OPTUMRxreg Utilization management updates - January 1 2020

Prior authorization mdash Premium

There are some medications that have to be authorized by a doctor before you can get them because the medications are approved or effective only for some conditions

Reviewing medications

A group of doctors and pharmacists meets often to review medications under pharmacy beneft plans They also recommend prior authorization guidelines

Safe and effective

When making recommendations the review committee focuses on medication safety effectiveness and cost including

bull US Food and Drug Administration (FDA) approved uses

bull Medication instruction labels

bull Accepted or published clinical recommendations

Getting a short-term supply

If you must take a medication that requires prior authorization right away there are two options that may work for you First ask your doctor if a sample is available Or check with your pharmacy to request a short-term supply of 5 days or less Keep in mind you will be responsible for the full cost at that time If the prior authorization request is approved then your pharmacist can fll the rest of your prescription

Requesting a prior authorization

You your pharmacist or your doctor can start the prior authorization process by contacting us We will work with your doctor to get the information needed for the review Once we receive a fnished prior authorization form from your doctor we will conduct a review within a few days and send you and your doctor a letter regarding the decision

In this drug list brand-name medications are shown in UPPERCASE (for example CLOBEX) and generic medications in lowercase (for example clobetasol)

Premium Formulary 1

Antibiotics

Antifungals

Antifungals

Antifungals

Antifungals

Antifungals

Antifungals

Antifungals

Antilipemic

Antilipemic

Antilipemic

Antilipemic

Heart Failure

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

Premium non-specialty prior authorization list

These medications may require prior authorization based on your beneft plan For more information contact customer service at the phone number on your member ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Anthelmintics ALBENZA (albendazole) None

Antibiotics AEMCOLO (rifamycin) None

XIFAXAN (rifaximin) None

Antifungals CICLODAN KIT (ciclopirox) None

CICLOPIROX KIT (ciclopirox) None

CNL8 NAIL KIT (ciclopirox) None

KERYDIN (tavaborole) None

ONMEL (itraconazole) None

PEDIPROX-4 (ciclopirox) nail kit None

SPORANOX (itraconazole) Soln None

SPORANOX (itraconazole) None

Antihelmintics ALBENZA (albendazole) None

Antimalarial QUALAQUIN (quinine) None

Antiretrovirals HIV Selzentry (maraviroc) None

Trogarzo (ibalizumab) None

Cardiology Antilipemic omega-3 fatty acid None

PRALUENT (alirocumab) 2 syringes28 days

REPATHA (evolocumab) 3 syringes28 days

REPATHA PUSH (evolocumab) 1 cartridge28 days

VASCEPA (icosapent ethyl) None

Heart Failure CORLANOR (ivabradine) 2 tabsday

CORLANOR (ivabradine) Soln 15 mLday

Central Nervous System ADHD Agents (PA age ADHANSIA XR (methylphenidate) 4 capsday 19+ only) 25 mg

ADHANSIA XR (methylphenidate) 1 capday

ADZENYS ER (amphetamine) 15 mLday

ADZENYS XR-ODT (amphetamine) 1 tabday

amphetamine 6 tabsday

amphetaminedetroamphetamine 2 tabsday 30 mg tab

2

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT amphetaminedetroamphetamine 3 tabsday

amphetaminedetroamphetamine ER 1 capday

APTENSIO XR (methylphenidate) 1 capday

COTEMPLA XR-ODT (methylphenidate) 86 mg COTEMPLA XR-ODT (methylphenidate) 173 mg COTEMPLA XR-ODT (methylphenidate) 259 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)

6 tabsday

3 tabsday

2 tabsday

1 patchday

5 tabsday

DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate

6 capsday

3 capsday

4 capsday

2 tabsday

DYANAVEL XR (amphetamine) 8 mLday

EVEKEO ODT (amphetamine) 5 mg 10 mg EVEKEO ODT (amphetamine) 15 mg 20 mg FOCALIN XR (dexmethylphenidate)

3 tabsday

2 tabsday

1 capday

FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)

2 capsday

1 capday

METADATE CD (methylphenidate) 1 capday

METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)

3 tabsday

3 tabsday

METHYLIN (methylphenidate) Soln 10 mg5 mL

30 mLday

3

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate

60 mLday

3 tabsday

6 tabsday

3 tabsday

3 tabsday

METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release

2 tabsday

2 tabsday

1 tabday

MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol

1 capday

60 mLday

QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)

2 tabsday

1 tabday

QUILLIVANT XR (methylphenidate) 12 mLday

RELEXXII (methylphenidate) 72 mg 1 tabday

RITALIN LA (methylphenidate) 1 capday

RITALIN SR (methylphenidate) 20 mg 3 tabsday

VYVANSE (lisdexamfetamine) 1 capday

VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)

1 tabday

2 tabsday

3 tabsday

Analgesics (non-opioid)

ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)

6 tabsday

4 patches3 months

4

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20

120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced

acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

ACTIQ (fentanyl citrate) 4 lozengesday

AVINZA (morphine ext-release) 1 capday

AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday

butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days

BUTRANS (buprenorphine) 4 patches28 days

codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced

codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced

codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced

DOLOPHINE (methadone) None

5

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less

than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2

flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

EMBEDA (morphinenaltrexone) 2 capsday

EXALGO (hydromorphone) 2 tabsday

fentanyl transdermal patch 15 patches30 days

fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180

mLday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

6

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Antibiotics

Antifungals

Antifungals

Antifungals

Antifungals

Antifungals

Antifungals

Antifungals

Antilipemic

Antilipemic

Antilipemic

Antilipemic

Heart Failure

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

Premium non-specialty prior authorization list

These medications may require prior authorization based on your beneft plan For more information contact customer service at the phone number on your member ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Anthelmintics ALBENZA (albendazole) None

Antibiotics AEMCOLO (rifamycin) None

XIFAXAN (rifaximin) None

Antifungals CICLODAN KIT (ciclopirox) None

CICLOPIROX KIT (ciclopirox) None

CNL8 NAIL KIT (ciclopirox) None

KERYDIN (tavaborole) None

ONMEL (itraconazole) None

PEDIPROX-4 (ciclopirox) nail kit None

SPORANOX (itraconazole) Soln None

SPORANOX (itraconazole) None

Antihelmintics ALBENZA (albendazole) None

Antimalarial QUALAQUIN (quinine) None

Antiretrovirals HIV Selzentry (maraviroc) None

Trogarzo (ibalizumab) None

Cardiology Antilipemic omega-3 fatty acid None

PRALUENT (alirocumab) 2 syringes28 days

REPATHA (evolocumab) 3 syringes28 days

REPATHA PUSH (evolocumab) 1 cartridge28 days

VASCEPA (icosapent ethyl) None

Heart Failure CORLANOR (ivabradine) 2 tabsday

CORLANOR (ivabradine) Soln 15 mLday

Central Nervous System ADHD Agents (PA age ADHANSIA XR (methylphenidate) 4 capsday 19+ only) 25 mg

ADHANSIA XR (methylphenidate) 1 capday

ADZENYS ER (amphetamine) 15 mLday

ADZENYS XR-ODT (amphetamine) 1 tabday

amphetamine 6 tabsday

amphetaminedetroamphetamine 2 tabsday 30 mg tab

2

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT amphetaminedetroamphetamine 3 tabsday

amphetaminedetroamphetamine ER 1 capday

APTENSIO XR (methylphenidate) 1 capday

COTEMPLA XR-ODT (methylphenidate) 86 mg COTEMPLA XR-ODT (methylphenidate) 173 mg COTEMPLA XR-ODT (methylphenidate) 259 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)

6 tabsday

3 tabsday

2 tabsday

1 patchday

5 tabsday

DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate

6 capsday

3 capsday

4 capsday

2 tabsday

DYANAVEL XR (amphetamine) 8 mLday

EVEKEO ODT (amphetamine) 5 mg 10 mg EVEKEO ODT (amphetamine) 15 mg 20 mg FOCALIN XR (dexmethylphenidate)

3 tabsday

2 tabsday

1 capday

FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)

2 capsday

1 capday

METADATE CD (methylphenidate) 1 capday

METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)

3 tabsday

3 tabsday

METHYLIN (methylphenidate) Soln 10 mg5 mL

30 mLday

3

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate

60 mLday

3 tabsday

6 tabsday

3 tabsday

3 tabsday

METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release

2 tabsday

2 tabsday

1 tabday

MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol

1 capday

60 mLday

QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)

2 tabsday

1 tabday

QUILLIVANT XR (methylphenidate) 12 mLday

RELEXXII (methylphenidate) 72 mg 1 tabday

RITALIN LA (methylphenidate) 1 capday

RITALIN SR (methylphenidate) 20 mg 3 tabsday

VYVANSE (lisdexamfetamine) 1 capday

VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)

1 tabday

2 tabsday

3 tabsday

Analgesics (non-opioid)

ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)

6 tabsday

4 patches3 months

4

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20

120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced

acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

ACTIQ (fentanyl citrate) 4 lozengesday

AVINZA (morphine ext-release) 1 capday

AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday

butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days

BUTRANS (buprenorphine) 4 patches28 days

codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced

codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced

codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced

DOLOPHINE (methadone) None

5

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less

than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2

flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

EMBEDA (morphinenaltrexone) 2 capsday

EXALGO (hydromorphone) 2 tabsday

fentanyl transdermal patch 15 patches30 days

fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180

mLday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

6

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT amphetaminedetroamphetamine 3 tabsday

amphetaminedetroamphetamine ER 1 capday

APTENSIO XR (methylphenidate) 1 capday

COTEMPLA XR-ODT (methylphenidate) 86 mg COTEMPLA XR-ODT (methylphenidate) 173 mg COTEMPLA XR-ODT (methylphenidate) 259 mg DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine)

6 tabsday

3 tabsday

2 tabsday

1 patchday

5 tabsday

DEXEDRINE (dextroamphetamine) 10 mg DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg dexmethylphenidate

6 capsday

3 capsday

4 capsday

2 tabsday

DYANAVEL XR (amphetamine) 8 mLday

EVEKEO ODT (amphetamine) 5 mg 10 mg EVEKEO ODT (amphetamine) 15 mg 20 mg FOCALIN XR (dexmethylphenidate)

3 tabsday

2 tabsday

1 capday

FOCALIN XR (dexmethylphenidate) 20 mg JORNAY PM (methylphenidate)

2 capsday

1 capday

METADATE CD (methylphenidate) 1 capday

METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate)

3 tabsday

3 tabsday

METHYLIN (methylphenidate) Soln 10 mg5 mL

30 mLday

3

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate

60 mLday

3 tabsday

6 tabsday

3 tabsday

3 tabsday

METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release

2 tabsday

2 tabsday

1 tabday

MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol

1 capday

60 mLday

QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)

2 tabsday

1 tabday

QUILLIVANT XR (methylphenidate) 12 mLday

RELEXXII (methylphenidate) 72 mg 1 tabday

RITALIN LA (methylphenidate) 1 capday

RITALIN SR (methylphenidate) 20 mg 3 tabsday

VYVANSE (lisdexamfetamine) 1 capday

VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)

1 tabday

2 tabsday

3 tabsday

Analgesics (non-opioid)

ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)

6 tabsday

4 patches3 months

4

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20

120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced

acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

ACTIQ (fentanyl citrate) 4 lozengesday

AVINZA (morphine ext-release) 1 capday

AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday

butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days

BUTRANS (buprenorphine) 4 patches28 days

codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced

codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced

codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced

DOLOPHINE (methadone) None

5

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less

than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2

flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

EMBEDA (morphinenaltrexone) 2 capsday

EXALGO (hydromorphone) 2 tabsday

fentanyl transdermal patch 15 patches30 days

fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180

mLday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

6

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)19+ only)

ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)ADHD Agents (PA age 19+ only)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT METHYLIN (methylphenidate) Soln 5 mg5 mL METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg methylphenidate

60 mLday

3 tabsday

6 tabsday

3 tabsday

3 tabsday

METHYLPHENIDATE ER (methylphenidate) 10 mg methylphenidate ER tab osmotic release 36 mg methylphenidate ER tab osmotic release

2 tabsday

2 tabsday

1 tabday

MYDAYIS (amphetamine dextroamphetamine) PROCENTRA (dextroamphetamine) Sol

1 capday

60 mLday

QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate)

2 tabsday

1 tabday

QUILLIVANT XR (methylphenidate) 12 mLday

RELEXXII (methylphenidate) 72 mg 1 tabday

RITALIN LA (methylphenidate) 1 capday

RITALIN SR (methylphenidate) 20 mg 3 tabsday

VYVANSE (lisdexamfetamine) 1 capday

VYVANSE CHEW TAB (lisdexamfetamine) ZENZEDI (dextroamphetamine) 30 mg ZENZEDI (dextroamphetamine)

1 tabday

2 tabsday

3 tabsday

Analgesics (non-opioid)

ZENZEDI (dextroamphetamine) 10 mg QUTENZA (capsaicin)

6 tabsday

4 patches3 months

4

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20

120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced

acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

ACTIQ (fentanyl citrate) 4 lozengesday

AVINZA (morphine ext-release) 1 capday

AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday

butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days

BUTRANS (buprenorphine) 4 patches28 days

codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced

codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced

codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced

DOLOPHINE (methadone) None

5

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less

than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2

flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

EMBEDA (morphinenaltrexone) 2 capsday

EXALGO (hydromorphone) 2 tabsday

fentanyl transdermal patch 15 patches30 days

fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180

mLday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

6

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Analgesics (opioid) acetaminophencodeine soln 136 mLday 7 day supply (age 20

120-12 mg5 mL and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 1665 mLday 2 flls60 days for treatment experienced

acetaminophencodeine tab 300-15 13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

ACTIQ (fentanyl citrate) 4 lozengesday

AVINZA (morphine ext-release) 1 capday

AVINZA (morphine ext-release) 2 capsday 120 mg BELBUCA (buprenorphine) flm 2 flmsday

butorphanol nasal spray 10 mgmL 1 bottlefll 2 flls60 days

BUTRANS (buprenorphine) 4 patches28 days

codeine tab 15 mg 21 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 40 tabsday 2 flls60 days for treatment experienced

codeine tab 30 mg 10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 20 tabsday 2 flls60 days for treatment experienced

codeine tab 60 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 100 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

DEMEROL (meperidine) tab 50 mg 9 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 tabsday 2 flls60 days for treatment experienced

DOLOPHINE (methadone) None

5

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less

than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2

flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

EMBEDA (morphinenaltrexone) 2 capsday

EXALGO (hydromorphone) 2 tabsday

fentanyl transdermal patch 15 patches30 days

fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180

mLday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

6

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT DILAUDID (hydromorphone) liq 1225 mLday 7 day supply (age 20 1 mgmL and older) 3 day supply (age less

than 20) 2 flls60 days for treatment naive 225 mLday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 6 tabsday 7 day supply (age 20 and tab 2 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 11 tabsday 2 flls60 days for treatment experienced

DILAUDID (hydromorphone) 3 tabsday 7 day supply 2 flls60 tab 4 mg days for treatment naiumlve 5 tabsday 2

flls60 days for treatment experienced DILAUDID (hydromorphone) tab 8 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

EMBEDA (morphinenaltrexone) 2 capsday

EXALGO (hydromorphone) 2 tabsday

fentanyl transdermal patch 15 patches30 days

fentanyl transdermal patch 75 mcg 30 patches30 days hr 100 mcghr HYCET (hydrocodone 98 mLday 7 day supply (age 20 and acetaminophen) sol 75-325 mg older) 3 day supply (age less than 20) 15 mL 2 flls60 days for treatment naive 180

mLday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 9 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

hydrocodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

6

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT hydromorphone supp 3 mg

HYSINGLA ER (hydrocodone bitartrate)

4 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 7 suppsday 2 flls60 days for treatment experienced 1 tabday

levorphanol tab 2 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

LORTAB (hydrocodone acetaminophen) elx 10-300 mg 15 mL

735 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 135 mLday 2 flls60 days for treatment experienced

meperidinepromethazine cap 50-25 mg

9 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 capsday 2 flls60 days for treatment experienced

mepridine sol 50 mg5 mL

MORPHABOND ER (morphine ext-release)

49 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 90 mLday 2 flls60 days for treatment experienced 2 tabsday

morphine sol 10 mg5 mL 245 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

morphine sol 20 mg5 mL 1225 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 225 mLday 2 flls60 days for treatment experienced

morphine sol 20 mgmL 24 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 45 mLday 2 flls60 days for treatment experienced

7

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT morphine supp 10 mg 4 suppsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 9 suppsday 2 flls60 days for treatment experienced

morphine supp 20 mg 2 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 suppsday 2 flls60 days for treatment experienced

morphine supp 30 mg 1 suppday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 suppsday 2 flls60 days for treatment experienced

morphine supp 5 mg 9 suppsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 18 suppsday 2 flls60 days for treatment experienced

morphine tab 15 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

morphine tab 30 mg

morphine sulfate ER cap

MS CONTIN (morphine ext-release)

1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced 2 capsday

3 tabsday

NALOCET (oxycodone acetaminophen)

13 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

OPANA (oxymorphone) tab 10 mg 1 tabday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

8

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OPANA (oxymorphone) tab 5 mg 3 tabsday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

OXAYDO (oxycodone) tab 75 mg 4 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodoneaspirin tab 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneibuprofen tab 5-400 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

oxycodone cap 5 mg 6 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

oxycodone conc 20 mgmL 16 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 mLday 2 flls60 days for treatment experienced

oxycodone sol 5 mg5 mL 326 mLday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodone tab 10 mg 3 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

9

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT oxycodone tab 20 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 3 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen sol 326 mLday 7 day supply (age 20 and 5-325 mg5 mL older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 60 mLday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 3 tabsday 7 day supply (age 20 and 10-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 12 tabsday 7 day supply (age 20 and 25-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 6 tabsday 7 day supply (age 20 and 5-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

oxycodoneacetaminophen tab 4 tabsday 7 day supply (age 20 and 75-325 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

OXYCONTIN (oxycodone ext-release) 4 tabsday

oxymorphone ER 4 tabsday

pentazocinenaloxone tab 50-05 mg 5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 3 tabsday 7 day supply (age 20 and acetaminophen) tab 10-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 6 tabsday 2 flls60 days for treatment experienced

10

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT PRIMLEV (oxycodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

PRIMLEV (oxycodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab 75-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 4 tabsday 7 day supply (age 20 and tab 10-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 9 tabsday 2 flls60 days for treatment experienced

REPREXAIN (hydrocodoneibuprofen) 9 tabsday 7 day supply (age 20 and tab 5-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 16 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 15 2 tabsday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 30 1 tabday 7 day supply (age 20 and mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

ROXICODONE (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 5 mg 6 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ROXYBOND (oxycodone) tab 15 mg 2 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 4 tabsday 2 flls60 days for treatment experienced

11

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ROXYBOND (oxycodone) tab 30 mg 1 tabday 7 day supply (age 20 and

older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 2 tabsday 2 flls60 days for treatment experienced

SYNALGOS-DC (aspirincaffeine dihydrocodeine) cap

11 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 11 capsday 2 flls60 days for treatment experienced

TREZIX (acetaminophencaffeine dihydrocodeine) cap

12 capsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 capsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 3

10 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

TYLENOL (acetaminophen)codeine 4

5 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 10 tabsday 2 flls60 days for treatment experienced

ULTRACET (tramadol acetaminophen) tab 375-325 mg

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced

ULTRAM (tramadol) tab 50 mg

ULTRAM ER (tramadol ext-release)

8 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 8 tabsday 2 flls60 days for treatment experienced 1 tabday

VERDROCET (hydrocodone acetaminophen) tab 25-325 mg

12 tabsday 7 day supply (age 20 and older) 3 day supply (age less than 20) 2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

12

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Analgesics (opioid)

Anticonvulsants

Anticonvulsants

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT VICODIN (hydrocodone 9 tabsday 7 day supply (age 20 and acetaminophen) tab 5-300 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 13 tabsday 2 flls60 days for treatment experienced

VICODIN ES (hydrocodone 6 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 75-300 mg 2 flls60 days for treatment naiumlve 12

tabsday 2 flls60 days for treatment experienced

VICODIN HP (hydrocodone 4 tabsday 7 day supply (age 20 and acetaminophen) tab older) 3 day supply (age less than 20) 10-300 mg 2 flls60 days for treatment naiumlve 9

tabsday 2 flls60 days for treatment experienced

VICOPROFEN (hydrocodone 6 tabsday 7 day supply (age 20 and ibuprofen) tab 75-200 mg older) 3 day supply (age less than 20)

2 flls60 days for treatment naiumlve 12 tabsday 2 flls60 days for treatment experienced

ZAMICET (hydrocodone 735 mLday 7 day supply (age 20 and acetaminophen) sol older) 3 day supply (age less than 20) 10-325 mg15 mL 2 flls60 days for treatment naiumlve 135

mLday 2 flls60 days for treatment experienced

Anticonvulsants BANZEL (rufnamide) None

clobazam None

HORIZANT (gabapentin enacarbil) 2 tabsday

Antipsychotics ADASUVE (loxapine) None

Antitussives (PA age CAPCOF (phenylephrine 240 mLfll 2 flls60 days lt18) chlorpheniraminecodeine)

CHERATUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODAR AR (chlorpheniramine 240 mLfll 2 flls60 days codeine) CODAR D (pseudoephedrine 240 mLfll 2 flls60 days codeine) CODAR GF (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN (guaifenesincodeine) 240 mLfll 2 flls60 days

CODITUSSIN AC (guaifenesin 240 mLfll 2 flls60 days codeine) FLOWTUSS (hydrocodone 240 mLfll 2 flls60 days guaifenesin)

13

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT guaifenesincodeine 240 mLfll 2 flls60 days

HISTEX-AC (phenylephrine triprolidinecodeine) hydrocodonechlorpheniramine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

HYDROMET (hydrocodone homatropine) LEXUSS 210 (chlorpheniramine codeine) MAR-COF BP (pseudoephedrine brompheniraminecodeine) MAR-COF CG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

M-CLEAR WC (guaifenesincodeine) 240 mLfll 2 flls60 days

M-END MAX D (pseudoephedrine chlorpheniraminecodeine) M-END PE (phenylephrine brompheniraminecodeine) M-END WC (pseudoephedrine brompheniraminecodeine) NINJACOF-XG (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

OBREDON (hydrocodone guaifenesin) PHENHIST DH (pseudoephedrine brompheniraminecodeine) POLY-TUSSIN (phenylephrine brompheniraminecodeine) PRO-CLEAR AC (codeinepyrilamine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

promethazinephenylephrine codeine promethazinecodeine

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

pseudoephedrinechlorpheniramine hydrocodone PRO-RED AC (phenylephrine dexchlorpheniraminecodeine) RELCOF C (guaifenesincodeine)

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

240 mLfll 2 flls60 days

REZIRA (pseudoephedrine hydrocodone)

240 mLfll 2 flls60 days

14

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Antitussives (PA age lt18)

Antitussives (PA age lt18)Antitussives (PA age lt18)Antitussives (PA age lt18)

Migraine

Migraine

Migraine

Parkinsonrsquos

Stimulants

Stimulants

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT RYDEX (pseudoephedrine 240 mLfll 2 flls60 days brompheniraminecodeine) TRICODE AR (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminecodeine) TRYMINE CG (guaifenesincodeine) 240 mLfll 2 flls60 days

TUSNEL C (pseudoephedrine w cod- 240 mLfll 2 flls60 days gg) TUSSICAPS (hydrocodone 2 capsday 7 day supply 2 flls60 days chlorpheniramine) 10-8 mg TUSSICAPS (hydrocodone 4 capsday 7 day supply 2 flls60 days chlorpheniramine) 5-4 mg TUSSIGON (hydrocodone 6 tabsday 7 day supply 2 flls60 days homatropine) TUSSIONEX (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) TUXARIN ER (codeine 2 tabsday 7 day supply 2 flls60 days chlorpheniramine) TUZISTRA XR (codeine 240 mLfll 2 flls60 days chlorpheniramine) VIRTUSSIN (pseudoephedrine w 240 mLfll 2 flls60 days cod-gg) VITUZ (hydrocodone 240 mLfll 2 flls60 days chlorpheniramine) Z-TUSS AC (chlorpheniramine 240 mLfll 2 flls60 days codeine) ZUTRIPRO (pseudoephedrine 240 mLfll 2 flls60 days chlorpheniraminehydrocodone)

Hypoactive Sexual ADDYI (fibanserin) 1 tabday Desire Disorder Migraine AIMOVIG (erenumab) 2 syringes30 days

AIMOVIG (erenumab) 140 mgmL 1 syringe30 days

EMGALITY (galcanezumab-gnlm) 1 syringeauto-injector30 days

EMGALITY (galcanezumab-gnlm) 3 syringesauto-injector30 days 100 mg

Miscellaneous NUEDEXTA (dextromethorphan None quinidine)

Parkinsonrsquos DUOPA (carbidopa-levodopa) Susp None

NUPLAZID (pimavanserin) None

Sedative Hypnotics FLURAZEPAM (furazepam) 1 capday

Stimulants armodafnil 1 tabday

armodafnil 50 mg 2 tabsday

modafnil 1 tabday

15

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Weight Loss

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (Oral)

Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)Acne (PA age gt25 only)

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Weight Loss BELVIQ (lorcaserin) None

BELVIQ XR (lorcaserin) None

BONTRIL (phendimetrazine) None

CONTRAVE (naltrexone-bupropion) None

DIDREX (benzphetamine) None

LOMAIRA (phentermine) None

phentermine None

QSYMIA (phenterminetopiramate) None

REGIMEX (benzphetamine) None

SAXENDA (liraglutide) None

SUPRENZA (phentermine) None

TENUATE (diethylpropion) None

XENICAL (orlistat) None

Dermatology Acne (Oral) ABSORICA (isotretinoin) None

AMNESTEEM (isotretinoin) None

CLARAVIS (isotretinoin) None

MYORISAN (isotretinoin) None

ZENATANE (isotretinoin) None

Acne (PA age gt25 adapalene None only)

ATRALIN (tretinoin) None

AVITA (tretinoin) None

PLIXDA (adapalene) None

RETIN-A (tretinoin) None

tretinoin microsphere gel None

TRETIN-X (tretinoin) None

Endocrinology amp Metabolism Androgens Testosterone (Oral)

ANADROL-50 (oxymetholone) None

ANDROID (methyltestosterone) None

ANDROXY (fuoxymesterone) None

METHITEST (methyltestosterone) None

16

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Androgens Testosterone (Oral)Androgens Testosterone (Oral)Androgens Testosterone (Oral)

Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)Androgens Testosterone (Injectable)

Androgens Testosterone (Topical)Androgens Testosterone (Topical)Androgens Testosterone (Topical)

Antidiabetic Agents

Antiemetics

Antiemetics

Antiemetics

Antiemetics

Irritable Bowel Syndrome

Allergen Extracts

Allergen Extracts

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT OXANDRIN (oxandrolone) 25 mg 8 tabsday

OXANDRIN (oxandrolone) 10 mg 2 tabsday

TESTRED (methyltestosterone) None

Androgens AVEED (testosterone undecanoate) None Testosterone (Injectable)

DELATESTRYL (testosterone None enanthate)

TESTOPEL (testosterone pellet) None

testosterone cypionate None

Androgens ANDRODERM (testosterone) None Testosterone (Topical)

NATESTO (testosterone nasal) None

STRIANT (testosterone) None

testosterone gel 162 None

Antidiabetic Agents AFREZZA (insulin regular) None

SYMLINPEN (pramlintide) None

Gastroenterology Antiemetics BONJESTA (doxylamine-pyridoxine) 2 tabsday

CESAMET (nabilone) 20 capsfll or 3 max days supply

DICLEGIS (doxylamine-pyridoxine) 4 tabsday

MARINOL (dronabinol) 2 capsday

SYNDROS (dronabinol) 120 mL30 days

Irritable Bowel LOTRONEX (alosetron) None Syndrome

VIBERZI (eluxadoline) 2 tabsday

Immunology Allergen Extracts GRASTEK (timothy grass pollen) 1 tabday

ODACTRA (house dust mite) 1 tabday

ORALAIR (mixed grass pollens 1 tabday allergen) 300 IR

17

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Allergen Extracts

Methotrexate Auto-Injectors

Miscellaneous

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT ORALAIR ADULT SAMPLE KIT (mixed 1 kityear grass pollens allergen) Kit ORALAIR ADULT STARTER PACK 1 packyear (mixed grass pollens allergen) ORALAIR CHILDRENADOLESCENTS 2 packsyear (mixed grass pollens allergen) Starter Pack ORALAIR CHILDRENADOLESCENTS 2 kitsyear (mixed grass pollens allergen) Sample Kit RAGWITEK (short ragweed pollen 1 tabday allergen)

Immunizations VARIZIG (varicella-zoster immune None globulin)

Miscellaneous Antimetabolites SIKLOS (hydroxyurea) 100 mg None

Calcium Modifer cinacalcet None

Methotrexate Auto- OTREXUP (methotrexate) 4 auto-injectors28 days Injectors

RASUVO (methotrexate) 4 auto-injectors28 days

Movement Disorder OSMOLEX ER (amantadine) None Agents Wound Care REGRANEX (becaplermin) None

Oncology Miscellaneous PROVENGE (sipuleucel-T) None

Ophthalmology Miscellaneous RESTASIS (cyclosporine) None

XIIDRA (liftegrast) None

Respiratory AsthmaCOPD DALIRESP (rofumilast) None

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and include all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Premium specialty prior authorization list

These medications may require prior authorization as defned by your beneft plan For more information contact customer service at the member phone number on your ID card

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Anti-infectives Antiprotozoals DARAPRIM (pyrimethamine) None

18

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Antilipemic

Pulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial HypertensionPulmonary Arterial Hypertension

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Antithrombotic Agents von Willebrand Factor-Directed Antibody

CABLIVI (caplacizumab-yhdp) 1 kit per day

Cardiology Antilipemic JUXTAPID (lomitapide) 1 tabday

KYNAMRO (mipomersen) 4 syringes28 days

Pulmonary Arterial ADEMPAS (riociguat) 3 tabsday Hypertension

ALYQ (tadalafl) 2 tabsday

ambrisentan 1 tabday

FLOLAN (epoprostenol) None

OPSUMIT (macitentan) 1 tabday

ORENITRAM (treprostinil diolamine) None

REVATIO (sildenafl) Soln None

REVATIO (sildenafl) Susp 2 bottles30 days

REVATIO (sildenafl) Tabs 3 tabsday

tadalafl 2 tabsday

TRACLEER (bosentan) Tabs 2 tabsday

TRACLEER (bosentan) Tabs for Susp 4 tabsday

treprostinil None

TYVASO (treprostinil) 1 ampuleday

UPTRAVI (selexipag) 2 tabsday

UPTRAVI (selexipag) Pack 2 packsyear

VELETRI (epoprostenol) None

VENTAVIS (iloprost) 9 ampulesday

19

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Transthyretin Stabilizers

Anticonvulsants

Anticonvulsants

Miscellaneous

Miscellaneous

Muscular Dystrophy

Musculoskeletal Agents

Neurological Agents

Neurotoxins

Neurotoxins

Neurotoxins

Neurotoxins

Parkinsonrsquos

Sleep Disorder

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Transthyretin Stabilizers VYNDAMAX (tafamidis) 1 capday

VYNDAQEL (tafamidis meglumine) 4 capsday

Vasopressors NORTHERA (droxidopa) None

Central Nervous System Anticonvulsants DIACOMIT (stiripentol) None

EPIDIOLEX (cannabidiol) soln None

vigabatrin tabs None

Antidepressant SPRAVATO (esketamine) ZULRESSO None (brexanolone)

Depressant XYREM (sodium oxybate) 3 bottles (540 mL)30 days

Miscellaneous RADICAVA (edaravone) Soln None

RILUTEK (riluzole) 2 tabsday

TIGLUTIK (riluzole susp) 20 mLday

Muscular Dystrophy EMFLAZA (defazacort) None

EXONDYS 51 (eteplirsen) None

Musculoskeletal FIRDAPSE (amifampridine phosphate) None Agents

RUZURGI (amifanpridine) None

Neurological Agents ONPATTRO (patisiran sodium) None

TEGSEDI (inotersen) None

Neurotoxins BOTOX (onabotulinumtoxinA) None

BOTOX COSMETIC None (onabotulinumtoxinA) DYSPORT (abobotulinumtoxinA) None

MYOBLOC (rimabotulinumtoxinB) None

XEOMIN (incobotulinumtoxinA) None

Parkinsonrsquos APOKYN (apomorphine) 30 cartridges30 days

INBRIJA (levodopa) None

Sleep Disorder HETLIOZ (tasimelteon) 1 capday

SUNOSI (solriamfetol) 1 capday

Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel None

Atopic Dermatitis DUPIXENT (dupilumab) Sosy 4 syringes28 days

Electrolyte amp Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabsday

Endocrinology amp Metabolism

20

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Gonadotropins

Growth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related TherapyGrowth Hormones and Related Therapy

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT

Gonadotropins ELIGARD (leuprolide) 225 mg 1 injection84 days (3-month) ELIGARD (leuprolide) 30 mg 1 injection112 days (4-month) ELIGARD (leuprolide) 45 mg 1 injection168 days (6-month) ELIGARD (leuprolide) 75 mg 1 injection28 days (1-month) FIRMAGON (degarelix) 120 mg 2 vialsyear

FIRMAGON (degarelix) 80 mg 1 vial28 days

LUPANETA PACK (leuprolide) 1125 1 pack84 days mg (3 mon) LUPANETA PACK (leuprolide) 1 pack28 days 375 mg (1 mon) LUPRON (leuprolide) 1 mg02 mL None

LUPRON DEPOT (leuprolide) 375 mg None amp 75 mg (1-month) LUPRON DEPOT-PED (leuprolide) None

ORILISSA (elagolix) 150 mg 1 tabday

ORILISSA (elagolix) 200 mg 2 tabday

SUPPRELIN LA (histrelin acetate) 1 kit365 days

TRELSTAR (triptorelin) 225 mg 1 injection168 days (6-month) TRELSTAR DEPOT (triptorelin) 375 1 injection28 days mg (1-month) TRELSTAR LA (triptorelin) 1125 mg 1 injection84 days (3-month) TRIPTODUR (triptorelin) 1 injection84 days

VANTAS (histrelin) 1 implantyear

Growth Hormones and EGRIFTA (tesamorelin) 1 mg 2 vials (1 mg each)day Related Therapy

EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)day

NORDITROPIN (somatropin) None

NUTROPIN (somatropin) None

NUTROPIN AQ (somatropin) None

OMNITROPE (somatropin) None

21

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Growth Hormones and Related TherapyGrowth Hormones and Related Therapy

Growth Hormones and Related Therapy (Acromegaly)

Hormone Modifers

Miscellaneous

Osteoporosis

Osteoporosis

Osteoporosis

Somatostatins

Somatostatins

Somatostatins

Somatostatins

Alpha-1 proteinase inhibitorAlpha-1 proteinase inhibitorAlpha-1 proteinase inhibitor

Cystine-depleting Agents

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT SEROSTIM (somatropin) None

ZORBTIVE (somatropin) None

Growth Hormones INCRELEX (mecasermin) None and Related Therapy (Acromegaly)

SOMAVERT (pegvisomant) None

Hormone Modifers MYALEPT (metreleptin) None

NATPARA (parathyroid hormone) 2 cartridges28 days

Miscellaneous ACTHAR (corticotropin) None

KORLYM (mifepristone) 4 tabsday

Osteoporosis EVENITY (romosozumab-aqqg) 2 syringes (234 mL) per 28 days

FORTEO (teriparatide) None

PROLIA (denosumab) 2 syringesyear

TYMLOS (abaloparatide) Sopn None

Somatostatins octreotide inj None

SANDOSTATIN LAR (octreotide) None

SIGNIFOR (pasireotide) 2 ampulesday

SIGNIFOR LAR (pasireotide) 1 vial28 days

SOMATULINE DEPOT (lanreotide) None

Enzyme-Related Alpha-1 proteinase ARALAST (alpha-1 proteinase None inhibitor inhibitor)

GLASSIA (alpha-1 proteinase None inhibitor) PROLASTIN-C (alpha-1 proteinase None inhibitor) ZEMAIRA (alpha-1 proteinase None inhibitor)

Cystine-depleting CYSTARAN (cysteamine) 4 bottles28 days Agents

PROCYSBI (cysteamine bitartrate) None

Enzyme Replacement ALDURAZYME (laronidase) None

BRINEURA (cerliponase) Soln None

CERDELGA (eliglustat) None

CEREZYME (imiglucerase) None

ELAPRASE (idursulfase) None

ELELYSO (taliglucerase) None

FABRAZYME (agalsidase beta) None 22

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Enzyme Replacement

Metabolic Agents

Phenylketonuria Treatment AgentsPhenylketonuria Treatment AgentsPhenylketonuria Treatment Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

Hematopoietic Agents

THERAPY CLASS MEDICATION NAME QUANTITY LIMIT GALAFOLD (migalastat hcl) cap 14 caps28 days

KANUMA (sebelipase alfa) None

LUMIZYME (alglucosidase alfa) None

MEPSEVII (vestronidase alfa) None

NAGLAZYME (galsulfase) None

RAVICTI (glycerol phenylbutyrate) None

STRENSIQ (asfotase alfa) None

VIMIZIM (elosulfase) None

VPRIV (velaglucerase) None

XURIDEN (uridine triacetate) 4 packetsday

ZAVESCA (miglustat) None

Enzyme Gout KRYSTEXXA (pegloticase) None

Metabolic Agents NITYR (nitisinone) None

ORFADIN (nitisinone) None

Phenylketonuria KUVAN (sapropterin) None Treatment Agents

PALYNZIQ (pegvaliase-pqpz) 1 syringeday 10 mg05 mL PALYNZIQ (pegvaliase-pqpz) 8 syringes28 days 25 mg05 mL PALYNZIQ (pegvaliase-pqpz) 2 syringesday 20 mgmL

Gastroenterology Bile Acid Agents CHOLBAM (cholic acid) None

Diarrhea XERMELO (telotristat ethyl) 3 tabsday

Hepatic Agents OCALIVA (obeticholic acid) 1 tabday

Short Bowel Syndrome GATTEX (teduglutide) None

Immunology Hematopoietic Agents DOPTELET (avatrombopag) None

LEUKINE (sargramostim) None

MIRCERA (methoxy polyethylene None glycol-epoetin) MOZOBIL (plerixafor) 8 vials (84 mL)transplant

MULPLETA (lusutrombopag) None

NEULASTA (pegflgrastim) None

NIVESTYM (flgrastim-aaf) None

NPLATE (romiplostim) None

PROMACTA (eltrombopag) None

RETACRIT (epoetin alfa-epbx) None

SOLIRIS (eculizumab) None

TAVALISSE (fostamatinib) None

23

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Hematopoietic Agents

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hemostatic Agent

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Hepatitis C Agents

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

Immune Globulins

ZARXIO (flgrastim) None

Hemostatic Agent BERINERT (c1 esterase) None

CINRYZE (c1 esterase) None

FIRAZYR (icatibant) Soln None

HAEGARDA (c1 esterase) None

KALBITOR (ecallantide) Soln None

RUCONEST (c1 esterase) Solr None

TAKHZYRO (lanadelumab-fyo) None

Hepatitis C Agents DAKLINZA (daclatasvir 1 tabday dihydrochloride) EPCLUSA (sofosbuvir-velpatasvir) 1 tabday

HARVONI (ledipasvir-sofosbuvir) 1 tabday

MAVYRET (glecaprevir-pibrentasvir) 3 tabsday

OLYSIO (simeprevir) 1 capday

PEGASYS (peginterferon alfa-2a) None

PEG-INTRON (peginterferon alfa-2b) None

SOVALDI (sofosbuvir) 1 tabday

TECHNIVIE (ombitasvir-paritaprevir- 2 tabsday ritonavir) VIEKIRA PAK (dasabuvir-ombitasvir- 4 tabsday paritaprevir-ritonavir) VIEKIRA XR (dasabuvir-ombitasvir- 3 tabsday paritaprevir-ritonavir) VOSEVI (sofosbuvir-velpatasivir) 1 tabday

ZEPATIER (elbasvir-grazoprevir) 1 tabday

Immune Globulins BIVIGAM (immune globulin) None

CARIMUNE (immune globulin) None

CUVITRU (immune globulin) None

CYTOGAM (cytomegalovirus None immune globulin) FLEBOGAMMA (immune globulin) None

FLEBOGAMMA DIF (immune None globulin) GAMASTAN (immune globulin) None

GAMMAGARD (immune globulin) None

GAMMAKED (immune globulin) None

GAMMAPLEX (immune globulin) None

GAMUNEX (immune globulin) None

GAMUNEX-C (immune globulin) None

HIZENTRA (immune globulin) None

HYQVIA (hyaluron immune globulin) None

OCTAGAM (immune globulin) None

PRIVIGEN (immune globulin) None

24

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Immunomodulators

Interleukins

Miscellaneous

Miscellaneous

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Immunomodulators ACTEMRA (tocilizumab) Sosy None

CIMZIA (certolizumab) None

ENBREL (etanercept) None

ENTYVIO (vedolizumab) None

HUMIRA (adalimumab) None

INFLECTRA (infiximab) None

KEVZARA (sarilumab) None

KINERET (anakinra) None

ORENCIA (abatacept) None

OTEZLA (apremilast) None

RENFLEXIS (infiximab) None

SILIQ (brodalumab) Sosy None

SIMPONI (golimumab) None

SIMPONI ARIA (golimumab) None

SKYRIZI (risankizumab-rzaa) None

STELARA (ustekinumab) None

TALTZ (ixekizumab) None

TREMFYA (guselkumab) None

XELJANZ (tofacitinib) None

XELJANZ XR (tofacitinib) None

Interleukins ARCALYST (rilonacept) None

ILARIS (canakinumab) 2 vials4 weeks

Miscellaneous ACTIMMUNE (interferon gamma-1b) None

BENLYSTA (belimumab) None

CRYSVITA (burosumab-twza) None

Multiple Sclerosis AMPYRA (dalfampridine) 2 tabsday

AUBAGIO (terifunomide) 1 tabday

AVONEX (interferon beta-1a) 1 kit (4 syringes)28 days

BETASERON (interferon beta-1b) 1 package28 days

COPAXONE (glatiramer) SOSY 20 30 syringes30 days mgml COPAXONE (glatiramer) SOSY 40 12 syringes28 days mgml GILENYA (fngolimod) 1 capday

GLATOPA (glatiramer) SOSY 20 mg 30 syringes30 days ml LEMTRADA (alemtuzumab) None

MAVENCLAD (cladribine) None

MAYZENT (siponimod fumarate) 4 tabsday 025 mg MAYZENT (siponimod fumarate) 1 tabday 2 mg

25

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Multiple Sclerosis

Transplant

Movement Disorder AgentsMovement Disorder AgentsMovement Disorder AgentsMovement Disorder Agents

Musculoskeletal Agents

Toxicology

Toxicology

Toxicology

Toxicology

Toxicology

Viscosupplements

Viscosupplements

Viscosupplements

MAYZENT (siponimod fumarate) 2 starter packs (24 tabs)365 days starter pack NOVANTRONE (mitoxantrone) None

OCREVUS (ocrelizumab) Soln 40 mL365 days

REBIF (interferon beta-1a) 12 syringes28 days

REBIF (interferon beta-1a) Starter 1 starter packyear Pack TECFIDERA (dimethyl fumarate) 2 capsday

TECFIDERA (dimethyl fumarate) 1 starter packyear Starter Pack TYSABRI (natalizumab) 1 injection 28 days

Transplant NULOJIX (belatacept) None

ZORTRESS (everolimus) None

Miscellaneous Amino Acid ENDARI (glutamine) None

Collagenase XIAFLEX (collagenase clostridium None histolyticum)

Diagnostic THYROGEN (thyrotropin alfa) None

Movement Disorder AUSTEDO (deutetrabenazine) 4 tabsday Agents

INGREZZA (valbenazine tosylate) 2 capsday

INGREZZA (valbenazine tosylate) 80 1 capday mg INGREZZA (valbenazine tosylate) 56 caps (2 packs) per 365 days pack XENAZINE (tetrabenazine) None

Musculoskeletal SPINRAZA (nusinersen) Soln None Agents

ZOLGENSMA (onasemnogene) None

Toxicology CUPRIMINE (penicillamine) None

EXJADE (deferasirox) None

FERRIPROX (deferiprone) None

JADENU (deferasirox) None

JADENU SPRINKLE (deferasirox) None

SYPRINE (trientine) None

Viscosupplements DUROLANE (sodium hyaluronate) None

EUFLEXXA (sodium hyaluronate) None

GELSYN-3 (sodium hyaluronate) None

HYALGAN (sodium hyaluronate) None

26

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Viscosupplements

Viscosupplements

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Fertility Agents

Hormone Replacement

Antifolate

Antimicrotubular

CAR-T Therapy

Interferons

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

Miscellaneous

Miscellaneous

Miscellaneous

Miscellaneous

HYMOVIS (sodium hyaluronate) None

VISCO-3 (sodium hyaluronate) None

Obstetrics amp Gynecology Fertility Agents chorionic gonadotropin None

FOLLISTIM AQ (follitropin beta) None

ganirelix acetate None

MENOPUR (menotropins) None

NOVAREL (chorionic gonadotropin) None

OVIDREL (chorionic gonadotropin) None

PREGNYL (chorionic gonadotropin) None

REPRONEX (menotropins) None Hormone Replacement hydroxyprogesterone caproate None

MAKENA (hydroxyprogesterone None caproate)

Oncology (Injectable) Alkylating Agents BENDEKA (bendamustine) None

TREANDA (bendamustine) None

Antifolate FOLOTYN (pralatrexate) Soln None

TECENTRIQ (atezolizumab) Soln None

Antimicrotubular HALAVEN (eribulin) None

JEVTANA (cabazitaxel) None

CAR-T Therapy KYMRIAH (tisagenlecleucel) None

YESCARTA (axicabtagene ciloleucel) None

Interferons INTRON A (interferon alfa-2b) None

SYLATRON (peginterferon alfa-2b) None

Interleukins ELZONRIS (tagraxofusp-erzs) None

Kinase and Molecular ALIQOPA (copanlisib) None Target Inhibitors

KYPROLIS (carflzomib) None

PORTRAZZA (necitumumab) Soln None

VELCADE (bortezomib) None

ZALTRAP (ziv-afibercept) None

Miscellaneous BELEODAQ (belinostat) None

DACOGEN (decitabine) None

ISTODAX (romidepsin) None

SYNRIBO (omacetaxine) None

VYXEOS (daunorubicin-cytarabine) None

Monoclonal Antibody ADCETRIS (brentuximab) None

27

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Monoclonal Antibody

Antiandrogen

Antiandrogen

Antiandrogen

ARZERRA (ofatumumab) None

AVASTIN (bevacizumab) None

BAVENCIO (avelumab) Soln None

BESPONSA (inotuzumab) None

BLINCYTO (blinatumomab) None

CYRAMZA (ramucirumab) None

DARZALEX (daratumumab) Soln None

EMPLICITI (elotuzumab) Solr None

ERBITUX (cetuximab) Soln None

GAZYVA (obinutuzumab) None

HERCEPTIN (trastuzumab) None

HERCEPTIN HYLECTA (trastuzumab None and hyaluronidase-oysk IMFINZI (durvalumab) Soln None

KADCYLA (ado-trastuzumab None emtansine) KANJINTI (trastuzumab-anns) None

KEYTRUDA (pembrolizumab) None

LARTRUVO (olaratumab) None

LIBTAYO (cemiplimab-rwlc) None

LUMOXITI (moxetumomab None pasudotox-tdfk) MVASI (bevacizumab-awwb) None

MYLOTARG (gemtuzumab) None

OPDIVO (nivolumab) None

PERJETA (pertuzumab) None

POLIVY (polatuzumab vedotin-piiq None

POTELIGEO (mogamulizumab-kpkc) None

RITUXAN (rituximab) None

RITUXAN HYCELA (rituximab- None hyaluronidase) SYLVANT (siltuximab) None

UNITUXIN (dinutuximab) None

XGEVA (denosumab) None

YERVOY (ipilimumab) None

Oncology (Oral) Alkylating Agents TEMODAR (temozolomide) None

Antiandrogen ERLEADA (apalutamide) None

XTANDI (enzalutamide ) None

YONSA (abiraterone) None

ZYTIGA (abiraterone) None

Kinase and Molecular AFINITOR (everolimus) 1 tabday Target Inhibitors

28

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

AFINITOR DISPERZ (everolimus) None

ALECENSA (alectinib) 8 capsday

ALUNBRIG (brigatinib) 30 mg 4 tabsday

ALUNBRIG (brigatinib) 90 mg 1 tabday 180 mg ALUNBRIG (brigatinib) Pack 1 packyear

BALVERSA (erdaftinib) None

BOSULIF (bosutinib) None

BRAFTOVI (encorafenib) None

CABOMETYX (cabozantinib None s-malate) CALQUENCE (acalabrutinib) None

CAPRELSA (vandetanib) None

CAPRELSA (vandetanib) 100 mg 2 tabsday

COMETRIQ (carbozantinib) None

COTELLIC (cobimetnib) None

ERIVEDGE (vismodegib) None

FARYDAK (panobinostat) None

GILOTRIF (afatinib) 1 tabday

GLEEVEC (imatinib) None

IBRANCE (palbociclib) None

ICLUSIG (ponatinib) 15 mg 2 tabday

ICLUSIG (ponatinib) 45 mg None

IDHIFA (enasidenib) None

IMBRUVICA (ibrutinib) None

29

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsTarget Inhibitors

Kinase and Molecular Target InhibitorsKinase and Molecular Target InhibitorsKinase and Molecular Target Inhibitors

INLYTA (axitinib) None

IRESSA (geftinib) None

JAKAFI (ruxolitinib) None

JAKAFI (ruxolitinib) 10 mg 2 tabsday

LENVIMA (lenvatinib) None

LYNPARZA (olaparib) None

MEKINIST (trametinib) None

MEKTOVI (binimetinib) None

NERLYNX (neratinib) 6 tabsday

NEXAVAR (sorafenib) None

NINLARO (ixazomib) None

ODOMZO (sonidegib) None

RYDAPT (midostaurin) None

SPRYCEL (dasatinib) None

STIVARGA (regorafenib) None

SUTENT (sunitinib) None

TAFINLAR (dabrafenib) None

TAGRISSO (osimertinib) 1 tabday

TAGRISSO (osimertinib) 40 mg None

TARCEVA (erlotinib) 100 mg None 150 mg TARCEVA (erlotinib) 25 mg 3 tabsday

TASIGNA (nilotinib) None

30

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Target Inhibitors TIBSOVO (ivosidenib) None

Kinase and Molecular TYKERB (lapatinib) None Target Inhibitors Kinase and Molecular VENCLEXTA (venetoclax) None Target Inhibitors Kinase and Molecular VERZENIO (abemaciclib) None Target Inhibitors Kinase and Molecular VOTRIENT (pazopanib) None Target Inhibitors Kinase and Molecular XALKORI (crizotinib) None Target Inhibitors Kinase and Molecular ZEJULA (niraparib tosylate) None Target Inhibitors Kinase and Molecular ZELBORAF (vemurafenib) None Target Inhibitors Kinase and Molecular ZYDELIG (idelalisib) None Target Inhibitors Kinase and Molecular ZYKADIA (ceritinib) None Target Inhibitors Miscellaneous bexarotene caps None

Miscellaneous KISQALI (ribociclib) None

Miscellaneous KISQALI FEMARA DOSE (ribociclib None succinate-letrozole) Pack

Miscellaneous LONSURF (trifuridine-tipiracil) None 15-614 mg

Miscellaneous LONSURF (trifuridine-tipiracil) None 20-819 mg

Miscellaneous RUBRACA (rucaparib camsylate) None

Miscellaneous XELODA (capecitabine) None

Miscellaneous ZOLINZA (vorinostat) None

Skin Cancer TARGRETIN GEL (bexarotene) None

Thalidomide-related POMALYST (pomalidomide) None Agents Thalidomide-related REVLIMID (lenalidomide) None Agents Thalidomide-related THALOMID (thalidomide) None Agents Ophthalmology Miscellaneous LUXTURNA (voretigene None

neparvovec-rzyl) Respiratory AsthmaCOPD CINQAIR (reslizumab) Soln None

31

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

OPTUMreg

AsthmaCOPD DUPIXENT (dupilumab) Sosy 4 syringes28 days

AsthmaCOPD FASENRA (benralizumab) None

AsthmaCOPD NUCALA (mepolizumab) 3 vials28 days

AsthmaCOPD XOLAIR (omalizumab) None

Cystic fbrosis CAYSTON (aztreonam) None

Cystic fbrosis KALYDECO (ivacaftor) None

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 4 tabsday

Cystic fbrosis ORKAMBI (lumacaftor-ivacaftor) 2 packetsday packets

Cystic fbrosis PULMOZYME (dornase alfa) None Cystic fbrosis SYMDEKO (tezacaftor-ivacaftor) 2 tabsday Pulmonary Fibrosis ESBRIET (pirfenidone) None

Pulmonary Fibrosis OFEV (nintedanib) None

Respiratory Syncytial SYNAGIS (palivizumab) None Virus Agents

PLEASE NOTE This drug list may have regular updates and may not include all medications Drugs in this list include brand and generic and all dosage types unless noted If a new drug is approved and falls into one of the targeted PA categories the new drug may be automatically added to this list

Rvs13 313201713 113 19199-shy‐3-shy‐201713

Rvs13 313201713 213 19199-shy‐3-shy‐201713

Rvs13 313201713 213 19199-shy‐3-shy‐201713