Biologic Immunomodulators Prior Authorization with Quantity Limit Program Summary Biologic Immunomodulators Prior Authorization with Quantity Limit – (with a preferred option) Actemra® (tocilizumab) Avsola (infliximab-axxq) Cimzia® (certolizumab pegol) Cosentyx® (secukinumab) Enbrel ® (etanercept) Entyvio (vedolizumab) Humira® (adalimumab) Ilumya™ (tildrakizumab-asmn) Inflectra (infliximab-dyyb) Kevzara® (sarilumab) Kineret® (anakinra) Olumiant® (baricitinib) Orencia® (abatacept) Remicade® (infliximab) Renflexis (infliximab-abda) Rinvoq™ (upadacitinib extended release) Siliq™ (brodalumab) Simponi® (golimumab) Simponi ARIA (golimumab) Skyrizi™ (risankizumab-rzaa) Stelara® (ustekinumab) Taltz® (ixekizumab) Tremfya® (guselkumab) Xeljanz® (tofacitinib) Xeljanz XR® (tofacitinib extended release) Disease Step 1 Step 2 (Non- Step 3a Step 3b Step 3c State (Preferred) preferred (Non- (Non- (Non- directed to preferred preferred preferred ONE step 1 directed to directed to directed to agent) TWO step 1 TWO agents THREE step agents) from step 1 1 agents) and/or step 2) Rheumatoid Disorders Ankylosing SQ: Cosentyx, N/A SQ: Cimzia, N/A N/A Spondylitis Enbrel, Simponi, Taltz (AS) Humira Nonradiograp SQ: Cimzia, N/A SQ: Taltz N/A N/A hic Axial Cosentyx Spondyloarthr HCSC_CS_reg_Biologic_Immunomodulators_PAQL_ProgSum_AR0420_r0321 Page 1 of 29 © Copyright Prime Therapeutics LLC. 03/2021 All Rights Reserved Effective: 03/22/2021 Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association itis (nr- axSpA) Polyarticular SQ: Enbrel, SQ: Actemra N/A SQ: Orencia N/A Juvenile Humira, (Humira is Idiopathic Xeljanz required Step Arthritis 1 agent) (PJIA) Psoriatic SQ: Cosentyx, N/A SQ: Cimzia, N/A N/A Arthritis (PsA) Enbrel, Orencia, Humira, Simponi, Taltz Stelara, Tremfya Oral: Otezla, Xeljanz, Xeljanz XR Rheumatoid SQ: Enbrel, SQ: Actemra Oral: N/A N/A Arthritis Humira (Humira is Olumiant required Step Oral: Rinvoq, 1 agent) SQ: Cimzia, Xeljanz, Kevzara, Xeljanz XR Kineret, Orencia, Simponi Dermatological Disorder Hidradenitis SQ: Humira N/A N/A N/A N/A Suppurativa (HS) Psoriasis (PS) SQ: Cosentyx, N/A SQ: Cimzia, N/A SQ: Taltz Enbrel, Ilumya, Siliq Humira, Skyrizi, Stelara, Tremfya Oral: Otezla Inflammatory Bowel Disease Crohn’s SQ: Humira, SQ: Cimzia N/A N/A N/A Disease Stelara (Humira is required Step 1 agent) Ulcerative SQ: Humira, SQ: Simponi N/A N/A N/A Colitis Stelara (Humira is required Step 1 agent) Oral: Xeljanz, Xeljanz XR Other Uveitis SQ: Humira N/A N/A N/A N/A Indications Without Preferred Agents Required Giant Cell N/A N/A N/A N/A N/A Arteritis (GCA) HCSC_CS_reg_Biologic_Immunomodulators_PAQL_ProgSum_AR0420_r0321 Page 2 of 29 © Copyright Prime Therapeutics LLC. 03/2021 All Rights Reserved Effective: 03/22/2021 Neonatal- Onset Multisystem Inflammatory Disease (NOMID) Systemic Juvenile Idiopathic Arthritis (SJIA) *Note: A trial of either or both Xeljanz products (Xeljanz and Xeljanz XR) collectively counts as ONE product QUANTITY LIMITS FOR TARGET AGENTS Brand (generic) GPI Quantity Limit Multisource Code Actemra® (tocilizumab) 162 mg/0.9 mL 4 autoinjectors (3.6 6650007000D520 M, N, O, or Y autoinjector mL)/28 days 4 syringes (3.6 mL) 162 mg/0.9 mL syringe 6650007000E520 M, N, O, or Y /28 days 10 vials (40 mL)/28 80 mg/4 mL vial 66500070002030 M, N, O, or Y days 4 vials (40 mL)/28 200 mg/10 mL vial 66500070002035 M, N, O, or Y days 2 vials (40 mL)/28 400 mg/20 mL vial 66500070002040 M, N, O, or Y days Avsola (infliximab-axxq) 100 mg/20 mL vial 52505040132120 N/A M, N, O, or Y Cimzia® (certolizumab) 2 kits/28 days 2 x 200 mg vial, kit 52505020106420 (2 kits of 4 x 200 mg M, N, O, or Y vials/28 days) 2 kits/28 days 2 x 200 mg/mL 52505020106440 (2 kits of 4 M, N, O, or Y syringe, kit syringes/28 days) 6 X 200 mg/mL 1 starter kit (3)/180 52505020106460 M, N, O, or Y syringe, starter kit days CosentyxTM (secukinumab) 300 mg/ 2 mL (2 x 9025057500D530 2 pens/28 days M, N, O, or Y 150 mg/mL) pen 150 mg/mL pen 9025057500D520 1 pen/28 days M, N, O, or Y 150 mg/mL pre-filled 9025057500E520 1 syringe/28 days M, N, O, or Y syringe 300 mg/2 mL (2 x 150 mg/mL) pre-filled 9025057500E530 2 syringes/28 days M, N, O, or Y syringe Enbrel® (etanercept) 25 mg/0.5 mL single 8 vials/28 days 66290030002015 M, N, O, or Y use vial 25 mg/vial, kit 66290030002120 8 vials/28 days M, N, O, or Y HCSC_CS_reg_Biologic_Immunomodulators_PAQL_ProgSum_AR0420_r0321 Page 3 of 29 © Copyright Prime Therapeutics LLC. 03/2021 All Rights Reserved Effective: 03/22/2021 Brand (generic) GPI Quantity Limit Multisource Code 50 mg/mL SureClick 4 autoinjectors (4 mL) 6629003000D530 M, N, O, or Y autoinjector /28 days 50 mg/mL Mini 6629003000E230 4 cartridges (4 mL) M, N, O, or Y injector cartridge /28 days 4 syringes (2.04 25 mg/0.5 mL syringe 6629003000E525 M, N, O, or Y mL)/28 days 4 syringes (4 mL)/28 50 mg/mL syringe 6629003000E530 M, N, O, or Y days Entyvio (vedolizumab) 300 mg/vial 52503080002120 1 vial/56 days M, N, O, or Y Humira® (adalimumab) 10 mg/0.1 mL syringe 6627001500F804 2 syringes/28 days M, N, O, or Y 10 mg/0.2 mL syringe 6627001500F805 2 syringes/28 days M, N, O, or Y 20 mg/0.2 mL syringe 6627001500F809 2 syringes/28 days M, N, O, or Y 20 mg/0.4 mL 6627001500F810 2 syringes/28 days M, N, O, or Y syringe, kit 6627001500F820 Pediatric Crohn’s 1 kit/180 days Disease Starter Kit 40 NDC: M, N, O, or Y mg/0.8mL (Both 3 [1 kit (3 syringes) [00074379903 and 6 syringe pack) 1 kit (6 syringes)] 00074379906] 40 mg/0.8 mL 6627001500F820 2 syringes/28 days M, N, O, or Y syringe, kit 40/0.4 mL syringe 6627001500F830 2 syringes/28 days M, N, O, or Y Pediatric Crohn’s 6627001500F840 Disease Starter kit 1 kit (3 syringes)/180 (NDC M, N, O, or Y (80 mg/0.8 mL days 00074379902) syringe) Pediatric Crohn’s Disease Starter kit 1 kit (2 syringes)/180 (40 mg/0.4 mL and 6627001500F880 M, N, O, or Y days 80 mg/0.8 mL syringe) 6627001500F420 2 pens/28 days 40 mg/0.8 mL pen, kit (NDC M, N, O, or Y 00074433902) Psoriasis/Uveitis 6627001500F420 1 kit (4 pens)/180 Starter kit (40 mg/0.8 (NDC M, N, O, or Y days mL pen) 00074433907) Crohn’s Disease, Ulcerative Colitis, or 6627001500F420 1 kit (6 pens)/180 Hidradenitis Starter (NDC M, N, O, or Y days Kit (40 mg/0.8 mL 00074433906) pen) 40 mg/0.4 mL pen 6627001500F430 2 pens/28 days M, N, O, or Y 80 mg/0.8 mL pen 6627001500F440 (NDC 2 pens/28 days M, N, O, or Y 00074012402) 80 mg/0.8 mL pen, Crohn’s disease, 6627001500F440 1 kit (3 pens)/180 ulcerative colitis, or (NDC M, N, O, or Y days hidradenitis 00074012403) suppurativa Starter kit HCSC_CS_reg_Biologic_Immunomodulators_PAQL_ProgSum_AR0420_r0321 Page 4 of 29 © Copyright Prime Therapeutics LLC. 03/2021 All Rights Reserved Effective: 03/22/2021 Brand (generic) GPI Quantity Limit Multisource Code 80 mg/0.8 mL pen, 6627001500F440 1 kit (4 pens)/180 Pediatric ulcerative (NDC M, N, O, or Y days colitis Starter kit 00074012404) 80 mg/0.8 mL and 40 mg/0.4 mL pen, 1 kit (3 pens)/180 6627001500F450 M, N, O, or Y Psoriasis, uveitis days Starter kit Ilumya (tildrakizumab-asmn) 100 mg/mL syringe 9025058010E520 1 syringe/84 days M, N, O, or Y Inflectra (infliximab -dyyb) 100 mg/20 mL vial 52505040202120 N/A M, N, O, or Y Kevzara (sarilumab) 2 pens (2.28 mL) /28 150 mg/1.14 mL pen 6650006000D520 M, N, O, or Y days 2 pens (2.28 mL) /28 200 mg/1.14 mL pen 6650006000D530 M, N, O, or Y days 150 mg/1.14 mL 2 syringes (2.28 mL) 6650006000E520 M, N, O, or Y syringe /28 days 200 mg/1.14 mL 2 syringes (2.28 mL) 6650006000E530 M, N, O, or Y syringe /28 days Kineret® (anakinra) 28 syringes (18.76 100 mg syringe 6626001000E520 M, N, O, or Y mL) /28 days Olumiant (baricitinib) 1 mg tablets 66603010000310 1 tablet/day M, N, O, or Y 2 mg tablets 66603010000320 1 tablet/day M, N, O, or Y Orencia® (abatacept) 4 syringes (1.6 50 mg/0.4 mL syringe 6640001000E510 M, N, O, or Y mL)/28 days 87.5 mg/ 0.7 mL 4 syringes (2.8 6640001000E515 M, N, O, or Y syringe mL)/28 days 4 syringes (4 mL)/28 125 mg/mL syringe 6640001000E520 M, N, O, or Y days 125 mg/mL ClickJect 4 autoinjectors/28 6640001000D520 M, N, O, or Y autoinjector days 250 mg vial 66400010002120 4 vials/28 days M, N, O, or Y Remicade (infliximab) 100 mg/20 mL vial 52505040002120 N/A M, N, O, or Y Renflexis (infliximab-abda) 100 mg/20 mL vial 52505040102120 N/A M, N, O, or Y Rinvoq (upadacitinib) 15 mg tablet 66603072007520 1 tablet/day M, N, O, or Y Siliq (brodalumab) 210 mg/1.5 mL 2 syringes (3 mL)/28 9025052000E520 M, N, O, or Y syringe days Simponi ARIA (golimumab) 5 vials (20 mL)/56 50 mg/4 mL vial 66270040002015 M, N, O, or Y days Simponi® (golimumab) 50 mg/0.5 mL auto- 1 auto-injector (0.5 6627004000D520 M, N, O, or Y injector mL)/28 days 1 syringe (0.5 mL)/28 50 mg/0.5 mL syringe 6627004000E520 M, N, O, or Y days HCSC_CS_reg_Biologic_Immunomodulators_PAQL_ProgSum_AR0420_r0321 Page 5 of 29 © Copyright Prime Therapeutics LLC.