Select Prior Authorization

Transcription

1 Select Prior Authorization Some medications must be authorized for coverage because they re only approved or effective in treating specific illnesses, they cost more or they may be prescribed for conditions for which safety and effectiveness have not been well established. Reviewing Medications Our review committee of independent doctors and pharmacists meets regularly to review medications and consider how they should be covered by pharmacy benefit plans. They also recommend prior authorization guidelines. Safe and Effective When making recommendations, the review committee focuses on proven medication safety, effectiveness and cost. The committee considers: U.S. Food and Drug Administration (FDA) approved indications Manufacturer s package labeling instructions Well-accepted and/or published clinical recommendations Getting a Short-Term Supply If you must start taking a medication that requires prior authorization right away, two options may be available to you. First, ask your doctor if a sample is available. If not, check with your pharmacy to request a short-term supply of five 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 dispense the rest of your prescription. Requesting a Prior Authorization You, your pharmacist or your doctor can start the prior authorization review process by contacting our prior authorization department. A pharmacy technician then works with your doctor to get the information needed for the review. Once we receive a completed prior authorization form from your doctor, we conduct a clinical review within two business days. We then send you and your doctor a letter regarding the prior authorization decision.

2 Select Prior Authorization Select Non-Specialty Prior Authorization List Products on these pages may require prior authorization as determined by your specific benefit plan design. For more information, contact customer service at the number on the back of your benefit plan ID card. THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Anti-infectives Antibiotics XIFAXAN (rifaximin) Antifungals CICLODAN KIT (ciclopirox) CICLOPIROX KIT (ciclopirox) CNL8 NAIL KIT (ciclopirox) JUBLIA (efinaconazole) KERYDIN (tavaborole) ONMEL (itraconazole) PEDIPIROX-4 NAIL KIT (ciclopirox) SPORANOX (itraconazole) Soln SPORANOX (itraconazole) Antimalarial QUALAQUIN (quinine) Antiprotozoal DARAPRIM (pyrimethamine) Cardiology Antilipemic VYTORIN MG (simvastatin/ezetimibe) ZOCOR 80 mg (simvastatin) Heart Failure CORLANOR (ivabradine) Central Nervous System ADHD Agents (PA age 19+ only) ENTRESTO (sacubitril/valsartan) ADDERALL (amphetamine/ dextroamphetamine) ADDERALL XR (amphetamine/ dextroamphetamine mixed salts) APTENSIO XR (methylphenidate) CONCERTA (methylphenidate) 36 mg CONCERTA (methylphenidate) DAYTRANA (methylphenidate transdermal) DESOXYN (methamphetamine) DEXEDRINE (dextroamphetamine) 5 mg DEXEDRINE (dextroamphetamine) 15 mg DEXEDRINE (dextroamphetamine) 10 mg 1 patch/day 5 tabs/day 3 caps/day 4 caps/day 6 caps/day OptumRx optumrx.com

3 DYANAVEL XR (amphetamine) EVEKEO (amphetamine) FOCALIN (dexmethylphenidate) FOCALIN XR (dexmethylphenidate) 20 mg FOCALIN XR (dexmethylphenidate) METADATE CD (methylphenidate) METADATE ER (methylphenidate) 20 mg METHYLIN (methylphenidate) METHYLIN CHEW TAB (methylphenidate) METHYLIN CHEW TAB (methylphenidate) 10 mg METHYLIN ER (methylphenidate) 20 mg METHYLPHENIDATE ER (methylphenidate) 10 mg PROCENTRA (dextroamphetamine) Sol QUILLICHEW ER (methylphenidate) 30 mg QUILLICHEW ER (methylphenidate) QUILLIVANT XR (methylphenidate) RITALIN (methylphenidate) RITALIN LA (methylphenidate) RITALIN SR (methylphenidate) 20 mg VYVANSE (lisdexamfetamine) ZENZEDI (dextroamphetamine) 10 mg ZENZEDI (dextroamphetamine) ZENZEDI (dextroamphetamine) 30 mg 24 ml/day 6 tabs/day 2 caps/day 6 tabs/day 60 ml/day 12 ml/day 6 tabs/day Analgesics (non-opioid) PENNSAID (diclofenac) QUTENZA (capsaicin) VIMOVO (naproxen/esomeprazole) 4 patches/3 months Analgesics (opioid) ABSTRAL (fentanyl citrate) 4 tabs/day ACTIQ (fentanyl citrate) BELBUCA (buprenorphine) film BUNAVAIL (buprenorphrine/naloxone) mg BUNAVAIL (buprenorphrine/naloxone) mg BUNAVAIL (buprenorphrine/naloxone) mg BUTRANS (buprenorphine) CONZIP (tramadol SR) FENTORA (fentanyl citrate) LAZANDA (fentanyl citrate) 4 lozenges/day 2 films/day 6 films/day 2 films/day 3 films/day 4 patches/28 days 4 tabs/day 1 bottle/day 3

4 Select Prior Authorization ONSOLIS (fentanyl citrate) SUBOXONE (buprenorphrine/naloxone) 8-2 mg SUBOXONE (buprenorphrine/naloxone) 12-3 mg SUBOXONE (buprenorphrine/naloxone) 4-1 mg SUBOXONE (buprenorphrine/naloxone) mg SUBSYS (fentanyl) SUBUTEX (buprenorphrine) 8 mg SUBUTEX (buprenorphrine) 2 mg ZUBSOLV (buprenorphine/naloxone) SL Tab MG ZUBSOLV (buprenorphine/naloxone) SL Tab 8.6/2.1 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 11.4/2.9 MG ZUBSOLV (buprenorphine/naloxone) SL Tab 2.9/0.71 MG ZUBSOLV (buprenorphine/naloxone) SL Tab MG 4 films/day 3 tabs or films/day 2 films/day 6 films/day 12 tabs or films/day 16 sprays/day 1 6 tabs/day 1 Anticonvulsants HORIZANT (gabapentin enacarbil) Antipsychotics ADASUVE (loxapine) Benzodiazepines FLURAZEPAM (flurazepam) Hypoactive Sexual Desire Disorder ONFI (clobazam) ADDYI (flibanserin) Miscellaneous RILUTEK (riluzole) Parkinson s DUOPA (carbidopa-levodopa) Susp Stimulants NUVIGIL (armodafinil) NUVIGIL (armodafinil) 50 mg PROVIGIL (modafinil) Weight Loss ADIPEX-P (phentermine) BELVIQ (lorcaserin) BONTRIL (phendimetrazine) CONTRAVE (naltrexone-bupropion) DIDREX (benzphetamine) QSYMIA (phentermine/topiramate) SAXENDA (liraglutide) OptumRx optumrx.com

5 Dermatology SUPRENZA (phentermine) TENUATE (diethylpropion) XENICAL (orlistat) Acne ABSORICA (isotretinoin) AMNESTEEM (isotretinoin) CLAVARIS (isotretinoin) MIRVASO (brimonidine tartrate) Gel MYORISAN (isotretinoin) ZENATANE (isotretinoin) Acne (PA age >25 only) ATRALIN (tretinoin) Miscellaneous AVITA (tretinoin) DIFFERIN (adapalene) EPIDUO (adapalene/benzoyl peroxide) EPIDUO FORTE (adapalene/benzoyl peroxide) RETIN-A (tretinoin) RETIN-A MICRO (tretinoin) TRETIN-X (tretinoin) VELTIN (clindamycin/tretinoin) ZIANA (clindamycin/tretinoin) ENSTILAR (calcipotriene-betamethasone dipropionate) Miscellaneous ( PA age >25 only) TAZORAC (tazarotene) Endocrinology & Metabolism FABIOR (tazarotene) Androgens, Anabolic Steroids ANADROL-50 (oxymetholone) OXANDRIN (oxandrolone) 10 mg OXANDRIN (oxandrolone) 2.5 mg 420 g/28 days 100 g/30 days 100 g/30 days 8 tabs/day Androgens, Testosterone ANDRODERM (testosterone) ANDROGEL (testosterone) ANDROID (methyltestosterone) ANDROXY (fluoxymesterone) AVEED (testosterone undecanoate) AXIRON (testosterone) DELATESTRYL (testosterone enanthate) DEPO-TESTOSTERONE (testosterone cypionate) FORTESTA (testosterone) 5

6 Select Prior Authorization Endocrinology & Metabolism METHITEST (methyltestosterone) NATESTO (testosterone nasal) STRIANT (testosterone) TESTIM (testosterone) TESTOPEL (testosterone pellet) TESTRED (methyltestosterone) VOGELXO (testosterone) Antidiabetic Agents AFREZZA (insulin regular) Antidiabetic Agents (PA age > 65 only) Gastroenterology GLUMETZA (metformin) 500 mg SYMLIN (pramlintide) CHLORPROPAMIDE (chlorpropamide) Antiemetics CESAMET (nabilone) 20 tabs/fill or 3 max days DICLEGIS (doxylamine-pyridoxine) MARINOL (dronabinol) 4 tabs/day Irritable Bowel Syndrome LOTRONEX (alosetron) VIBERZI (eluxadoline) 60 caps/30 days Opioid-induced Constipation RELISTOR (methylnaltrexone) 1 syringe/day. Miscellaneous RELISTOR (methylnaltrexone) Kit 1 vial/day Calcium Modifier SENSIPAR (cinacalcet) Methotrexate Auto-Injectors OTREXUP (methotrexate) RASUVO (methotrexate) 12.5 MG/0.25ML RASUVO (methotrexate) 7.5 MG/0.15ML RASUVO (methotrexate) 30 MG/0.6ML RASUVO (methotrexate) 27.5 MG/0.55ML RASUVO (methotrexate) 25 MG/0.5ML RASUVO (methotrexate) 22.5 MG/0.45ML RASUVO (methotrexate) 20 MG/0.4ML RASUVO (methotrexate) 15 MG/0.3ML RASUVO (methotrexate) 10 MG/0.2ML RASUVO (methotrexate) 17.5 MG/0.35ML Wound Care REGRANEX (becaplermin) Oncology Miscellaneous PROVENGE (sipuleucel-t) OptumRx optumrx.com

7 Ophthalmology Miscellaneous RESTASIS (cyclosporine) Respiratory Asthma/COPD DALIRESP (roflumilast) PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected include both brand and generic where applicable and includes all dosage formulations unless otherwise specifically notated. If a new drug is approved and falls into one of the targeted PA categories, the new drug may automatically be added to this list. Quantity limits may also apply. Select Specialty Prior Authorization List Products on these pages may require prior authorization as determined by your specific benefit plan design. For more information, contact customer service at the number on the back of your benefit plan ID card. THERAPY CLASS MEDICATION NAME QUANTITY LIMIT Anti-infectives Antiretrovirals, HIV SELZENTRY (maraviroc) Cardiology Antilipemic JUXTAPID (lomitapide) KYNAMRO (mipomersen) PRALUENT (alirocumab) REPATHA (evolocumab) 4 syringes/28 days 2 syringes/28 days 3 syringes/28 days Pulmonary Arterial Hypertension ADCIRCA (tadalafil) ADEMPAS (riociguat) FLOLAN (epoprostenol) LETAIRIS (ambrisentan) OPSUMIT (macitentan) ORENITRAM (treprostinil diolamine) REMODULIN (treprostinil) REVATIO (sildenafil) Soln REVATIO (sildenafil) Susp REVATIO (sildenafil) Tabs TRACLEER (bosentan) TYVASO (treprostinil) UPTRAVI (selexipag) UPTRAVI (selexipag) Pack VELETRI (epoprostenol) VENTAVIS (iloprost) 90 tabs/30 days 2 bottles/30 days 1 ampule/day 2 packs/year Vasopressors NORTHERA (droxidopa) 9 ampules/day 7

8 Select Prior Authorization Central Nervous System Anticonvulsants SABRIL (vigabatrin) pack Depressant SABRIL (vigabatrin) Tabs XYREM (sodium oxybate) Neurotoxins BOTOX (onabotulinumtoxina) DYSPORT (abobotulinumtoxina) MYOBLOC (rimabotulinumtoxinb) XEOMIN (incobotulinumtoxina) 3 bottles (540 ml)/30 days Opiate Antagonist VIVITROL (naltrexone) Parkinson's APOKYN (apomorphine) 20 cartridges/30 days Sleep Disorder HETLIOZ (tasimelteon) Dermatology Alkylating Agents VALCHLOR (mechlorethamine) Gel Electrolyte & Renal Agents Diuretics KEVEYIS (dichlorphenamide) 4 tabs/day Endocrinology & Metabolism Gonadotropins ELIGARD (leuprolide) 22.5 mg (3-month) 1 injection/84 days Growth Hormones and Related Therapy ELIGARD (leuprolide) 30 mg (4-month) ELIGARD (leuprolide) 45 mg (6-month) ELIGARD (leuprolide) 7.5 mg (1-month) FIRMAGON (degarelix) 120 mg FIRMAGON (degarelix) 80 mg LUPANETA PACK (leuprolide) mg (3 mon) LUPANETA PACK (leuprolide) 3.75 mg (1 mon) LUPRON (leuprolide) 1 mg/0.2 ml LUPRON DEPOT (leuprolide) 3.75 mg & 7.5 mg (1-month) LUPRON DEPOT-PED (leuprolide) SUPPRELIN LA (histrelin acetate) 1 injection/112 days 1 injection/168 days 1 injection/28 days 2 vials/year 1 vial/28 days 1 pack/84 days 1 pack/28 days 1 kit/365 days TRELSTAR (triptorelin) 22.5 mg (6-month) 1 injection/168 days TRELSTAR DEPOT (triptorelin) 3.75 mg (1-month) TRELSTAR LA (triptorelin) mg (3-month) VANTAS (histrelin) EGRIFTA (tesamorelin) 1 mg 1 injection/28 days 1 injection/84 days 1 implant/year 2 vials (1 mg each)/day OptumRx optumrx.com

9 EGRIFTA (tesamorelin) 2 mg 1 vial (2 mg each)/day GENOTROPIN (somatropin) HUMATROPE (somatropin) INCRELEX (mecasermin) NORDITROPIN (somatropin) NUTROPIN (somatropin) NUTROPIN AQ (somatropin) OMNITROPE (somatropin) SAIZEN (somatropin) SEROSTIM (somatropin) SOMAVERT (pegvisomant) TEV-TROPIN (somatropin) ZOMACTON (somatropin) ZORBTIVE (somatropin) Hormone Modifiers MYALEPT (metreleptin) NATPARA (parathyroid hormone) 2 cartridges/28 days Miscellaneous H.P. ACTHAR (corticotropin) Korlym (mifepristone) 4 tabs/day Osteoporosis FORTEO (teriparatide) PROLIA (denosumab) 2 syringes/year Somatostatins SANDOSTATIN (octreotide) SANDOSTATIN LAR (octreotide) SIGNIFOR (pasireotide) 2 ampules/day SIGNIFOR LAR (pasireotide) 1 vial/28 days SOMATULINE DEPOT (lanreotide) Enzyme-Related Alpha-1 proteinase inhibitor ARALAST (alpha-1 proteinase inhibitor) GLASSIA (alpha-1 proteinase inhibitor) PROLASTIN (alpha-1 proteinase inhibitor) ZEMAIRA (alpha-1 proteinase inhibitor) Cystine-depleting Agents CYSTARAN (cysteamine) 4 bottles/28 days PROCYSBI (cysteamine bitartrate) Cystine-depleting Agents ALDURAZYME (laronidase) CERDELGA (eliglustat) CEREZYME (imiglucerase) ELAPRASE (idursulfase) ELELYSO (taliglucerase) FABRAZYME (agalsidase beta) 9

10 Select Prior Authorization KANUMA (sebelipase alfa) Soln LUMIZYME (alglucosidase alfa) MYOZYME (alglucosidase alfa) NAGLAZYME (galsulfase) RAVICTI (glycerol phenylbutyrate) STRENSIQ (asfotase alfa) VIMIZIM (elosulfase) VPRIV (velaglucerase) XURIDEN (uridine triacetate) ZAVESCA (miglustat) 4 packets/day Enzyme, Gout KRYSTEXXA (pegloticase) Phenylketonuria Treatment Agents Gastroenterology KUVAN (sapropterin) Bile Acid Agents CHOLBAM (cholic acid) Short Bowel Syndrome GATTEX (teduglutide) Immunology Allergen Extracts GRASTEK (timothy grass pollen) ORALAIR (mixed grass pollens allergen) 300 IR ORALAIR ADULT SAMPLE KIT (mixed grass pollens allergen) Kit ORALAIR ADULT STARTER PACK (mixed grass pollens allergen) ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allerg ORALAIR CHILDREN/ADOLESCENTS (mixed grass pollens allerg RAGWITEK (short ragweed pollen allergen) 1 kit per year 1 pack per year 2 kits/year 2 packs/year Hematopoietic Agents ARANESP (darbepoetin alfa) EPOGEN (epoetin alfa) GRANIX (tbo-filgrastim) LEUKINE (sargramostim) MIRCERA (methoxy polyethylene glycol-epoetin) MOZOBIL (plerixafor) NEULASTA (pegfilgrastim) NEUMEGA (oprelvekin) 8 vials (9.6 ml) per transplant OptumRx optumrx.com

11 NEUPOGEN (filgrastim) NPLATE (romiplostim) PROCRIT (epoetin alfa) PROMACTA (eltrombopag) SOLIRIS (eculizumab) ZARXIO (filgrastim) Hemostatic Agent BERINERT (c1 esterase) Hepatitis C Agents CINRYZE (c1 esterase) FIRAZYR (icatibant) Soln KALBITOR (ecallantide) Soln RUCONEST (c1 esterase) Solr DAKLINZA (daclatasvir dihydrochloride) 30 mg DAKLINZA (daclatasvir dihydrochloride) 60 mg HARVONI (ledipasvir-sofosbuvir) OLYSIO (simeprevir) PEGASYS (peginterferon alfa-2a) PEG-INTRON (peginterferon alfa-2b) SOVALDI (sofosbuvir) TECHNIVIE (ombitasvir-paritaprevirritonavir) VIEKIRA (simeprevir) ZEPATIER (elbasvir-grazoprevir) 4 tabs/day Immune Globulins BIVIGAM (immune globulin) CARIMUNE (immune globulin) CYTOGAM (cytomegalovirus immune globulin) FLEBOGAMMA (immune globulin) FLEBOGAMMA DIF (immune globulin) GAMASTAN (immune globulin) GAMMAGARD (immune globulin) GAMMAKED (immune globulin) GAMMAPLEX (immune globulin) GAMUNEX (immune globulin) GAMUNEX-C (immune globulin) HIZENTRA (immune globulin) HYQVIA (hyaluron immune globulin) OCTAGAM (immune globulin) PRIVIGEN (immune globulin) 11

12 Select Prior Authorization VARIZIG (varicella-zoster immune globulin) Immunomodulators ACTEMRA (tocilizumab) Sosy CIMZIA (certolizumab) COSENTYX (secukinumab) ENBREL (etanercept) ENTYVIO (vedolizumab) HUMIRA (adalimumab) KINERET (anakinra) ORENCIA (abatacept) OTEZLA (apremilast) REMICADE (infliximab) SIMPONI (golimumab) SIMPONI ARIA (golimumab) STELARA (ustekinumab) XELJANZ (tofacitinib) XELJANZ XR (tofacitinib) Interleukins ARCALYST (rilonacept) ILARIS (canakinumab) Miscellaneous BENLYSTA (belimumab) 2 vials/4 weeks Multiple Sclerosis AMPYRA (dalfampridine) AUBAGIO (teriflunomide) AVONEX (interferon beta-1a) BETASERON (interferon beta-1b) COPAXONE (glatiramer) SOSY 20 mg/ml COPAXONE (glatiramer) SOSY 40 mg/ml EXTAVIA (interferon beta-1b) GILENYA (fingolimod) GLATOPA (glatiramer) SOSY 20 mg/ml LEMTRADA (alemtuzumab) NOVANTRONE (mitoxantrone) PLEGRIDY (peginterferon beta) PLEGRIDY (peginterferon beta) Starter Pack REBIF (interferon beta-1a) REBIF (interferon beta-1a) Starter Pack TECFIDERA (dimethyl fumarate) 1 kit (4 syringes)/28 days 1 package/28 days 1 kit/30 days 1 kit/30 days 1 package/28 days 1 kit/30 days 2 PENS/SYR PER 28 DAYS. 1 starter pack/30 days 12 syringes/28 days 1 starter pack/year 2 caps/day OptumRx optumrx.com

13 TECFIDERA (dimethyl fumarate) Starter Pack TYSABRI (natalizumab) Transplant NULOJIX (belatacept) Miscellaneous Collagenase ZORTRESS (everolimus) XIAFLEX (collagenase clostridium histolyticum) 1 starter pack/year 1 injection /28 days Diagnostic THYROGEN (thyrotropin alfa) Movement Disorder Agents XENAZINE (tetrabenazine) Toxicology CUPRIMINE (penicillamine) EXJADE (deferasirox) FERRIPROX (deferiprone) Soln FERRIPROX (deferiprone) Tabs JADENU (deferasirox) SYPRINE (trientine) Viscosupplements EUFLEXXA (sodium hyaluronate) Obstetrics & Gynecology GEL-ONE (sodium hyaluronate) HYALGAN (sodium hyaluronate) MONOVISC (hyaluronan) ORTHOVISC (sodium hyaluronate) SUPARTZ (sodium hyaluronate) SYNVISC (sodium hyaluronate) SYNVISC-ONE (sodium hyaluronate) Fertility Agents BRAVELLE (urofollitropin) CETROTIDE (cetrorelix) Chorionic gonadotropin (chorionic gonadotropin) FOLLISTIM AQ (follitropin beta) Ganirelix acetate (ganirelix) GONAL-F (follitropin alfa) 450 IU GONAL-F RFF (follitropin alfa) Pens 300 IU GONAL-F RFF REDIINJECT (follitropin alfa) Soln 900 IU MENOPUR (menotropins) NOVAREL (chorionic gonadotropin) PREGNYL (chorionic gonadotropin) REPRONEX (menotropins) Hormone Replacement MAKENA (hydroxyprogesterone caproate) 13

14 Select Prior Authorization Oncology Alkylating Agents TEMODAR (temozolomide) Antiandrogen XTANDI (enzalutamide ) ZYTIGA (abiraterone) Antifolate FOLOTYN (pralatrexate) Soln Antimicrotubular HALAVEN (eribulin) JEVTANA (cabazitaxel) Interferons INTRON A (interferon alfa-2b) Kinase and Molecular Target Inhibitors SYLATRON (peginterferon alfa-2b) AFINITOR (everolimus) AFINITOR DISPERZ (everolimus) ALECENSA (alectinib) BOSULIF (bosutinib) CAPRELSA (vandetanib) 100 mg CAPRELSA (vandetanib) 300 mg COMETRIQ (carbozantinib) COTELLIC (cobimetnib) ERIVEDGE (vismodegib) FARYDAK (panobinostat) GILOTRIF (afatinib) GLEEVEC (imatinib) IBRANCE (palbociclib) ICLUSIG (ponatinib) 15 mg ICLUSIG (ponatinib) 45 mg IMBRUVICA (ibrutinib) INLYTA (axitinib) IRESSA (gefitinib) JAKAFI (ruxolitinib) JAKAFI (ruxolitinib) 10 mg KYPROLIS (carfilzomib) LENVIMA (lenvatinib) LYNPARZA (olaparib) MEKINIST (trametinib) NEXAVAR (sorafenib) NINLARO (ixazomib) ODOMZO (sonidegib) PORTRAZZA (necitumumab) Soln 8 caps/day 63 tabs/28 days 6 caps/ 21 days 3 caps/28 days 2 vials/21 days OptumRx optumrx.com

15 SPRYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib) TAFINLAR (dabrafenib) TAGRISSO (osimertinib) TARCEVA (erlotinib) 100 mg, 150 mg TARCEVA (erlotinib) 25 mg TASIGNA (nilotinib) TYKERB (lapatinib) VELCADE (bortezomib) VOTRIENT (pazopanib) XALKORI (crizotinib) ZALTRAP (ziv-aflibercept) ZELBORAF (vemurafenib) ZYDELIG (idelalisib) ZYKADIA (ceritinib) Miscellaneous BELEODAQ (belinostat) DACOGEN (decitabine) ISTODAX (romidepsin) LONSURF (trifluridine-tipiracil) MG LONSURF (trifluridine-tipiracil) MG SYNRIBO (omacetaxine) TARGRETIN (bexarotene) caps TARGRETIN (bexarotene) Gel XELODA (capecitabine) ZOLINZA (vorinostat) 100 tabs/28 days 80 tabs/28 days Monoclonal Antibody ADCETRIS (brentuximab) ARZERRA (ofatumumab) BLINCYTO (blinatumomab) CYRAMZA (ramucirumab) DARZALEX (daratumumab) Soln EMPLICITI (elotuzumab) Solr ERBITUX (cetuximab) Soln GAZYVA (obinutuzumab) HERCEPTIN (trastuzumab) KADCYLA (ado-trastuzumab emtansine) 15

16 KEYTRUDA (pembrolizumab) Soln KEYTRUDA (pembrolizumab) Solr OPDIVO (nivolumab) PERJETA (pertuzumab) RITUXAN (rituximab) SYLVANT (siltuximab) XGEVA (denosumab) YERVOY (ipilimumab) Thalidomide-related Agents POMALYST (pomalidomide) Respiratory REVLIMID (lenalidomide) THALOMID (thalidomide) Asthma/COPD NUCALA (mepolizumab) 1 vial/28 days XOLAIR (omalizumab) Cystic fibrosis CAYSTON (aztreonam) KALYDECO (ivacaftor) KALYDECO (ivacaftor) Packs ORKAMBI (lumacaftor-ivacaftor) PULMOZYME (dornase alfa) 112 tabs/28 days Pulmonary Fibrosis ESBRIET (pirfenidone) Respiratory Syncytial Virus Agents OFEV (nintedanib) SYNAGIS (palivizumab) PLEASE NOTE: This drug list is subject to periodic updates and may not be all inclusive. Drugs affected include both brand and generic where applicable and includes all dosage formulations unless otherwise specifically notated. If a new drug is approved and falls into one of the targeted PA categories, the new drug may automatically be added to this list. Quantity limits may also apply. optumrx.com OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health products. We are an Optum company a leading provider of integrated health services. Learn more at optum.com. All Optum trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or registered marks of their respective owners OptumRx, Inc. ORX0800A-CTRX_