance or contraindication. cardiologist improvement in condition. prolongation, hepatic impairment, liver cirrhosis, for doses higher than 2,000mg per day, or coadministration with inducers and strong inhibitors of CYP3A.

REGORAFENIB (STIVARGA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

RELUGOLIX (ORGOVYX) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

RIBOCICLIB (KISQALI) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

RIFAXIMIN (XIFAXAN) 1 - All FDA-approved Diagnosis. For hepatic encephalopathy: must have trial and failure of lactulose. For diarrhea-predominant Hepatic encephalopathy Hepatic encephalopathy: by or Hepatic For IBS-D: members who experience a recurrence of symptoms can be Indications. irritable bowel syndrome (IBS-D): documentation of chronic IBS symptom diarrhea lasting at least 12 weeks and IBS-D: 18 years of in consultation with a encephalopathy retreated up to two times with the same dosage regimen. Reauth for IBS- and an adequate trial and failure of two medications used in the treatment of IBS-D (i.e. loperamide, age or older, Travelers gastroenterologist, : 12 months, IBS- D: must have documentation from prescriber indicating recurrence of IBS- antispasmodics) with inadequate responses or significant side effect/toxicity unless contraindicated. For diarrhea: 12 years of age hepatologist, or infectious D: 2 weeks, D symptoms after a successful treatment with rifaximin. Traveler's diarrhea: must have a trial and failure, intolerance, or contraindication to one of the following: a or older disease specialist, IBS-D: Travelers fluoroquinolone (i.e. ciprofloxacin, levofloxacin) or azithromycin. gastroenterologist diarrhea: 3 days

RILONACEPT (ARCALYST) 1 - All FDA-approved Diagnosis. Negative TB test, baseline lipid panel assessment. For Muckle-Wells: must have chart doc of Coverage provided for By or in consultation with a Initial: 3 For reauthorization: documentation from prescriber indicating Indications. diagnosis confirmed by genetic test (must have documentation of lab result confirming mutation in NLRP3 members age 12 years hematologist, dermatologist, months, stabilization or improvement in condition. gene) or a clinical diagnosis (must have 3 of following: autosomal dominant pattern of disease inheritance, and older. rheumatologist, neurologist, Reauth: 12 presence of severe fatigue, presence of musculoskeletal symptoms, presence of ocular symptoms, allergist, immunologist or a months presence of erythematous rash, duration of most febrile episodes lasting greater than 24 hours, presence genetic specialist of amyloidosis, presence of hearing loss). For Familial Cold Autoinflammatory Syndrome: must have chart doc of diagnosis confirmed by genetic test (must have documentation of lab result confirming mutation in NLRP3 gene) or a clinical diagnosis (must have 4 of following: recurrent intermittent episodes of fever and rash that primarily follow natural/experimental/both types of generalized cold exposures, autosomal dominant pattern of disease inheritance, age of onset less than 6 months of age, duration of most attacks less than 24 hours, presence of conjunctivitis associated with attacks, absence of deafness/periorbital edema/lymphadenopathy/serositis).

RIOCIGUAT (ADEMPAS) 1 - All FDA-approved Coverage will not be provided Diagnosis of PAH (WHO Group I) confirmed by chart documentation of right heart catheterization indicating Prescribed by or in Initial: 3 For reauth: documentation from prescriber that demonstrates member is Indications. for patients taking nitrates a mean pulmonary arterial pressure greater than or equal to 20 mmHg, pulmonary capillary wedge consultation with cardiologist months, tolerating and receiving clinical benefit from treatment (nitrates in any form) or a PDE pressure OR left atrial pressure OR left ventricular end diastolic pressure less than or equal to 15 mmHg, or pulmonologist. Reauth: 12 inhibitor (e.g. sildenafil). pulmonary vascular resistance greater than 3 Wood units or echocardiography if the provider indicates RHC months is not recommended.

RIPRETINIB (QINLOCK) 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months Indications. oncologist or hematologist

RISANKIZUMAB-RZAA 1 - All FDA-approved Diagnosis. For plaque psoriasis: minimum BSA involvement of at least 5% (not required if on palms, soles, Member must be 18 years By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating (SKYRIZI) Indications. head/neck, genitalia), a history of trial and failure, contraindication, or intolerance to a three-month trial of of age or older. rheumatologist or stabilization or improvement in condition. systemic treatment (methotrexate, cyclosporine, oral retinoids, etc.). dermatologist.

RISPERIDONE INJECTION 1 - All FDA-approved Diagnosis. Documentation of prior oral risperidone therapy. Coverage provided for 12 months (RISPERDAL CONSTA and Indications. members age 18 years PERSERIS) and older. RISPERIDONE INJECTION 1 - All FDA-approved Diagnosis. Documentation of prior oral risperidone therapy. Coverage provided for 12 months (RISPERDAL CONSTA) Indications. members age 18 years and older. RITUXIMAB-PVVR (RUXIENCE) 3 - All Medically-accepted Diagnosis. For cancer diagnoses: must be CD20-positive. For Granulomatosis with Polyangiitis (GPA, aka For cancer diagnoses, GPA, 12 months For reauthorization: documentation from prescriber indicating Indications. Wegener's Granulomatosis) and Microscopic Polyangitis (MPA): must be on concomitant therapy w/ and MPA: by or in consultation stabilization or improvement in condition. glucocorticoids. with a hematologist or oncologist.

ROFLUMILAST (DALIRESP) 1 - All FDA-approved Moderate to sever liver Diagnosis of GOLD Stage III or IV COPD associated with chronic bronchitis. Documentation of COPD 12 months For reauthorization must have documentation from prescriber indicating Indications. impairment exacerbation within the past year. Must have adequate trial and failure of inhaled long-acting beta-agonist improvement in condition. or inhaled long-acting anticholinergic or a contraindication to these agents. Must have trial and failure of inhaled glucocorticosteroid or a contraindication to these agents.

ROTIGOTINE (NEUPRO) 1 - All FDA-approved Diagnosis. For Parkinson's disease and primary restless legs syndrome: must have adequate trial and Coverage is provided for 12 months For reauthorization: documentation from prescriber indicating Indications. failure, contraindication, or intolerance to both pramipexole and ropinirole. members 18 years of age stabilization or improvement in condition. or older. RUCAPARIB (RUBRACA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

RUFINAMIDE (BANZEL) 1 - All FDA-approved Not covered for patients with Diagnosis. Must have had an inadequate response or intolerance to two generic antiepileptic drugs (e.g. Coverage is provided for By or in consultation with a 12 months Indications. Familial Short QT Syndrome lamotrigine, topiramate, felbamate) and be using rufinamide as adjunctive therapy to other antiepileptic members 1 year of age or neurologist. drugs (which can include medication from trial above). older. Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration RUXOLITINIB (JAKAFI) 1 - All FDA-approved Diagnosis. Intermediate or high-risk myelofibrosis includes primary myelofibrosis, post-polycythemia vera GVHD: age 12 years or By or in consultation with an 6 months For reauthorization: must have documentation from prescriber indicating Indications. myelofibrosis, and post-essential thrombocythemia myelofibrosis. Members using medication for older All Others: age 18 oncologist or hematologist stabilization or improvement in condition. diagnosis of Polycythemia vera must have adequate trial and failure, intolerance, or contraindication of years or older hydroxyurea. Members using medication for diagnosis of Graft versus host disease (GVHD) must have had an allogeneic hematopoietic stem cell transplantation in addition to an adequate trial and failure, intolerance, or contraindication to corticosteroids

SAPROTERIN 1 - All FDA-approved Diagnosis. For treatment of Hyperphenylalaninemia. Clinically diagnosed with hyperphenylalaninemia due Initial: 3 For reauthorization, must maintain Phe levels below member's baseline DIHYDROCHLORIDE (KUVAN) Indications. to tetrahydrobiopterin responsive phenylketonuria. Phe levels must be greater than 6 mg/dL for neonates months, levels. through 12 years of age. Phe levels must be greater than 15 mg/dL on average after the age of 12. Reauth: 12 months SATRALIZUMAB-MWGE 1 - All FDA-approved Active hepatitis B infection, For Neuromyelitis Optica Spectrum Disorder (NMOSD): positive test for AQP4-IgG antibodies. At least 1 Coverage is provided for By or in consultation with a 12 months For reauth: documentation of stabilization or improvement in condition (ENSPRYNG) Indications. active or untreated latent relapse in the last 12 months or 2 relapses in the last 24 months that required rescue therapy. Expanded members 18 years of age neurologist or tuberculosis Disability Status Scale (EDSS) score of less than or equal to 6.5. Must have documentation of inadequate and older ophthalmologist response, contraindication or intolerance to rituximab or any of its biosimilars.

SELINEXOR (XPOVIO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

SELPERCATINIB (RETEVMO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months Indications. oncologist or hematologist

SELUMETINIB (KOSELUGO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

SILDENAFIL CITRATE 1 - All FDA-approved Coverage will not be provided Diagnosis of PAH (WHO Group I) confirmed by right heart catheterization. Must have chart documentation Prescribed by or in Initial: 3 For reauth: documentation from prescriber that demonstrates member is (REVATIO) Indications. for patients taking nitrates of right heart catheterization that indicates the following hemodynamic values: mean pulmonary arterial consultation with a months, tolerating and receiving clinical benefit from treatment (nitrates in any form) or a pressure greater than or equal to 20 mmHg, pulmonary capillary wedge pressure OR left atrial pressure OR pulmonologist or cardiologist Reauth: 12 guanylate cyclase stimulator left ventricular end diastolic pressure less than or equal to 15 mmHg, pulmonary vascular resistance months (e.g. Adempas). greater than 3 Wood units or echocardiography if the provider indicates RHC is not recommended.

SODIUM OXYBATE (XYREM) 1 - All FDA-approved Diagnosis. For excessive daytime sleepiness associated with narcolepsy: a sleep study (e.g. Coverage is provided for By or in consultation with a Initial: 3 Reauthorization: must have documentation from prescriber indicating Indications. polysomnogram, multiple sleep latency Test) confirming diagnosis and documentation of trial and failure of members 7 years of age neurologist or sleep specialist months, stabilization or improvement in condition. at least 2 stimulants (or documented clinical rationale as to why stimulants may not be used). For cataplexy or older Reauthorization associated with narcolepsy: a sleep study confirming the diagnosis. : 12 months

SODIUM PHENYLBUTYRATE 1 - All FDA-approved Diagnosis. By or in consultation with 12 months Indications. physician who specializes in the treatment of inherited metabolic disorders, a hematologist or a nephrologist.

SOFOSBUVIR-VELPATASVIR- 1 - All FDA-approved Coadministration with Criteria will be applied consistent with current AASLD/IDSA guidance and/or FDA approved labeling Coverage is provided for By or in consultation with a Criteria will be VOXILAPREVIR (VOSEVI) Indications. rifampin members who are age- gastroenterologist, applied appropriate according to hepatologist, infectious consistent with AASLD/IDSA guidance disease or transplant current and/or FDA-approved specialist. AASLD/IDSA labeling. guidance and/or FDA approved labeling

SOFOSUVIR-VELPATASVIR 1 - All FDA-approved Criteria will be applied consistent with current AASLD/IDSA guidance and/or FDA approved labeling Coverage is provided for By or in consultation with a Criteria will be (EPCLUSA) Indications. members who are age- gastroenterologist, applied appropriate according to hepatologist, infectious consistent with AASLD/IDSA guidance disease or transplant current and/or FDA-approved specialist. AASLD/IDSA labeling. guidance and/or FDA approved labeling

SOMATROPIN (GENOTROPIN) 1 - All FDA-approved Coverage will not be provided Diagnosis. Growth chart required for all diagnoses except Adult Growth Hormone Deficiency (GHD). By or in consultation with an 7 months For reauth for pediatric GHD, Turner syndrome, SGA, Prader-Willi Indications. for members with active Documentation that epiphyses are open for all pediatric indications. For pediatric GHD: a height greater endocrinologist or syndrome, and ISS: Documentation the patient has open epiphyses. For malignancy in the past year. than or equal to 2 standard deviations below the mean for age and gender, documentation of growth neonatologist. reauth for adult GHD: current IGF-1 level is normal for age and gender Active proliferative or severe velocity, skeletal maturation, 2 provocative stimulation tests which demonstrate GHD through peak growth (does not apply to patients with structural abnormality of the non-proliferative diabetic hormone concentrations less than 10 ng/ml or IGF-1 or IGFBP-3 levels or only one stim test is needed in the hypothalamus/pituitary and 3 or more pituitary hormone deficiencies and retinopathy. Pediatric presence of a pituitary abnormality. For Small for Gestational Age (SGA), a height greater than or equal to 2 childhood-onset growth hormone deficiency with congenital abnormality member with closed standard deviations below the mean for age and gender, and EITHER a birth weight less than 2500 g at a of the hypothalamus/pituitary). For reauth for Prader Willi: epiphysis, For Prader-Willi: gestational age greater than 37 weeks, OR weight or length at birth greater than 2 standard deviations documentation growth hormone has resulted in an increase in lean body severely obese (BMI greater below the mean for gestational age and documentation that catch up growth not achieved by age 2. For mass or decrease in fat mass. than 35), history of upper adult GHD: documentation the deficiency is a result of pituitary or hypothalamic disease, surgery, radiation airway obstruction, history of therapy, trauma, or childhood onset GHD and showing clinical benefit (i.e., increase in total lean body upper respiratory impairment, mass, exercise capacity or IGF-1 and IGFBP-3 levels) . Adult GHD must be confirmed by a growth hormone or severe respiratory stimulation test with peak growth hormone concentrations less than 5ng/ml . A growth hormone impairment. stimulation test is not needed when the patient has panhypopituitarism or a structural abnormality affecting the pituitary and an IGF-1 level below the reference range as indicated on the assay. For Idiopathic Short Stature (ISS), a height below or equal to -2.25 standard deviations of the mean, and a predicted adult height that is below the normal range, this corresponds to an adult height of less than 63 inches for males, or less than 59 inches for females. For Turner's Syndrome, a height more than 2 standard deviations below the mean for age and gender.

SONIDEGIB PHOSPHATE 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (ODOMZO) Indications. oncologist or hematologist Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration SORAFENIB (NEXAVAR) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

SOTORASIB (LUMAKRAS) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

STIRIPENTOL (DIACOMIT) 1 - All FDA-approved Diagnosis. Must have had an inadequate response or intolerance to two generic antiepileptic drugs (e.g. Member must be 2 years By or in consultation with a 12 months Indications. valproate, topiramate, clobazam). Must be using in combination with clobazam. of age or older neurologist

SUNITINIB (SUTENT) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

TADALAFIL (ADCIRCA) 1 - All FDA-approved Coverage will not be provided Diagnosis of PAH (WHO Group I) confirmed by right heart catheterization. Must have chart documentation By or in consultation with Initial: 3 For reauth: documentation from prescriber that demonstrates member is Indications. for patients taking nitrates of right heart catheterization that indicates the following hemodynamic values: mean pulmonary arterial cardiologist or pulmonologist. months, tolerating and receiving clinical benefit from treatment (nitrates in any form) or a pressure greater than or equal to 20 mmHg, pulmonary capillary wedge pressure OR left atrial pressure OR Reauth: 12 guanylate cyclase stimulator left ventricular end diastolic pressure less than or equal to 15 mmHg, pulmonary vascular resistance months (e.g. Adempas). greater than 3 Wood units or echocardiography if the provider indicates RHC is not recommended. TASIMELTEON (HETLIOZ) 1 - All FDA-approved Diagnosis. Must submit chart documentation describing how diagnosis was confirmed (e.g. sleep-wake Coverage is provided for By or in consultation with a 12 months For Reauth: documentation from prescriber indicating stabilization or Indications. logs, melatonin secretion abnormalities, or progress notes, etc.) members 3 years of age neurologist or a physician who improvement in condition. or older. specializes in sleep medicine TAZEMETOSTAT (TAZVERIK) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

TEDUGLUTIDE (GATTEX) 1 - All FDA-approved Active intestinal obstruction or Diagnosis. For diagnosis of short bowel syndrome, member must be receiving parenteral support. By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating Indications. active gastrointestinal gastroenterologists stabilization or improvement in condition. malignancy. TEPOTINIB (TEPMETKO) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

TETREBENAZINE (XENAZINE) 1 - All FDA-approved Uncontrolled depression, Diagnosis. Must have confirmed Huntington's disease either by Huntington Disease Mutation analysis (with Coverage is provided for By or in consultation with a 12 months Maximum dose approved is 100mg/day. For reauthorization: must have Indications. actively suicidal. Currently laboratory result indicating expanded CAG repeat of greater than or equal to 36 in the Huntington gene) or members 18 years of age neurologist. documentation from prescriber indicating stabilization or improvement in using a monoamine oxidase a positive family history of Huntington's Disease with autosomal dominant inheritance pattern. Must have or older. condition. TIVOZANIB (FOTIVDA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

TOFACITINIB (XELJANZ) 1 - All FDA-approved Evidence of infection. Use of Diagnosis. Must have lymphocyte count greater than or equal to 500 cells per cubic mm, ANC greater than For Polyarticular course By or in consultation with Initial: 3 Reauth:Documentation from the prescriber indicating stabilization or Indications. biologic disease-modifying or equal to 1000 cells per cubic mm, and Hgb level greater than or equal to 9g/dL. Must have moderately to juvenile idiopathic dermatolgist, rheumatologist months, improvement in condition AND recent lymphocyte count greater than or antirheumatic drug or potent severely active rheumatoid arthritis (RA), active psoriatic arthritis (PsA), Polyarticular course juvenile arthritis: Coverage is or gastroenterologist. Reauth: 12 equal to 500 cells per cubic mm, ANC greater than or equal to 1000 cells immunosuppressive agent idiopathic arthritis (pcJIA) or ulcerative colitis (UC). For rheumatoid arthritis (RA): history of trial and failure, provided for members 2 months per cubic mm and Hgb greater than or equal to 9g/dLts completed w/in (e.g. azathioprine, contraindication, or intolerance to a three-month trial with methotrexate or another DMARD. For years of age and older. 3mo of therapy start and regular intervals thereafter cyclosporine) in combination peripheral PsA or PsA w/dactylitis: adequate trial of 1 NSAID at target anti-inflammatory dose and 1 For all other diagnoses with tofacitinib. Severe conventional systemic therapy (e.g.methotrexate,leflunomide, sulfasalazine)w/inadequate responses or coverage is provided for hepatic impairment. significant side effects/toxicities or have contraindication to these therapies. For axial PsA,or PsA w/ members 18 years of age enthesitis: adequate trial of 2 NSAIDs at target anti-inflammatory dose w/inadequate responses or and older significant side effects/toxicity or have contraindication. For PsA w/skin or nail involvement: adequate trial of 1 topical treatment or phototherapy or photochemotherapy w/inadequate response or significant side effects/toxicity or have a contraindication, and must have adequate trial of 1 conventional systemic therapy (e.g.methotrexate, acitretin,cyclosporine) w/inadequate response or significant side effects/toxicity or have a contraindication. For Ulcerative Colitis: adequate trial of 2 of the following therapy options: aminosalicylates, corticosteroids, or immunomodulators with inadequate response or side effects/toxicity TOLVAPTAN (JYNARQUE) 1 - All FDA-approved History of significant liver Diagnosis. Must meet one of the following criteria defining risk of rapidly progressing disease: (1) age 55 or Member must be 18 years By or in consultation with a 12 months For reauthorization: documentation from prescriber indicating Indications. impairment or injury (not younger and eGFR between 25 and 65 mL/min/1.73m^2, (2) age 56 to 65 and eGFR between 25 and 44 of age or older nephrologist stabilization or improvement in condition. including uncomplicated mL/min/1.73m^2 plus eGFR decline of greater than 2.0 mL/min/1.73m^2/year, (3) estimated CrCl greater Coverage Group Indication Indicator Off-Label Uses Exclusion Criteria Required Medical Information Age Restriction Prescriber Restriction Other Criteria Duration TRAMETINIB (MEKINIST) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

TRIENTINE HCL (SYPRINE) 1 - All FDA-approved Diagnosis. Must have adequate trial of penicillamine (Depen) with an inadequate response or significant By or in consultation with a 12 months For reauth: must have documentation from prescriber indicating Indications. side effects/toxicity or must have a contraindication to this therapy. For reauth: must have documentation gastroenterologist, an improvement in condition. from prescriber indicating improvement in condition. ophthalmologist or a physician TRIFLURIDINE/TIPIRACIL HCL 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months (LONSURF) Indications. oncologist or hematologist

TRIMIPRAMINE 1 - All FDA-approved Diagnosis. Requests for enrollees aged 65 or older must document intolerance to or clinical failure of 2 Prior authorization only 12 months Indications. alternatives such as an SSRI (except paroxetine), SNRI, bupropion, viibryd, trazodone or mirtazapine for applies to enrollees aged depression. 65 or older. All enrollees TUCATINIB (TUKYSA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 12 months Indications. oncologist or hematologist

UBROGEPANT (UBRELVY) 1 - All FDA-approved Diagnosis. Must have a history of trial and failure, contraindication, or intolerance to two different triptans. Coverage is provided for 12 months For reauth: documentation of improvement or stabilization. Indications. members 18 years of age and older. UMBRALISIB (UKONIQ) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

UPADACITINIB (RINVOQ) 1 - All FDA-approved Diagnosis. For rheumatoid arthritis (RA): history of trial and failure, contraindication, or intolerance to a Member must be 18 years By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating Indications. three-month trial with methotrexate or another DMARD. of age or older. rheumatologist. stabilization or improvement in condition.

USTEKINUMAB (STELARA) 1 - All FDA-approved Diagnosis. For Crohns Disease: adequate trial of adalimumab (Humira) with inadequate response or side Coverage is provided for Prescribed by or in Initial: 6 months For reauthorization: documentation from prescriber indicating Indications. effects/toxicity unless contraindicated. For Ulcerative Colitis (UC): adequate trial of both adalimumab members 6 years of age consultation with a Reauthorization stabilization or improvement in condition. VALBENAZINE (INGREZZA) 1 - All FDA-approved Diagnosis. Member has been diagnosed with moderate to severe tardive dyskinesia (TD) according to the Coverage is provided for By or in consultation with a 12 months For reauthorization: must have documentation from prescriber indicating Indications. DSM V criteria including involuntary athetoid or choreiform movements and has a history of treatment with members 18 years of age neurologist or psychiatrist stabilization or improvement in condition. neuroleptic agent (i.e. antipsychotic). Adjustments to possible offending medication such as dose reduction or older or discontinuation were attempted but ineffective in resolving TD symptoms or member is not a candidate for dose reduction or discontinuation of the offending medication. If the member is using the offending medication for a behavioral health indication, the use of a second generation atypical antipsychotic has been attempted unless contraindicated.

VANDETANIB (CAPRELSA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

VEMURAFENIB (ZELBORAF) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

VENETOCLAX (VENCLEXTA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

V-GO KIT 1 - All FDA-approved Must have documentation of previous insulin use. 12 months Indications.

VIGABATRIN (SABRIL) 1 - All FDA-approved Diagnosis. Must undergo vision testing prior to beginning treatment. For Refractory Complex Partial By or in consultation with a 12 months Indications. Seizures: must have inadequate response to at least two alternative anticonvulsant therapies for complex neurologist. partial seizures. Must be using in combination with at least one other anticonvulsant medication. VILAZODONE (VIIBRYD) 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic antidepressants. Coverage is provided for 12 months Indications. members 18 years of age and older. VISMODEGIB (ERIVEDGE) 3 - All Medically-accepted Diagnosis. Coverage is provided for By or in consultation with an 6 months Indications. members 18 years of age oncologist or hematologist and older. VORINOSTAT (ZOLINZA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist

VORTIOXETINE (TRINTELLIX) 1 - All FDA-approved Diagnosis. Documentation of trial and failure of at least two generic antidepressants. Coverage is provided for 12 months Indications. members 18 years of age and older.

VOXELOTOR (OXBRYTA) 1 - All FDA-approved Diagnosis. Diagnosis must be confirmed by electrophoresis demonstrating the presence of sickle cell Coverage is provided for By or in consultation with a Initial: 6 months For reauthorization: Documentation there has been a reduction in vaso- Indications. disease (HbSS, HbSC,HbSbeta0-thalassemia, or HbSbeta+-thalassemia). Member must have a hemoglobin members 12 years of age hematologist, oncologist or Reauthorization occlusive events or an improvement in condition. level of 5.5 g/dL to 10.5 g/dL. Documentation the member has tried and failed or had an intolerance or and older. sickle cell disease specialist : 12 months ZANUBRUTINIB (BRUKINSA) 3 - All Medically-accepted Diagnosis. By or in consultation with an 6 months Indications. oncologist or hematologist